Keratoconjunctivitis sicca is the diagnosis here which is described as decreased lacrimal secretion characterized by conjunctival hyperaemia and itchiness.

It occurs commonly as part of Sjogren’s syndrome. Keratoconjunctivitis sicca is confirmed by Schirmer’s test and the treatment always includes the use of artificial tears. Schirmer’s test determines whether the eye produces enough tears to keep it moist.

It is considered negative or normal when there is more than 10 mm of moisture on the filter paper in 5 minutes.

Various tear substitutes can be used to treat dry eyes. They can be in the form of drops, gels, and ointments.

Examples of drops include:

• Hypromellose

• Sodium chloride

• Sodium hyaluronate Note that topical ciclosporin is also useful for dry eyes but it should not be used as the first line.

Scleral lenses can also be used as they create a tear-filled reservoir which prevents the feeling of dry eyes but again should not be used as the first line. Scleral lenses are expensive.

Bacterial conjunctivitis management :

• Most cases of infective conjunctivitis do not need medical treatment and clear up in one to two weeks.

• Gently clean away sticky discharge from your eyelids and lashes using cotton wool soaked in water.

• If the decision is made to use antibiotics. Chloramphenicol drops are the drug of choice.

Types of conjunctivitis:

1. Bacterial conjunctivitis:

• Purulent discharge

• Eyes may be ‘stuck together’ in the morning.

2.Viral conjunctivitis:

• Serous discharge

• Recent URTI

• Preauricular lymph nodes

Allergic conjunctivitis:

• Bilateral symptoms

• Itch is prominent

• May give a history of atopy

• May be seasonal (due to pollen) or perennial.

One of the rare manifestations of cytomegalovirus includes retinitis. It is usually seen in an immunocompromised host (e.g. a positive HIV patient) like in this stem. Although it is rare, retinitis is still the most common manifestation of CMV disease in patients who are HIV positive.

Very early CMV may resemble cotton wool spots.

Cytomegalovirus retinitis :

- Decreased visual acuity, floaters, and loss of visual fields on one side

- Examination shows yellow-white cloudy retinal lesions. Lesions may appear at the periphery of the fundus, but they progress centrally.

- It begins as a unilateral disease, but in many cases, it progresses to bilateral involvement.

Given that, if a patient with positive HIV attends with visual deterioration, cytomegalovirus should be at the top of your differential.

Optic neuritis is a relatively common presenting symptom of Multiple Sclerosis. It is due to the demyelination of the optic nerve.

OPTIC NEURITIS :

Inflammation of the optic nerve.

One of the most common causes of optic neuritis is multiple sclerosis.

The stem would usually include a female patient as multiple sclerosis is more prevalent in the female gender.

Examination- 

Swollen optic disc

Optic disc becomes pale later (4 to 6 weeks after onset)

Relative pupillary defect (RAPD) of affected eye. 

Because of this patient’s past medical history of cervical spondylitis, iridocyclitis is the most likely answer.

Please note the following for exam:

1. Anterior uveitis is also referred to as iritis and iridocyclitis

2. Intermediate uveitis is also known as pars planitis or varitis

3. Posterior uveitis is also called chorioretinitis

4. The most common cause of chronic anterior uveitis is sarcoidosis

5. The most common form of uveitis is anterior uveitis Anterior uveitis. Also referred to as iritis. It is one of the important differentials of a red eye.

The diagnosis here is background retinopathy. Remember how to distinguish the types of diabetic retinopathy. Also, remember that type I diabetes mellitus is a common cause of retinopathy.

Background retinopathy (nonproliferative) :

- Microaneurysms (dots)

- Haemorrhage (blots)

- Hard exudates

Preproliferative retinopathy :

- Addition of Cotton wool spots

Proliferative retinopathy :

- Addition of new vessel formation (neovascularization)

- More serious.

- Progresses rapidly to blindness.

- May lead to vitreous haemorrhage

- Floaters in vision

- Laser photocoagulation is needed.

A middle-aged man with early morning back pain and stiffness is suggestive of seronegative arthritis likely ankylosing spondylitis where anterior uveitis (iritis) is a known association.

It is also important to note that visual acuity for iritis is initially normal but can worsen as time passes. The abnormally shaped pupil is another giveaway.

