12 - Ophthalmology Passmedicine Q. Bank PART I 2017

Relationship with Korsakoff syndrome
If not treated Korsakoff's syndrome may develop as well. This is termed Wernicke-Korsakoff
syndrome and is characterised by the addition of antero- and retrograde amnesia and
confabulation in addition to the above symptoms.
Question 1 of 56
A 65-year-old man with a 16 year history of type 2 diabetes mellitus presents complaining of poor eye
sight and blurred vision. Visual acuity measured using a Snellen chart is reduced to 6/12 in the right
eye and 6/18 in the left eye. Fundoscopy reveals a number of yellow deposits in the left eye consistent
with drusen formation. Similar changes but to a lesser extent are seen in the right eye. What is the
most likely diagnosis?
Wet age-related macular degeneration

Pre-proliferative diabetic retinopathy
Chronic open angle glaucoma
Proliferative diabetic retinopathy
Dry age-related macular degeneration
Question 1 of 56
A 65-year-old man with a 16 year history of type 2 diabetes mellitus presents complaining of poor eye
sight and blurred vision. Visual acuity measured using a Snellen chart is reduced to 6/12 in the right
eye and 6/18 in the left eye. Fundoscopy reveals a number of yellow deposits in the left eye consistent
with drusen formation. Similar changes but to a lesser extent are seen in the right eye. What is the
Wet age-related macular degeneration

Pre-proliferative diabetic retinopathy
Chronic open angle glaucoma
Dry age-related macular degeneration
Drusen = Dry macular degeneration
Discuss and give feedback
Age related macular degeneration
External links
Webvision
Age related macular degeneration fundoscopy findings

Question 2 of 56
Which one of the following is associated with the Holmes-Adie pupil?
Decreased ankle reflexes

Pupillary constriction
Ptosis in 10-20% of cases
An increased of developing multiple sclerosis
Neurosyphilis
Question 2 of 56
Which one of the following is associated with the Holmes-Adie pupil?
Decreased ankle reflexes

Pupillary constriction
Ptosis in 10-20% of cases
An increased of developing multiple sclerosis
Neurosyphilis
Holmes ADIe = DIlated pupil, females, absent leg reflexes
Holmes-Adie pupil
Question 3 of 56
A 71-year-old man presents with a burning sensation around his right eye. On examination an
erythematous blistering rash can be seen in the right trigeminal distribution. What is the most likely
diagnosis?
Ramsay Hunt syndrome

Cluster headache
Fungal keratitis
Herpes zoster ophthalmicus
Trigeminal neuralgia
Question 3 of 56
A 71-year-old man presents with a burning sensation around his right eye. On examination an
erythematous blistering rash can be seen in the right trigeminal distribution. What is the most likely
diagnosis?
Ramsay Hunt syndrome

Cluster headache
Fungal keratitis
Trigeminal neuralgia

Question 4 of 56
Which one of the following is least associated with the development of optic atrophy?
Ataxic telangiectasia
Longstanding papilloedema
Multiple sclerosis
Glaucoma
Retinitis pigmentosa
Question 4 of 56
Ataxic telangiectasia
Longstanding papilloedema
Multiple sclerosis
Glaucoma
Optic atrophy
Question 5 of 56
A 34-year-old woman presents complaining of headaches. Examination of her pupils using a light
shone alternately in each eye reveals that when the light is shone in the right eye both pupils constrict
but when the light source immediately moves to the left eye both eyes appear to dilate.
What is the most likely diagnosis?
Right optic neuritis

Left sided Horner's syndrome
Craniopharyngioma
Left optic neuritis
Right Holmes-Adie pupil
Question 5 of 56
A 34-year-old woman presents complaining of headaches. Examination of her pupils using a light
shone alternately in each eye reveals that when the light is shone in the right eye both pupils constrict
but when the light source immediately moves to the left eye both eyes appear to dilate.
What is the most likely diagnosis?
Right optic neuritis

Left sided Horner's syndrome
Craniopharyngioma
Left optic neuritis
Right Holmes-Adie pupil
is the 'swinging light test' and reveals a relative afferent pupillary defect. As there is a defect in
the afferent nerve on the left side the pupils constrict less than normal, giving the impression of
dilation.
g optic neuritis is the likely underlying diagnosis. Optic

neuritis typically causes a dull ache in the region of the eye which is aggravated by movement
Relative afferent pupillary defect
External links
almostadoctor
Relative afferent pupillary defect tutorial

Question 6 of 56
A 65-year-old man with a known history of Paget's disease is noted to have irregular dark red lines
radiating from the optic nerve. What is the likely diagnosis?
Optic neuritis
Angioid retinal streaks
Choroidoretinitis
Malignant hypertension
Question 6 of 56
A 65-year-old man with a known history of Paget's disease is noted to have irregular dark red lines
radiating from the optic nerve. What is the likely diagnosis?
Optic neuritis
Choroidoretinitis
Malignant hypertension
This is a typical description of angioid retinal streaks which are associated with Paget's disease

Question 7 of 56
A 64-year-old woman presents with bilateral sore eyelids. She also complains of her eyes being dry all
the time. On examination her eyelid margins are erythematous at the margins but are not swollen. Of
the given options, what is the most appropriate initial management?
Topical chloramphenicol + mechanical removal of lid debris

Hot compresses + topical steroids
Topical chloramphenicol + topical steroids
Hot compresses + mechanical removal of lid debris
Topical chloramphenicol + hot compresses
Question 7 of 56
A 64-year-old woman presents with bilateral sore eyelids. She also complains of her eyes being dry all
the time. On examination her eyelid margins are erythematous at the margins but are not swollen. Of
the given options, what is the most appropriate initial management?
Topical chloramphenicol + mechanical removal of lid debris

Hot compresses + topical steroids
Topical chloramphenicol + topical steroids
Hot compresses + mechanical removal of lid debris
Topical chloramphenicol + hot compresses
Blepharitis
External links
Clinical Knowledge Summaries
Blepharitis guideline
Question 8 of 56
A 67-year-old woman presents for review. She has recently been diagnosed with dry age-related
macular degeneration. Which one of the following is the strongest risk factor for developing this
condition?
Hypertension
Poor diet
Smoking
Diabetes mellitus
Alcohol excess
Question 8 of 56
A 67-year-old woman presents for review. She has recently been diagnosed with dry age-related
macular degeneration. Which one of the following is the strongest risk factor for developing this
condition?
Hypertension
Poor diet
Smoking
Diabetes mellitus
Alcohol excess
Macular degeneration - smoking is risk factor
Having a balanced diet, with plenty of fresh fruits and vegetables may also slow the progression of
macular degeneration. There is still ongoing research looking at the role of supplementary antioxidants
External links
Webvision