Periorbital cellulitis presents similarly to this stem whereby there is an acute onset of swelling, redness, increased warmth, and tenderness of the eyelid. Fever is often a feature. Periorbital cellulitis is also commonly seen in children.

Do not confuse periorbital cellulitis with orbital cellulitis which involves orbital signs such as gaze restriction, proptosis, and pain on eye movements. Orbital cellulitis is an emergency and requires intravenous antibiotics.

This is a case of oculomotor nerve palsy. Diplopia, mydriasis, ptosis, and outward downward deviation of the eye as described here are clinical features of oculomotor nerve palsy.

An oculomotor nerve palsy can be associated with vascular disorders such as diabetes, or particularly posterior communicating artery aneurysm. Other causes include space-occupying tumours and infarction. abscess and trauma.

Angiographic imaging studies are often necessary in the evaluation of acute oculomotor nerve palsy.

A computed tomographic angiography would be a good option here to help exclude a posterior communicating artery aneurysm.

The diagnosis here is steroid-induced cataracts. Long-term use of steroids can cause cataracts. Oral corticosteroids have more of a systemic effect compared to inhaled corticosteroids. Thus, oral steroids are more likely to be the cause of his cataracts.

There are certain keywords or hints that you may find on the test that would lead towards cataracts.

These are: Exposure to great amounts of UV light i.e. person from Australia who never wears sunglasses. Long-term use of steroids (They may not say the words “steroids” but they may give a scenario with someone who has a long-standing condition that needs the use of steroids)

The most important diagnosis here to exclude would be giant cell arteritis. An old man with symptoms of headache and pain on chewing are classic features.

The central retinal artery can be affected by giant cell arteritis. 

The diagnosis here is proliferative retinopathy. Remember how to distinguish the types of diabetic retinopathy. Also, remember that type I diabetes mellitus is a common cause of retinopathy.

Laser photocoagulation is needed for proliferative retinopathy.

Central Retinal Vein Occlusion :

Clinical Presentation : These patients have a clinical presentation similar to those with retinal artery occlusion. There is a sudden loss of vision without pain, redness, or abnormality in pupillary dilation. 

Ocular examination by fundoscopy reveals disk swelling, venous dilation, tortuosity, and retinal haemorrhages.

Diagnosis : Retinal haemorrhages are the main way of distinguishing venous obstruction from arterial obstruction.

You cannot have a hemorrhage in the retina if you don't have blood getting into the eye.

Treatment of CRVO is beyond the scope of what you need to know for the exam but it involves immediate referral to an ophthalmologist and/or intra-vitreal steroids.

Please see Q-11

Papilloedema is optic disc swelling resulting from raised intracranial pressure.

The diagnosis here is steroid-induced cataracts. Long-term use of steroids as seen in someone with an autoimmune condition like rheumatoid arthritis can cause cataracts. 

There are certain keywords or hints that you may find on the exam that would lead towards cataracts.

These are:

- Exposure to great amounts of UV light i.e. person from Australia who never wears sunglasses.

- Long-term use of steroids.

- High myopia

- Trauma to the eye.

One of the ocular manifestations of rheumatoid arthritis is scleritis which presents with an erythematous, painful eye.

Ocular manifestations of rheumatoid arthritis are common.

Remember these 4:

- Keratoconjunctivitis sicca is the most common.

- Episcleritis presents with erythema (pain is also present but less severe than scleritis)

- Scleritis presents with erythema and pain

- Iatrogenic steroid

- Induced cataracts

Angle-closure glaucoma (ACG) is associated with a physically obstructed anterior chamber angle.

This question tests your knowledge of acute angle closure glaucoma. It is important to remember the symptoms of acute angle closure glaucoma worsen when the pupils are dilated (e.g. in a dark room). The history of having her eyes checked but the optician gives us the idea that either :

1.A mildly illuminated room like an optician's room would dilate the pupils enough to worsen symptoms.

2. Topical mydriatics were applied which case led to pupillary dilation which can push the iris into the angle and precipitate AAC in anyone with narrow angles.

Mooren’s ulceration is characterized by painful peripheral corneal ulceration of unknown aetiology. It is not a degenerative corneal disease.

Pain is almost always associated with the onset of Mooren’s ulcer. The eye is usually red and the vision may or may not be affected.

The given scenario is a clinical presentation of bacterial conjunctivitis. The term itself gives away the anatomical location of the infection – conjunctiva.

It is important to remember the management of bacterial conjunctivitis as this can be asked.

Most patients with hypertensive retinopathy have no symptoms.

Chronic hypertension (blood pressure > 140/90 mmHg):

- Usually asymptomatic

- Fundoscopy reveals bilateral attenuation of arterial vessels ('copper or silver wiring), arteriovenous nipping (where the arteries cross the veins) & eventually haemorrhage and exudates.

Key phrases in the exam that help you pick Hypertensive retinopathy as the answer:

- Copper or silver wiring

- Arteriovenous nipping

- Flamed-shaped haemorrhage

Usually one of these 3 terms would appear in the stem

Management :

- Aimed at controlling hypertension.

Please see Q-13

Please see Q- 5

The hint here is the homosexual man. For a very inappropriate reason, question writers tend to use the phrase homosexual to hint at the possibility of AIDS in this case. 

The combination of weight loss is another clue towards the diagnosis of HIV.

One of the rare manifestations of cytomegalovirus includes retinitis.

It is usually seen in an immunocompromised host (e.g. a positive HIV patient) like in this stem. Although it is rare, retinitis is still the most common manifestation of CMV disease in patients who are HIV positive.

Retinal haemorrhoage is a recognized association with cytomegalovirus retinitis.

Acute dacrocystitis is an acute inflammation of the lacrimal sac, often as a result of infection.

Presentation : Symptoms and signs are over the region of the lacrimal sac (but may spread to the nose and face with teeth pain being experienced by some). Therefore, look just lateral and below the bridge of the nose for:

• Excess tears (epiphora)

• Pain

• Swelling and erythema at the inner canthus of the eye Immediate antibiotic therapy may resolve the infection.

The case here is one of acute angle closure glaucoma. Measurement of intraocular pressure would help establish the diagnosis.

Please see Q-10

Optic neuritis is the likely diagnosis here. It usually presents with an acute or subacute unilateral decrease in vision and eye pain particularly on movement. The fact that she has multiple sclerosis is a huge hint. Visual field loss is a known feature of optic neuritis. 

Some may argue that scotoma can also be present in optic neuritis but in reality, monocular visual field loss is more frequently seen.

Causes of sudden painless loss of vision:

- Retinal detachment

- Vitreous haemorrhage

- Retinal vein occlusion

- Retinal artery occlusion

- Optic neuritis

- Cerebrovascular accident

Among all the causes of painless loss of vision, retinal detachment fits as they give clues like the tiny black dots which are “floaters” and the typical description of a “curtain falling”.

This patient has uncontrolled blood pressure. The major risk for arteriosclerotic hypertensive retinopathy is the duration of elevated blood pressure which is seen here as 10 years. 

The clinical appearance on a dilated fundoscopic exam and the coexisting hypertension give the diagnosis of hypertensive retinopathy.

It is important to note that background retinopathy (non-proliferative) may also have similar findings on the fundoscopy which include microaneurysms (dots), haemorrhage (flame-shaped or blots), and hard exudates (yellow patches) but the history of uncontrolled hypertension makes hypertensive retinopathy a better choice.

The diagnosis here is retinal detachment.

Treatment options include scleral buckling.

Among all the causes of painless loss of vision, retinal detachment fits as they give clues like the description of a “curtain falling”.

Myopia is also another hint as it is a predisposing factor.

Please see Q-21

In acute angle closure glaucoma, coloured halos around lights are often a complaint by patients. Nausea and vomiting are common and may be the main presenting feature in some patients.

If the patient has infective conjunctivitis for more than 7 days, then start the patient on topical antibiotics.

If it is less than 7 days, then choose the option that has self-care rather than topical antibiotics.

Topical steroids are always going to be the wrong answer unless it is herpes simplex virus conjunctivitis. It is only used if keratitis extends deep into the stroma.

Herpes zoster ophthalmicus describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve.

It accounts for around 10-20% of cases of shingles.