Question 9 of 56
A 34-year-old man is referred to ophthalmology following a deterioration in his vision. He is noted to

be tall with thin, long fingers and a degree of learning disabilities. Following review he is suspected as
having a displacement of his lens on the right side. What is the most likely underlying diagnosis?
Ehlers-Danlos syndrome
Homocystinuria
Rapadilino syndrome
Marfan's syndrome
Crouzon disease
Question 9 of 56
A 34-year-old man is referred to ophthalmology following a deterioration in his vision. He is noted to

be tall with thin, long fingers and a degree of learning disabilities. Following review he is suspected as
having a displacement of his lens on the right side. What is the most likely underlying diagnosis?
Ehlers-Danlos syndrome
Homocystinuria
Rapadilino syndrome
Marfan's syndrome
Crouzon disease
The presence of learning difficulties points to a diagnosis of homocystinuria rather than Marfan's
syndrome.
Homocystinuria
External links
Patient.info
Homocystinuria review
Question 10 of 56
A 62-year-old man presents with sudden visual loss in his right eye. He is otherwise asymptomatic.
Which one of the following conditions is least likely to be responsible?
Ischaemic optic neuropathy

Occlusion of the central retinal vein
Occlusion of the central retinal artery
Optic neuritis
Vitreous haemorrhage
Question 10 of 56
A 62-year-old man presents with sudden visual loss in his right eye. He is otherwise asymptomatic.
Which one of the following conditions is least likely to be responsible?

Occlusion of the central retinal vein
Occlusion of the central retinal artery
Optic neuritis
Whilst optic neuritis can present with sudden loss, in this 62-year-old man it is the least likely option.
Typically there is a unilateral decrease in visual acuity over hours or days. There may be poor
discrimination of colours and eye pain on movement
Sudden painless loss of vision

External links
American Academy of Ophthalmology
Central Retinal Vein Occlusion

Central Retinal Artery Occlusion
Patient.info
Retinal artery occlusions
Question 11 of 56
A 63-year-old man presents to his GP complaining of pain in his right eye. On examination the sclera
is red and the pupil is dilated with a hazy cornea. What is the most likely diagnosis?
Scleritis
Conjunctivitis
Acute angle closure glaucoma
Anterior uveitis
Subconjunctival haemorrhage
Question 11 of 56
A 63-year-old man presents to his GP complaining of pain in his right eye. On examination the sclera
is red and the pupil is dilated with a hazy cornea. What is the most likely diagnosis?
Scleritis
Conjunctivitis
Anterior uveitis
Subconjunctival haemorrhage
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, 'semi-dilated' pupil
uveitis: small, fixed oval pupil, ciliary flush
Red eye
Question 12 of 56
A 74-year-old man presents to ophthalmology clinic after seeing his optician. They have noticed raised
intra-ocular pressure and decreased peripheral vision. His past medical history includes asthma and
type 2 diabetes mellitus. What is the most appropriate treatment given the likely diagnosis?
Latanoprost
Pilocarpine
Timolol
Dorzolamide
Brimonidine
Question 12 of 56
A 74-year-old man presents to ophthalmology clinic after seeing his optician. They have noticed raised
intra-ocular pressure and decreased peripheral vision. His past medical history includes asthma and
type 2 diabetes mellitus. What is the most appropriate treatment given the likely diagnosis?
Latanoprost
Pilocarpine
Timolol
Dorzolamide
Brimonidine
A prostaglandin analogue should be used first-line in patients with a history of asthma.
Primary open-angle glaucoma: management
External links
Glaucoma guidelines
NICE
2009 Glaucoma guidelines

Question 13 of 56
A 93-year-old female patient on the ward is brought to your attention by the nurses. They are
concerned she is experiencing visual hallucinations. She was admitted following a decline in mobility
that was thought to be secondary to a urinary tract infection (UTI). She has improved clinically and
biochemically during her time on the ward and she is awaiting a increase package of care before
discharge.
You review the patient who tells you she earlier saw very small children running across the end of the
bed. She reports she regularly sees similar images at home and has done so for many years. She has a
background of hypertension, depression and age-related macular degeneration. What is the most
appropriate step in this patient's management?
Reassure the patient

Urgent psychiatric evaluation
Consider treatment failure of her UTI
Prescribe 40mg of chlordiazepoxide
Consider commencing an antidepressant
Question 13 of 56
A 93-year-old female patient on the ward is brought to your attention by the nurses. They are
concerned she is experiencing visual hallucinations. She was admitted following a decline in mobility
that was thought to be secondary to a urinary tract infection (UTI). She has improved clinically and
biochemically during her time on the ward and she is awaiting a increase package of care before
discharge.
You review the patient who tells you she earlier saw very small children running across the end of the
bed. She reports she regularly sees similar images at home and has done so for many years. She has a
background of hypertension, depression and age-related macular degeneration. What is the most
appropriate step in this patient's management?
Reassure the patient

Urgent psychiatric evaluation
Consider treatment failure of her UTI
Prescribe 40mg of chlordiazepoxide
Consider commencing an antidepressant
This most likely represents Charles Bonnet syndrome. Reassurance is usually the best treatment,
helping people to understand and come to terms with their hallucinations. It is importance to ensure
there is not an alternative cause e.g. infection, psychosis, dementia (particularly Lewy body dementia),
intoxication, metabolic abnormalities, focal neurological illness.
Charles Bonnet syndrome

Question 14 of 56
A 54-year-old woman presents with a persistent watery left eye for the past 4 days. On examination
there is erythema and swelling of the inner canthus of the left eye. What is the most likely diagnosis?
Blepharitis
Meibomian cyst
Dacryocystitis
Pinguecula
Question 14 of 56
A 54-year-old woman presents with a persistent watery left eye for the past 4 days. On examination
there is erythema and swelling of the inner canthus of the left eye. What is the most likely diagnosis?
Blepharitis
Meibomian cyst
Dacryocystitis
Pinguecula
Lacrimal duct problems

Question 15 of 56
A 71-year-old man presents with severe pain around his right eye and vomiting. On examination the
right eye is red and decreased visual acuity is noted. Which one of the following options is the most
appropriate initial treatment?
Topical pilocarpine + oral prednisolone

Topical pilocarpine + topical steroids
Topical steroids
Topical pilocarpine + intravenous acetazolamide
Topical steroids + intravenous acetazolamide
Question 15 of 56
A 71-year-old man presents with severe pain around his right eye and vomiting. On examination the
right eye is red and decreased visual acuity is noted. Which one of the following options is the most
appropriate initial treatment?
Topical pilocarpine + oral prednisolone

Topical pilocarpine + topical steroids
Topical steroids
Topical pilocarpine + intravenous acetazolamide
Topical steroids + intravenous acetazolamide
Treatment of acute glaucoma - acetazolamide + pilocarpine
External links
Patient.info

review
Question 16 of 56
A 35-year-old man presents with visual problems. He has had very poor vision in the dark for a long
time but is now worried as he is developing 'tunnel vision'. He states his grandfather had a similar
problem and was registered blind in his 50's. What is the most likely diagnosis?
Leber's congenital amaurosis

Vitelliform macular dystrophy
Central serous retinopathy
Primary open angle glaucoma
Question 16 of 56
A 35-year-old man presents with visual problems. He has had very poor vision in the dark for a long
time but is now worried as he is developing 'tunnel vision'. He states his grandfather had a similar
problem and was registered blind in his 50's. What is the most likely diagnosis?
Leber's congenital amaurosis

Vitelliform macular dystrophy
Central serous retinopathy
Retinitis pigmentosa - night blindness + tunnel vision
Question 17 of 56
A 60-year-old woman who has recently started treatment for polymyalgia rheumatica presents with a
five day history of headaches and reduced vision on the right side since this morning There is no eye
pain but the there is a 'large, dark shadow' covering the superior visual field on the right side. On
examination she has a tender, palpable right temporal artery. What is the most likely explanation for
the reduced vision?
Anterior ischemic optic neuropathy

Central retinal vein occlusion
Optic neuritis
Ophthalmic arteritis
Central retinal artery occlusion
Question 17 of 56
A 60-year-old woman who has recently started treatment for polymyalgia rheumatica presents with a
five day history of headaches and reduced vision on the right side since this morning There is no eye
pain but the there is a 'large, dark shadow' covering the superior visual field on the right side. On
examination she has a tender, palpable right temporal artery. What is the most likely explanation for
the reduced vision?
Anterior ischemic optic neuropathy

Optic neuritis
Ophthalmic arteritis
Temporal arteritis
Temporal arteritis is large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR).
Histology shows changes which characteristically 'skips' certain sections of affected artery whilst
damaging others.
Features
typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
headache (found in 85%)
jaw claudication (65%)
visual disturbances secondary to anterior ischemic optic neuropathy
tender, palpable temporal artery
features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
also lethargy, depression, low-grade fever, anorexia, night sweats
Investigations
raised inflammatory markers: ESR > 50 mm/hr (note ESR < 30 in 10% of patients). CRP may
also be elevated
temporal artery biopsy: skip lesions may be present
note creatine kinase and EMG normal
Treatment:
high-dose prednisolone - there should be a dramatic response, if not the diagnosis should be
reconsidered
urgent ophthalmology review. Patients with visual symptoms should be seen the same-day by
an ophthalmologist. Visual damage is often irreversible
Question 18 of 56
Which one of the following statements regarding macular degeneration is true?
Drusen are characteristic of wet macular degeneration

Photodynamic therapy is useful in dry macular degeneration
Asian ethnicity is a risk factor
Male sex is a risk factor
Wet macular degeneration carries the worst prognosis
Question 18 of 56
Which one of the following statements regarding macular degeneration is true?
Drusen are characteristic of wet macular degeneration

Photodynamic therapy is useful in dry macular degeneration
Asian ethnicity is a risk factor
Male sex is a risk factor
Wet macular degeneration carries the worst prognosis
External links
Webvision

Question 19 of 56
Tobacco
Methanol
Vitamin B12 deficiency
Lead
Zinc deficiency
Question 19 of 56
Tobacco
Methanol
Vitamin B12 deficiency
Lead
Zinc deficiency
Optic atrophy
Question 20 of 56
Which one of the following causes of Horner's syndrome is due to a central lesion?
Cavernous sinus thrombosis

Internal carotid aneurysm
Syringomyelia
Pancoast's tumour
Cervical rib
Question 20 of 56
Which one of the following causes of Horner's syndrome is due to a central lesion?
Cavernous sinus thrombosis

Internal carotid aneurysm
Syringomyelia
Pancoast's tumour
Cervical rib
Horner's syndrome - anhydrosis determines site of lesion:
head, arm, trunk = central lesion: stroke, syringomyelia
just face = pre-ganglionic lesion: Pancoast's, cervical rib
absent = post-ganglionic lesion: carotid artery
Horner's syndrome
Question 21 of 56
A 68-year-old man with a history of type 2 diabetes mellitus presens with worsening eye sight.
Mydriatic drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. A referral to
ophthalmology is made. Later in the evening whilst driving home he develops pain in his left eye
associated with decreased visual acuity. What is the most likely diagnosis?
Keratitis secondary to mydriatic drops

Question 21 of 56
A 68-year-old man with a history of type 2 diabetes mellitus presens with worsening eye sight.
Mydriatic drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. A referral to
ophthalmology is made. Later in the evening whilst driving home he develops pain in his left eye
associated with decreased visual acuity. What is the most likely diagnosis?
Keratitis secondary to mydriatic drops

Mydriatic drops are a known precipitant of acute angle closure glaucoma. This scenario is more
common in exams than clinical practice.
External links
Patient.info
Acute angle closure glaucoma review

Question 22 of 56
A 71-year-old with a history of type 2 diabetes mellitus and hypertension presents due to the sensation
of light flashes in his right eye. These symptoms have been present for the past 2 days and seem to
occur more at the peripheral part of vision. There is no redness or pain in the affected eye. Corrected
visual acuity is measured as 6/9 in both eyes. What is the most likely diagnosis?
Change in shape of eye secondary to variations in blood sugar

Vitreous detachment
Normal phenomenon in diabetic retinopathy
Normal phenomenon in healthy eyes
Question 22 of 56
A 71-year-old with a history of type 2 diabetes mellitus and hypertension presents due to the sensation
of light flashes in his right eye. These symptoms have been present for the past 2 days and seem to
occur more at the peripheral part of vision. There is no redness or pain in the affected eye. Corrected
visual acuity is measured as 6/9 in both eyes. What is the most likely diagnosis?
Change in shape of eye secondary to variations in blood sugar

Vitreous detachment
Normal phenomenon in diabetic retinopathy
Normal phenomenon in healthy eyes
Flashes and floaters - vitreous/retinal detachment.
Flashes and floaters are symptoms of vitreous detachment. The patient is at risk of retinal detachment
and should be referred urgently to an ophthalmologist
External links
Patient.info
Retinal artery occlusion

Question 23 of 56
A 67-year-old man presents as he has developed a painful blistering rash around his right eye. On
examination a vesicular rash covering the right trigeminal nerve dermatome is seen. Currently he has
no eye symptoms or signs. Which one of the following is most likely to predict future eye
involvement?
Presence of the rash on the tip of his nose

Smoking history
Increasing age
Previous courses of corticosteroids
Presence of the rash in the ear canal
Question 23 of 56
A 67-year-old man presents as he has developed a painful blistering rash around his right eye. On
examination a vesicular rash covering the right trigeminal nerve dermatome is seen. Currently he has
no eye symptoms or signs. Which one of the following is most likely to predict future eye
involvement?
Presence of the rash on the tip of his nose

Smoking history
Increasing age
Previous courses of corticosteroids
Presence of the rash in the ear canal
This is Hutchinson's sign which is strongly predictive for ocular involvement.