Ophthalmic herpes is a danger to sight and the patient should see an ophthalmologist the same day.

Features :

- Vesicular rash around the eye, which may or may not involve the actual eye itself.

- Hutchinson's sign: rash on the tip or side of the nose.

- Indicates nasociliary involvement and is a strong risk factor for ocular involvement

Management :

- Oral antiviral treatment

- Oral corticosteroids may reduce the duration of pain

- Ocular involvement requires urgent ophthalmology review

Complications :

- Ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis

- Ptosis

- Post-herpetic neuralgia

Keratitis is a condition in which the eye's cornea, the front part of the eye, becomes inflamed. Another infectious cause of keratitis is Herpes simplex keratitis which presents with a dendritic corneal ulcer. For herpes simplex keratitis, topical acyclovir is used.

Please see Q-35

Optic neuritis is diagnosed clinically by symptoms of acute unilateral decrease in vision, eye pain-especially with movement decreased color vision, and documentation of a visual field defect.

The pain is worse on eye movements because the rectus muscle contraction pulls on the optic nerve sheath.

The focal neurological symptoms and exaggerated reflexes all point towards multiple sclerosis which is probably the cause of optic neuritis in which case corticosteroids would be used as part of the management.

Please see Q-5

The findings in this patient (diplopia, tachycardia, lid lag, restricted eye movements) all point towards thyroid eye disease. 90% of thyroid eye diseases are associated with Graves’ disease. Most cases of lid lag are seen in thyroid ophthalmopathy which is known as Graves’ ophthalmopathy.

The inferior rectus muscle is the most commonly affected muscle in Graves’ ophthalmopathy which leads to experiencing vertical diplopia on upgaze with difficulty in elevating eyes due to fibrosis of the muscle.

The best investigation to do in this patient would be a thyroid function test. A free T4 level alone is not the best option to diagnose thyrotoxicosis.

The likely diagnosis here is central retinal artery occlusion. An ocular massage can dislodge the embolus to a point further down the arterial circulation and improve retinal perfusion.

According to question it a case of Acute Angle Closure glaucoma.
In a clinical scenario, the patient would need Pilocarpine eye drop with oral carbonic anhydrase inhibitor (Diamox) and YAG peripheral iridotomy

A painless transient loss of vision is termed amaurosis fugax. They occur when a thrombotic embolus passes through the retinal circulation.

This patient would need to be referred for a cardiovascular workup and antiplatelet treatment. As the thrombus most likely originates from the carotid artery, he would require a carotid artery doppler and possibly an endarterectomy.

The symptoms and progressive decrease in vision and myopia point towards open-angle glaucoma. Simple open-angle glaucoma is present in around 2% of people older than 40 years. Other than age, risk factors that need to be known for exam include:

- family history

- black patients

- myopia

The slit-lamp findings are consistent with acute closed-angle glaucoma. This is supported by the history of entering a dark room (movie theater) when symptoms started along with the severe painful red eye.

The history is consistent with acute angle closure glaucoma. Headaches and blurry vision are common.

Symptoms tend to worsen with pupil dilation as seen in this stem when she is watching a movie in a dark theatre.

Vomiting is also a common feature of acute glaucoma. Ocular tonometry is needed to determine the intraocular pressure to help diagnose glaucoma.

The key to note here is the frequent change spectacles due to changes in refraction. This on top of the complaints of glare and reduced vision points towards cataracts. Sometimes in the exam, they will also give a history of long-term steroid which may be the etiology behind cataract formation.

Prolonged corticosteroids [also topical i.e. eye drops] can cause cataract.

This is not angle closure glaucoma as angle closure glaucoma occurs usually after the age of 50;

In open angle glaucoma visual loss is not evenly gradual rather occurs a bit suddenly at its later part.

It is not cataract as cataract occurs usually in the elderly. In macular degeneration near blindness does not occur rather causes the inability to identify the face or cannot read small prints; otherwise, peripheral vision is not that depressed. In keratitis, pain, redness, photophobia, and vision are ok.

Likely affected muscle is right medial rectus supplied by right oculomotor. It is not right trochlear palsy as in such one iris will be higher than other.

Prolonged steroid use leads to cataract formation.