Question 24 of 56
Each one of the following is a cause of a mydriatic pupil, except:
Third nerve palsy

Atropine
Holmes-Adie pupil
Argyll-Robertson pupil
Traumatic iridoplegia
Question 24 of 56
Each one of the following is a cause of a mydriatic pupil, except:
Third nerve palsy

Atropine
Holmes-Adie pupil
Traumatic iridoplegia
Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis
and is often said to be the prostitute's pupil - accommodates but doesn't react. Another mnemonic used
for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex
Absent (PRA)
Features
small, irregular pupils
no response to light but there is a response to accommodate
Causes
diabetes mellitus
syphilis
Mydriasis
Question 25 of 56
A 45-year-old woman with Graves' disease comes for review. She has recently been diagnosed with
thyroid eye disease and is being considered for radiotherapy. Over the past three days her right eye has
become red and painful. On examination there is proptosis and erythema of the right eye. Visual acuity
is 6/9 in both eyes. What complication is she most likely to have developed?
Exposure keratopathy
Optic neuropathy
Carbimazole-related neutropaenia
Sjogren's Syndrome
Question 25 of 56
A 45-year-old woman with Graves' disease comes for review. She has recently been diagnosed with
thyroid eye disease and is being considered for radiotherapy. Over the past three days her right eye has
become red and painful. On examination there is proptosis and erythema of the right eye. Visual acuity
is 6/9 in both eyes. What complication is she most likely to have developed?
Exposure keratopathy
Optic neuropathy
Carbimazole-related neutropaenia
Sjogren's Syndrome
Thyroid eye disease

Thyroid eye disease affects between 25-50% of patients with Graves' disease.
Pathophysiology:
it is thought to be caused by an autoimmune response against an autoantigen, possibly the TSH
-orbital inflammation
the inflammation results in glycosaminoglycan and collagen deposition in the muscles
Prevention:
smoking is the most important modifiable risk factor for the development of thyroid eye
disease
radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye disease. In
a recent study of patients with Graves' disease around 15% developed, or had worsening of,
eye disease. Prednisolone may help reduce the risk
Features:
the patient may be eu-, hypo- or hyperthyroid at the time of presentation
exophthalmos
conjunctival oedema
optic disc swelling
ophthalmoplegia
inability to close the eye lids may lead to sore, dry eyes. If severe and untreated patients can be
at risk of exposure keratopathy
Management:
topical lubricants may be needed to help prevent corneal inflammation caused by exposure
steroids
radiotherapy
surgery.
Monitoring patients with established thyroid eye disease
For patients with established thyroid eye disease the following symptoms/signs should indicate
the need for urgent review by an ophthalmologist (see EUGOGO guidelines):
unexplained deterioration in vision
awareness of change in intensity or quality of colour vision in one or both eyes
history of eye suddenly 'popping out' (globe subluxation)
obvious corneal opacity
cornea still visible when the eyelids are closed
disc swelling
Question 26 of 56
Which one of the following is not a risk factor for primary open-angle glaucoma?
Diabetes mellitus
Family history
Hypertension
Afro-Caribbean ethnicity
Hypermetropia
Question 26 of 56
Which one of the following is not a risk factor for primary open-angle glaucoma?
Diabetes mellitus
Family history
Hypertension
Afro-Caribbean ethnicity
Hypermetropia
Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle
glaucoma is associated with myopia
Primary open-angle glaucoma
External links
NICE

Question 27 of 56
A 70-year-old man is investigated for blurred vision. Fundoscopy reveals drusen, retinal epithelial and
macular neovascularisation. A diagnosis of age related macular degeneration is suspected. What is the
most appropriate next investigation?
Vitreous fluid sampling

MRI orbits
Ocular tonometry
Fluorescein angiography
Kinetic perimetry
Question 27 of 56
A 70-year-old man is investigated for blurred vision. Fundoscopy reveals drusen, retinal epithelial and
macular neovascularisation. A diagnosis of age related macular degeneration is suspected. What is the
most appropriate next investigation?
Vitreous fluid sampling

MRI orbits
Ocular tonometry
Fluorescein angiography
Kinetic perimetry
External links
Webvision

Question 28 of 56
A 39-year-old male with a history of type 1 diabetes mellitus presents to his general practice with
diplopia. It exacerbates when looking right and improved upon covering the right eye.
What nerve is likely to be responsible?
Right optic nerve

Right trochlear
Right oculomotor
Right abducens
Left abducens
Question 28 of 56
A 39-year-old male with a history of type 1 diabetes mellitus presents to his general practice with
diplopia. It exacerbates when looking right and improved upon covering the right eye.
What nerve is likely to be responsible?
Right optic nerve

Right trochlear
Right oculomotor
Right abducens
Left abducens
covering the
right eye then the right abducens is affected as this controls the right lateral rectus and thus rightward
gaze.
Third nerve palsy

Question 29 of 56
During routine follow-up at renal clinic a man is noted to have corpuscular pigmentation of the left
retina. Which one of the following conditions is associated with retinitis pigmentosa?
Autosomal dominant polycystic kidney disease

Tuberous sclerosis
Von Hippel-Lindau syndrome
Alport's syndrome
Medullary sponge kidney
Question 29 of 56
During routine follow-up at renal clinic a man is noted to have corpuscular pigmentation of the left
retina. Which one of the following conditions is associated with retinitis pigmentosa?
Autosomal dominant polycystic kidney disease

Tuberous sclerosis
Von Hippel-Lindau syndrome
Alport's syndrome
Medullary sponge kidney
Question 30 of 56
An 84-year-old man presents with loss of vision in his left eye since the morning. He is otherwise
asymptomatic and of note has had no associated eye pain or headaches. His past medical history
includes ischaemic heart disease but he is otherwise well. On examination he has no vision in his left
eye. The left pupil responds poorly to light but the consensual light reaction is normal. Fundoscopy
reveals a red spot over a pale and opaque retina. What is the most likely diagnosis?
Retinal detachment
Question 30 of 56
An 84-year-old man presents with loss of vision in his left eye since the morning. He is otherwise
asymptomatic and of note has had no associated eye pain or headaches. His past medical history
includes ischaemic heart disease but he is otherwise well. On examination he has no vision in his left
eye. The left pupil responds poorly to light but the consensual light reaction is normal. Fundoscopy
reveals a red spot over a pale and opaque retina. What is the most likely diagnosis?
Retinal detachment
External links
Patient.info
Retinal artery occlusion

Question 31 of 56
Which one of the following is least recognised as a cause of tunnel vision?
Papilloedema
Choroidoretinitis
Glaucoma
Question 31 of 56
Which one of the following is least recognised as a cause of tunnel vision?
Papilloedema
Choroidoretinitis
Glaucoma
Tunnel vision
Question 32 of 56
A 70-year-old woman presents with loss of vision in her left eye. For the past two weeks she has
painful frontal headaches and has been feeling generally lethargic. On examination visual acuity is 6/9
in the right eye but on the left side only hand movements can be made seen. Fundoscopy of the left
side reveals a pale and oedematous optic disc. What is the most likely diagnosis?.

Multiple sclerosis
Methanol poisoning
Temporal arteritis
Question 32 of 56
A 70-year-old woman presents with loss of vision in her left eye. For the past two weeks she has
painful frontal headaches and has been feeling generally lethargic. On examination visual acuity is 6/9
in the right eye but on the left side only hand movements can be made seen. Fundoscopy of the left
side reveals a pale and oedematous optic disc. What is the most likely diagnosis?.

Multiple sclerosis
Methanol poisoning
Temporal arteritis
This patient has likely developed anterior ischemic optic neuropathy on the left side
Temporal arteritis
damaging others.
Features
Investigations:
also be elevated
Treatment:
reconsidered
an ophthalmologist. Visual damage is often irreversible.
Question 33 of 56
A 52-year-old old man who has a history of alcohol excess is brought to the Emergency Department
by paramedics. He is a frequent attender and this time has a laceration on his scalp following a fall.
Whilst examining him he seems confused and complains of problems with his vision. Which one of
the following is the most commonly found ocular abnormality in patients with Wernicke's
encephalopathy?
Ophthalmoplegia
Lateral rectus palsy
Nystagmus
Mydriasis
Scotomata
Question 33 of 56
A 52-year-old old man who has a history of alcohol excess is brought to the Emergency Department
by paramedics. He is a frequent attender and this time has a laceration on his scalp following a fall.
Whilst examining him he seems confused and complains of problems with his vision. Which one of
the following is the most commonly found ocular abnormality in patients with Wernicke's
encephalopathy?
Ophthalmoplegia
Lateral rectus palsy
Nystagmus
Mydriasis
Scotomata
Wernicke's encephalopathy
Question 34 of 56
Which one of the following is not a feature of background diabetic retinopathy?
Microaneurysms
Blot haemorrhages
Cotton wool spots
Seen in both type 1 and type 2 diabetes mellitus
Hard exudates
Question 34 of 56
Which one of the following is not a feature of background diabetic retinopathy?
Microaneurysms
Blot haemorrhages
Cotton wool spots
Seen in both type 1 and type 2 diabetes mellitus
Hard exudates
Cotton wool spots are seen in pre-proliferative retinopathy
Diabetic retinopathy
-65 years-old.
Hyperglycaemia is thought to cause increased retinal blood flow and abnormal metabolism in the
retinal vessel walls. This precipitates damage to endothelial cells and pericytes.
exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms.

Neovasculization is thought to be caused by the production of growth factors in response to retinal
ischaemia
eristic features of the various stages/types
of diabetic retinopathy.
Recently a new classification system has been proposed, dividing patients into those with non-
proliferative diabetic retinopathy (NPDR) and those with proliferative retinopathy (PDR):
Traditional classification New classification

Background retinopathy: Mild NPDR
microaneurysms (dots) 1 or more microaneurysm
blot haemorrhages (<=3) Moderate NPDR
hard exudates
microaneurysms
Pre-proliferative retinopathy blot haemorrhages
cotton wool spots (soft hard exudates
exudates; ischaemic nerve cotton wool spots, venous beading/looping and
fibres) intraretinal microvascular abnormalities (IRMA)
> 3 blot haemorrhages less severe than in severe NPDR.
venous beading/looping
deep/dark cluster haemorrhages Severe NPDR
more common in Type I DM, blot haemorrhages and microaneurysms in 4
treat with laser quadrants
photocoagulation venous beading in at least 2 quadrants
IRMA in at least 1 quadrant
Proliferative retinopathy
retinal neovascularisation - may lead to vitrous haemorrhage
fibrous tissue forming anterior to retinal disc
more common in Type I DM, 50% blind in 5 years
Maculopathy
based on location rather than severity, anything is potentially serious
hard exudates and other 'background' changes on macula
check visual acuity
more common in Type II DM
External links
Birmingham University
Diabetic retinopathy tutorial with fundoscopy images

Question 35 of 56
A 24-year-old man presents to the emergency department complaining of left eye pain. He has not
been able to wear his contact lenses for the past 24 hours due to the pain. He describes the pain as
severe and wonders whether he has 'got something stuck in his eye'. On examination there is diffuse
hyperaemia of the left eye. The left cornea appears hazy and pupillary reaction is normal. Visual
acuity is reduced on the left side and a degree of photophobia is noted. A hypopyon is also seen. What
is the most likely diagnosis?

Viral conjunctivitis
Keratitis
Episcleritis
Anterior uveitis
Question 35 of 56
A 24-year-old man presents to the emergency department complaining of left eye pain. He has not
been able to wear his contact lenses for the past 24 hours due to the pain. He describes the pain as
severe and wonders whether he has 'got something stuck in his eye'. On examination there is diffuse
hyperaemia of the left eye. The left cornea appears hazy and pupillary reaction is normal. Visual
acuity is reduced on the left side and a degree of photophobia is noted. A hypopyon is also seen. What
is the most likely diagnosis?

Viral conjunctivitis
Keratitis
Episcleritis
Anterior uveitis
Whilst a hypopyon can of course be seen in anterior uveitis the combination of a normal pupillary
reaction and contact lens use make a diagnosis of keratitis more likely.
Keratitis
Question 36 of 56
Each one of the following predisposes to cataract formation, except:
Down's syndrome
Hypercalcaemia
Diabetes mellitus
Long-term steroid use
Uveitis
Question 36 of 56
Each one of the following predisposes to cataract formation, except:
Down's syndrome
Hypercalcaemia
Diabetes mellitus
Long-term steroid use
Uveitis
Cataracts
Question 37 of 56
A 65-year-old woman presents to the Emergency Department with visual problems. She has
rheumatoid arthritis, depression and takes medication to control her blood pressure. Over the past few
days she has been getting troublesome headaches and blurred vision but today has noted a marked
reduction in vision in the right eye. On examination her right eye is red, has a sluggish pupil and a
corrected visual acuity 6/30. Her medication has recently been changed. Which one of the following
drugs is most likely to have precipitated this event?
Methotrexate
Doxazosin
Amitriptyline
Atenolol
Bendroflumethiazide
Question 37 of 56
A 65-year-old woman presents to the Emergency Department with visual problems. She has
rheumatoid arthritis, depression and takes medication to control her blood pressure. Over the past few
days she has been getting troublesome headaches and blurred vision but today has noted a marked
reduction in vision in the right eye. On examination her right eye is red, has a sluggish pupil and a
corrected visual acuity 6/30. Her medication has recently been changed. Which one of the following
drugs is most likely to have precipitated this event?
Methotrexate
Doxazosin
Amitriptyline
Atenolol
Bendroflumethiazide
Drugs which may precipitate acute glaucoma include anticholinergics and tricyclic antidepressants
External links
Patient.info
Acute angle closure glaucoma review