Central retinal vein thrombosis.

Cataract is unlikely at this age. Uveitis and iritis don’t have such degree of vision loss and iritis and anterior uveitis have pain, redness, and photophobia.

Open-angle glaucoma mostly occurs after the age of 50 years. The answer should be retinopathy (example retinitis pigmentosa).

Age and normal pupil and cornea are suggestive of cataract. If it was glaucoma pupil would be a bit dilated and/or oval in shape.

At an early stage optic disc remains normal in the retinal detachment.

Causes of sudden painless loss of vision:  Retinal detachment, Vitreous haemorrhage, Retinal vein occlusion, Retinal artery occlusion, Optic neuritis, Cerebrovascular accident.

It is a case of retinal detachment with the treatment option of scleral buckling.

Bacterial conjunctivitis is treated with antibiotic drops.

This is a case of open-angle glaucoma, treatment is with pilocarpine.

Oculomotor may cause palsy of the inferior rectus, medial rectus, and superior rectus causing double vision in multiple gaze! But trochlear involving superior oblique only causes diplopia in downgaze.

Large multiple cotton wool spots are seen in an early stage of CMV retinitis.

Acute dacryocystitis

Pale retina with a cherry red spot in the macular region is seen in CRAO.

Probable case of angle closure glaucoma requiring measurement of IOP to establish the diagnosis.

Darkness can cause dilatation of the pupil (which occurred in the darkness of the theatre room) which (halfway dilatation) most often precipitates acute attack of angle closure glaucoma and the test to diagnose this is application tonometry.

Glaucoma may have dilated oval pupil.

In iritis there are flares and cells in the anterior chamber. In iritis pupil may be irregular but in angle closure, glaucoma pupil is slightly dilated and oval in shape. In iritis, there is no halo around light but in glaucoma, there is a halo around light.

Bacterial conjunctivitis can cause sticky greenish discharge.

In acute angle closure glaucoma half-dilated pupil is the most likely position which precipitates an acute attack as the trabecular meshworks are mostly closed by peripheral anterior synechia of peripheral iris in this position.

And mild illuminated darkened room like of an optician (also the use of mydriatics accelerates this) or opera (cinema hall) are culprits to make this! As the block occurs in the anterior chamber it is the likely option here.

Amaurosis fugax is a temporary loss of vision in one or both eyes due to a lack of blood flow to the retina.

In central retinal artery occlusion (CRAO) retina becomes pale and the fovea becomes cherry red. Hypertension is a major cause of CRAO.

Apply direct pressure for 5-15 seconds, then release. Repeat several times. Ocular massage can dislodge the embolus to a point further down the arterial circulation and improve retinal perfusion.

The diagnosis is glaucoma (headache and haloes especially at night). In glaucoma there occurs tunnel vision.

Optic disc

Microenurism, hard exudates are seen in background diabetic retinopathy.

Stages of hypertensive retinopathy:

Grade 1: Silver wiring

Grade 2: 1 + AV nipping

Grade 3: 2 + flame-shaped hemorrhage

Grade 4: 3 + optic disc edema + macular star.

MS--optic neuropathy which affects optic nerve and long standing optic neuropathy can be seen as pallor of the optic disc in opthalmoscope.

All other options are the degenerative disease of cornea except Mooren’s ulcer which is a type of ulcerative keratitis.

Prolonged use of steroids (here in RA) is a known cause of cataracts.

Presentation can be described by either optic neuritis or retrobulbar neuritis. In optic neuritis, there is disc pallor. As in this case disc is normal it is a case of retrobulbar neuritis.

CRVO

In early disease, the macula shows yellowish-colored subretinal deposits called “drusen”.

CRVO

Neovascularization suggests proliferative diabetic retinopathy which is treated with laser photocoagulation.

IV morphine and immediate ophthalmoscopy

Redness with foreign body sensation of the eye in a laborer is most likely due to foreign body in cornea.

Sudden severe eye pain, red eye, visual blurring, acuity of only finger counting, nausea, vomiting, shallow anterior chamber that is hazy on shining torch are all classic presentations of acute closed-angle glaucoma.

In a 75-year-old man with normal cornea and pupils and papilloedema suggests macular degeneration.