Question 38 of 56
Which one of the following is associated with heterochromia in congenital disease?
Holmes-Adie pupil
Third nerve palsy
Sixth nerve palsy
Horner's syndrome
Question 38 of 56
Which one of the following is associated with heterochromia in congenital disease?
Holmes-Adie pupil
Third nerve palsy
Sixth nerve palsy
Horner's syndrome
Horner's syndrome
Features
miosis (small pupil).
ptosis.
enophthalmos* (sunken eye).
anhidrosis (loss of sweating one side).
Distinguishing between causes:
heterochromia (difference in iris colour) is seen in congenital Horner's
anhidrosis: see below.
Central lesions Pre-ganglionic lesions Post-ganglionic lesions

Anhidrosis of the face, arm and trunk Anhidrosis of the face No anhidrosis
Stroke Pancoast's tumour Carotid artery dissection
Syringomyelia Thyroidectomy Carotid aneurysm
Multiple sclerosis Trauma Cavernous sinus thrombosis
Tumour Cervical rib Cluster headache
Encephalitis
*in reality the appearance is due to a narrow palpebral aperture rather than true enophthalmos
Question 39 of 56
A 64-year-old woman with type 2 diabetes mellitus presents as she has started to bump into things
since the morning. Over the previous two days she had noticed some 'floating spots in her eyes'.
Examination reveals she has no vision in her right eye. The red reflex on the right side is difficult to
elicit and you are unable to visualise the retina on the right side during fundoscopy. Examination of
the left fundus reveals changes consistent with pre-proliferative diabetic retinopathy. What is the
Occlusion of central retinal vein

Cataract
Retinal detachment
Question 39 of 56
A 64-year-old woman with type 2 diabetes mellitus presents as she has started to bump into things
since the morning. Over the previous two days she had noticed some 'floating spots in her eyes'.
Examination reveals she has no vision in her right eye. The red reflex on the right side is difficult to
elicit and you are unable to visualise the retina on the right side during fundoscopy. Examination of
the left fundus reveals changes consistent with pre-proliferative diabetic retinopathy. What is the

Cataract
Retinal detachment
The history of diabetes, complete loss of vision in the affected eye and inability to visualise the retina
point towards a diagnosis of vitreous haemorrhage. Please see the table below for help in
differentiating retinal detachment from vitreous haemorrhage.
External links
Patient.info

Question 40 of 56
A 72-year-old woman presents with a vesicular rash around her left eye. The left eye is red and there is
a degree of photophobia. A presumptive diagnosis of herpes zoster ophthalmicus is made and an
urgent referral to ophthalmology is made. What treatment is she most likely to be given?
Oral aciclovir + topical aciclovir

Intravenous aciclovir + topical aciclovir
Oral famciclovir + topical aciclovir
Topical aciclovir
Oral aciclovir
Question 40 of 56
A 72-year-old woman presents with a vesicular rash around her left eye. The left eye is red and there is
a degree of photophobia. A presumptive diagnosis of herpes zoster ophthalmicus is made and an
urgent referral to ophthalmology is made. What treatment is she most likely to be given?
Oral aciclovir + topical aciclovir

Intravenous aciclovir + topical aciclovir
Oral famciclovir + topical aciclovir
Topical aciclovir
Oral aciclovir

Question 41 of 56
An 80-year-old woman presents with 'funny spots' affecting her vision. Over the past week she has
noticed a number of flashes and floaters in the visual field of the right eye. What is the most likely
diagnosis?
Retinal detachment
Posterior vitreous detachment
Optic neuritis
Depression
Question 41 of 56
An 80-year-old woman presents with 'funny spots' affecting her vision. Over the past week she has
noticed a number of flashes and floaters in the visual field of the right eye. What is the most likely
diagnosis?
Retinal detachment
Posterior vitreous detachment
Optic neuritis
Depression
-75% of the population over 65 years

and is the most likely diagnosis here. Such patients are normally reviewed by an ophthalmologist to
assess the risk of progressing to retinal detachment.
External links
Patient.info

Question 42 of 56
A 71-year-old female with dry age-related macular degeneration is reviewed. Unfortunately her
eyesight has deteriorated over the past six months. She has never smoked and is taking antioxidant
supplements. What is the most appropriate next step?
Retinal transplant
Intravitreal ranibizumab
Explain no other medical therapies currently available
Photodynamic therapy
Photocoagulation
Question 42 of 56
A 71-year-old female with dry age-related macular degeneration is reviewed. Unfortunately her
eyesight has deteriorated over the past six months. She has never smoked and is taking antioxidant
supplements. What is the most appropriate next step?
Retinal transplant
Intravitreal ranibizumab
Explain no other medical therapies currently available
Photodynamic therapy
Photocoagulation
External links
Webvision

Question 43 of 56
Which one of the following statements regarding the Holmes-Adie pupil is incorrect?
May be associated with absent ankle/knee reflexes

Bilateral in 80% of cases
It is a benign condition
Slowly reactive to accommodation but very poorly (if at all) to light
Causes a dilated pupil
Question 43 of 56
Which one of the following statements regarding the Holmes-Adie pupil is incorrect?
May be associated with absent ankle/knee reflexes

Bilateral in 80% of cases
It is a benign condition
Slowly reactive to accommodation but very poorly (if at all) to light
Causes a dilated pupil
The Holmes-Adie pupil is unilateral, rather than bilateral, in 80% of patients.
Holmes-Adie pupil
Question 44 of 56
Which one of the following features is not characteristic of optic neuritis?
Eye pain worse on movement

Poor discrimination of colours, 'red desaturation'
Sudden onset of visual loss
Central scotoma
Question 44 of 56
Which one of the following features is not characteristic of optic neuritis?
Eye pain worse on movement

Poor discrimination of colours, 'red desaturation'
Sudden onset of visual loss
Central scotoma
Visual loss typically occurs over days rather than hours. Sudden visual loss due to optic neuritis
is very unusual.
Optic neuritis
Question 45 of 56
A 69-year-old man presents to the Emergency Department with blurred vision. The examining doctor
suspects a diagnosis of primary open-angle glaucoma (POAG). Which one of the following features
would be most consistent with a diagnosis of POAG?
Symptoms worse with mydriasis

Eye pain
Semi-dilated non-reacting pupil
Loss of nasal visual field
Red eye
Question 45 of 56
A 69-year-old man presents to the Emergency Department with blurred vision. The examining doctor
suspects a diagnosis of primary open-angle glaucoma (POAG). Which one of the following features
would be most consistent with a diagnosis of POAG?
Symptoms worse with mydriasis

Eye pain
Semi-dilated non-reacting pupil
Loss of nasal visual field
Red eye
The other listed symptoms are seen with acute angle closure glaucoma
Primary open-angle glaucoma
External links
NICE

Question 46 of 56
A 74-year-old man presents with a severe throbbing headache on the right side of his head. He has
now had this pain for around 6-7 days but reports no obvious trigger. There have been no visual
disturbances or episodes of limb weakness. Neurological examination is unremarkable. The right side
of his head is tender to touch but he cannot remember falling. Given the likely diagnosis what is the
most important initial step?
Give high-dose oral prednisolone

Arrange an urgent orbital x-ray for suspected blow-out fracture
Arrange an urgent temporal artery biopsy
Arrange an urgent CT head
Ocular pilocarpine + intravenous acetazolamide
Question 46 of 56
A 74-year-old man presents with a severe throbbing headache on the right side of his head. He has
now had this pain for around 6-7 days but reports no obvious trigger. There have been no visual
disturbances or episodes of limb weakness. Neurological examination is unremarkable. The right side
of his head is tender to touch but he cannot remember falling. Given the likely diagnosis what is the
most important initial step?
Give high-dose oral prednisolone

Arrange an urgent orbital x-ray for suspected blow-out fracture
Arrange an urgent temporal artery biopsy
Arrange an urgent CT head
Ocular pilocarpine + intravenous acetazolamide
This patient has temporal arteritis and requires high-dose oral steroids to prevent ocular complications
Temporal arteritis
damaging others.
Features:

Investigations
also be elevated
Treatment
reconsidered
an ophthalmologist. Visual damage is often irreversible
Question 47 of 56
A 47-year-old female with a history of rheumatoid arthritis presents with a painful and red left eye.
Visual acuity is normal. Fundoscopy is also unremarkable. What is the most likely diagnosis?
Scleritis
Episcleritis
Glaucoma
Anterior uveitis
Keratoconjunctivitis sicca
Question 47 of 56
A 47-year-old female with a history of rheumatoid arthritis presents with a painful and red left eye.
Visual acuity is normal. Fundoscopy is also unremarkable. What is the most likely diagnosis?
Scleritis
Episcleritis
Glaucoma
Anterior uveitis
Keratoconjunctivitis sicca
Scleritis is painful, episcleritis is not painful.
A key way to discriminate between scleritis and episcleritis is the presence of pain.
Keratoconjunctivitis sicca is usually bilateral and associated more with dryness, burning and
itch.
Rheumatoid arthritis: ocular manifestations

Question 48 of 56
A 43-year-old who is noted to have a high-arched palate, arachnodactyly and a late-systolic murmur
presents with visual problems. Which one of the following eye disorders is most associated with his
underlying condition?
Superotemporal ectopia lentis

Inferonasal ectopia lentis
Acute glaucoma
Retinal detachment
Question 48 of 56
A 43-year-old who is noted to have a high-arched palate, arachnodactyly and a late-systolic murmur
presents with visual problems. Which one of the following eye disorders is most associated with his
underlying condition?
Superotemporal ectopia lentis

Inferonasal ectopia lentis
Acute glaucoma
Retinal detachment
are seen they are not as common as superotemporal ectopia lentis (upwards lens dislocation), which is
seen in around 50% of patients. Inferonasal ectopia lentis is characteristic of homocystinuria
-systolic murmur. This feature helps distinguish the above
description from that of a patient with homocystinuria
Marfan's syndrome
Marfan's syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the
fibrillin-1 gene on chromosome 15 and affects around 1 in 3,000 people.
Features:
tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly
pectus excavatum
pes planus
scoliosis of > 20 degrees
heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic
dissection, aortic regurgitation, mitral valve prolapse (75%),
lungs: repeated pneumothoraces
eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
dural ectasia (ballooning of the dural sac at the lumbosacral level)
The life expectancy of patients used to be around 40-50 years. With the advent of regular
echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly
over recent years. Aortic dissection and other cardiovascular problems remain the leading cause of
death however.
Question 49 of 56
A 40-year-old man presents with bilateral dry, gritty eyes. A diagnosis of blepharitis is considered.
Which one of the following is least likely to be associated with blepharitis?
Meibomian gland dysfunction

Seborrhoeic dermatitis
Staphylococcal infection
Acne rosacea
Viral upper respiratory tract infection
Question 49 of 56
A 40-year-old man presents with bilateral dry, gritty eyes. A diagnosis of blepharitis is considered.
Which one of the following is least likely to be associated with blepharitis?
Meibomian gland dysfunction

Seborrhoeic dermatitis
Staphylococcal infection
Acne rosacea
Viral upper respiratory tract infection
Blepharitis
External links
Blepharitis guidelines
Question 50 of 56
Which one of the following best describes the action of latanoprost in the management of
primary open-angle glaucoma?
Carbonic anhydrase inhibitor

Reduces aqueous production + increases outflow
Opens up drainage pores
Increases uveoscleral outflow
Reduces aqueous production
Question 50 of 56
Which one of the following best describes the action of latanoprost in the management of
primary open-angle glaucoma?

Reduces aqueous production + increases outflow
Opens up drainage pores
Increases uveoscleral outflow
Reduces aqueous production
External links
Glaucoma guidelines
Question 51 of 56
A 25-year-old woman presents with a one-day history of a painful and red left eye. She describes how
her eye is continually streaming tears. On examination she exhibits a degree of photophobia in the
affected eye and application of fluorescein demonstrates a dendritic pattern of staining. Visual acuity
is 6/6 in both eyes. What is the most appropriate management?
Topical steroid
Perform a lumbar puncture
Treat with subcutaneous sumatriptan
Topical aciclovir
Topical chloramphenicol
Question 51 of 56
A 25-year-old woman presents with a one-day history of a painful and red left eye. She describes how
her eye is continually streaming tears. On examination she exhibits a degree of photophobia in the
affected eye and application of fluorescein demonstrates a dendritic pattern of staining. Visual acuity
is 6/6 in both eyes. What is the most appropriate management?
Topical steroid
Perform a lumbar puncture
Treat with subcutaneous sumatriptan
Topical aciclovir
Topical chloramphenicol
This patient has a dendritic corneal ulcer. Topical aciclovir and ophthalmology review is required.
Giving a topical steroid in this situation could be disastrous as it may worsen the infection.
Herpes simplex keratitis

Question 52 of 56
A 24-year-old man who has a family history of retinitis pigmentosa is reviewed in the ophthalmology
clinic. He reports worsening vision over the past few months. During fundoscopy, which of the
following findings with most support a diagnosis of retinitis pigmentosa?
Pigmented scrambled egg appearance concentrated around the macula

Central irregular pigmentation with bull's eye maculopathy
Black bone spicule-shaped pigmentation in the peripheral retina
Drusen with haemorrhagic atrophic changes concentrated at the periphery of the retina
Pigmented choroidal neovascularisation throughout the retina
Question 52 of 56
A 24-year-old man who has a family history of retinitis pigmentosa is reviewed in the ophthalmology
clinic. He reports worsening vision over the past few months. During fundoscopy, which of the
following findings with most support a diagnosis of retinitis pigmentosa?
Pigmented scrambled egg appearance concentrated around the macula

Central irregular pigmentation with bull's eye maculopathy
Black bone spicule-shaped pigmentation in the peripheral retina
Drusen with haemorrhagic atrophic changes concentrated at the periphery of the retina
Pigmented choroidal neovascularisation throughout the retina
Question 53 of 56
A 45-year-old woman who has a history of Graves' disease presents with visual problems. She is
known to have Graves' ophthalmopathy and does not currently smoke. Her most recent thyroid
function tests are shown below:
Free T4 15 pmol/l
TSH 1.6 mu/l
Which one of the following features is the strongest indicator of the need for urgent
ophthalmology review?
Sensitivity of eyes to light

Diplopia
Troublesome eyelid retraction
Awareness of change in intensity or quality of colour vision
Erythema of the conjunctiva
Question 53 of 56
A 45-year-old woman who has a history of Graves' disease presents with visual problems. She is
known to have Graves' ophthalmopathy and does not currently smoke. Her most recent thyroid
function tests are shown below:
Free T4 15 pmol/l
TSH 1.6 mu/l
Which one of the following features is the strongest indicator of the need for urgent
ophthalmology review?
Sensitivity of eyes to light

Diplopia
Troublesome eyelid retraction
Awareness of change in intensity or quality of colour vision
Erythema of the conjunctiva
The other symptoms/signs indicate the need for non-urgent review by an opthalmologist. Please see
the EUGOGO guidelines for more details.
Thyroid eye disease
Thyroid eye disease affects between 25-50% of patients with Graves' disease.
Pathophysiology
it is thought to be caused by an autoimmune response against an autoantigen, possibly the TSH

-orbital inflammation
the inflammation results in glycosaminoglycan and collagen deposition in the muscles
Prevention
smoking is the most important modifiable risk factor for the development of thyroid eye
disease
radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye disease. In
a recent study of patients with Graves' disease around 15% developed, or had worsening of,
eye disease. Prednisolone may help reduce the risk
Features
the patient may be eu-, hypo- or hyperthyroid at the time of presentation
exophthalmos
conjunctival oedema
optic disc swelling
ophthalmoplegia
inability to close the eye lids may lead to sore, dry eyes. If severe and untreated patients can be
at risk of exposure keratopathy
Management
topical lubricants may be needed to help prevent corneal inflammation caused by exposure
steroids
radiotherapy
surgery
Monitoring patients with established thyroid eye disease:
For patients with established thyroid eye disease the following symptoms/signs should indicate the
need for urgent review by an ophthalmologist (see EUGOGO guidelines):
unexplained deterioration in vision
awareness of change in intensity or quality of colour vision in one or both eyes
history of eye suddenly 'popping out' (globe subluxation)
obvious corneal opacity
cornea still visible when the eyelids are closed
disc swelling
External links
Consensus Statement of the European Group on Graves' Orbitopathy
Management of Graves' Orbitopathy

Question 54 of 56
A 65-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss
of vision in his right eye. On examination of the right eye the optic disc is swollen with multiple
flame-shaped and blot haemorrhages. What is the most likely diagnosis?
Occlusion of central retinal artery
Question 54 of 56
A 65-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss
of vision in his right eye. On examination of the right eye the optic disc is swollen with multiple
flame-shaped and blot haemorrhages. What is the most likely diagnosis?
Occlusion of central retinal artery
Central retinal vein occlusion - sudden painless loss of vision, severe retinal haemorrhages on
fundoscopy
External links
Patient.info 00

Question 55 of 56
A 71-year-old man who has recently been diagnosed with macular degeneration asks for advice
regarding antioxidant dietary supplements. Which one of the following may contraindicate the
prescription of such supplements?
Current smoker
Pernicious anaemia
Treated hypertension
History of depression
Previous episodes of tendonitis
Question 55 of 56
A 71-year-old man who has recently been diagnosed with macular degeneration asks for advice
regarding antioxidant dietary supplements. Which one of the following may contraindicate the
prescription of such supplements?
Current smoker
Pernicious anaemia
Treated hypertension
History of depression
Previous episodes of tendonitis
Beta-carotene has been found to increase the risk of lung cancer and hence antioxidant dietary
supplements are not recommended for smokers.
External links
Webvision

Question 56 of 56
A 67-year-old man who is known to have raised intraocular pressure is prescribed dorzolamide eye
drops. What is the mechanism of action of this drug?
Prostaglandin analogue
Alpha2-adrenoceptor agonist
Muscarinic receptor agonist
Beta-blocker
Question 56 of 56
A 67-year-old man who is known to have raised intraocular pressure is prescribed dorzolamide eye
drops. What is the mechanism of action of this drug?
Prostaglandin analogue
Alpha2-adrenoceptor agonist
Muscarinic receptor agonist
Beta-blocker
External links
Glaucoma guidelines

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Relationship with Korsakoff syndrome

Wet age-related macular degeneration

Wet age-related macular degeneration

Drusen = Dry macular degeneration

Discuss and give feedback

Age related macular degeneration

Age related macular degeneration fundoscopy findings

Which one of the following is associated with the Holmes-Adie pupil?

Decreased ankle reflexes

Which one of the following is associated with the Holmes-Adie pupil?

Decreased ankle reflexes

Holmes ADIe = DIlated pupil, females, absent leg reflexes

Discuss and give feedback

Ramsay Hunt syndrome

Ramsay Hunt syndrome

Discuss and give feedback

Herpes zoster ophthalmicus

Discuss and give feedback

Right optic neuritis

What is the most likely diagnosis?

Right optic neuritis

g optic neuritis is the likely underlying diagnosis. Optic

Discuss and give feedback

Relative afferent pupillary defect

Relative afferent pupillary defect tutorial

Discuss and give feedback

Angioid retinal streaks

Topical chloramphenicol + mechanical removal of lid debris

Topical chloramphenicol + mechanical removal of lid debris

Discuss and give feedback

Clinical Knowledge Summaries

Macular degeneration - smoking is risk factor

Discuss and give feedback

Age related macular degeneration

Age related macular degeneration fundoscopy findings

A 34-year-old man is referred to ophthalmology following a deterioration in his vision. He is noted to

A 34-year-old man is referred to ophthalmology following a deterioration in his vision. He is noted to

Discuss and give feedback

Ischaemic optic neuropathy

Ischaemic optic neuropathy

Discuss and give feedback

Sudden painless loss of vision

Central Retinal Vein Occlusion

Red eye - glaucoma or uveitis?

glaucoma: severe pain, haloes, 'semi-dilated' pupil

uveitis: small, fixed oval pupil, ciliary flush

Discuss and give feedback

A prostaglandin analogue should be used first-line in patients with a history of asthma.

Discuss and give feedback

Primary open-angle glaucoma: management

Clinical Knowledge Summaries

2009 Glaucoma guidelines

Reassure the patient

Reassure the patient

Discuss and give feedback

Charles Bonnet syndrome

Discuss and give feedback

Lacrimal duct problems