ORY >» ID © Pu B 11:52 Question 1 of 1 A patient presents with a first episode of a painful reduction in visual acuity in one eye. The acuity is 6/60, ocular movements produce pain and the optic disc is normal. Which one of the following investigations supports the diagnosis of optic neuritis? A Abnormal visual evoked potentials (VEP) B Abnormal electroretinogram CERG) Cc Abnormal electro-oculogram (EOG) D Abnormal electroencephalogram (EEG)ID! © WP ua & 11:54 Question 1 of 1 Abnormal visual evoked potentials (VEP) In optic neuritis, demyelination causes a reduction in the velocity of the propagation of action potentials and so the VEP response is delayed. The ERG is normal as the retina is unaffected. B Abnormal electroretinogram (ERG) Abnormal electroretinogram is incorrect. The ERG measures retinal electrical activity and is often used to validate the significance of an abnormal VEP response Cie if the VEP is abnormal but so is the ERG, then the VEP abnormality might be secondary to an eye condition and be a false- positive for optic nerve disease).Oo RY (OD © F i 11:54 Question 1 of 1 Cc Abnormal electro-oculogram (EOG) Abnormal electro-oculogram is incorrect. The EOG measures the overall electrical activity of the eye and is reduced in degenerative eye conditions affecting the pigment epithelial layer, such as Best’s disease. D Abnormal electroencephalogram (EEG) Abnormal electroencephalogram is incorrect. An EEG is not an optimal investigation for assessing vision impairment. Ee Abnormal electronystagmogram (ENG) Abnormal electronystagmogram is inerarract Tha ENIC ic cimnily a mathnnORY >» ID © Pu OB 11:55 Question 1 of 75 A patient is being referred to the eye clinic with suspected early diabetic retinopathy. Which one of the following tests, if abnormal, most strongly supports the diagnosis? A Electroretinography B Fluorescein angiography Cc B-scan ultrasound D Visual evoked potentials (VEP) E Intraocular pressureVv >} ID © Pu OB 11:56 a < Question 1 of 75 Fluorescein angiography The earliest sign of diabetic retinopathy is the presence of micro- aneurysms. This is usually a clinical diagnosis with a simple fundal examination and/or fundal photographs. However, of the above options, micro-aneurysms may be seen clearly on fluorescein angiography as small areas of leakage. A Electroretinography Electroretinography (ERG) is incorrect. Electroretinography is not classically performed in any stage of diabetic retinopathy, as the diagnosis may be made clinically with or without fluorescein angiography. It would be unlikely to add any value unless there is doubt regarding the cause of retinal findings.vb ID © Wu OB 11:56 a < Question 1 of 75 Cc B-scan ultrasound B-scan ultrasound is incorrect. B-scan ultrasound is particularly useful in examining the vitreous and the vitreo- retinal interface. It is not used to diagnose diabetic retinopathy. It is typically used in diabetic patients in the presence of vitreous haemorrhage, to exclude a retinal detachment, but would not be used to identify micro- aneurysms and early diabetic changes. D Visual evoked potentials (VEP) Visual evoked potentials (VEP) is incorrect. This test measures the electrical signal over the occipital cortex in response to a light stimulus, evaluating the afferent visual pathway. It is typically used to diagnose optic nerve dysfunction, demyelination and albinism. It has no role in the diagnosis1 Rv ID © Pu OB 11:56 9: (= @ mypastest.pastestcom ® : Question 1 of 75 nerve dysfunction, demyelination and albinism. It has no role in the diagnosis of diabetic retinopathy. E Intraocular pressure Intraocular pressure is incorrect. Intraocular pressure (IOP) is not used to diagnose diabetic retinopathy. IOP may become useful in the later stages of diabetic retinopathy where there is a concern regarding neovascularisation of the angle, or when considering steroid treatments for maculopathy. Rate this question: ©ORY >» ID © PY sf & 12:02 < Question 2 of 75 A 72-year-old woman presents to the Emergency Department with a one- week history of double vision when looking to the right. When she looks straight at you the right eye appears deviated medially. Apart from a mild headache at the onset of her symptoms, she otherwise feels well. Past medical history includes controlled hypertension and hypercholesterolaemia. She is a non- smoker. Ocular movements demonstrate a failure of the right eye to abduct beyond the midline and confirm symptomatic diplopia when looking to the right. All other movements appear normal, and a full neurological examination reveals no further abnormality. Pupil reactions are normal. There is no ptosis. Visual acuities are normal. Cardiovascular examination is normal, with a blood pressure of 124/86 mmHg.Oo RY ‘OD © Y 6 @ 12:02 CxXd GUO O al, pressure of 124/86 mmHg. Which one of the following is the most likely diagnosis? A Duane syndrome Ww Myasthenia gravis D Thyroid eye disease E Cerebral infarct Explanation %ORY >» ID © PY .6 & 12:03 Question 2 of 75 Failure of adduction of the right eye is consistent with a lateral rectus palsy. There are no other neurological deficits mentioned in the scenario, suggesting an isolated sixth nerve palsy. This is commonly caused by microvascular disease, with diabetes, hypertension and hyperlipidaemia known risk factors. The patient should be followed up to ensure resolution over 6-12 weeks. If there is no improvement, neuroimaging is advised to exclude compressive causes. A Duane syndrome Duane syndrome is incorrect. Duane syndrome is a congenital condition and thus commonly presents in childhood. Acute onset of double vision, as in this adiilt natieant ic not ciriqqective ofORY >» ID © PY .6 & 12:03 adult patient, is not suggestive of Duane syndrome. There is failure of abduction of the affected eye, with retraction of the globe on adduction and narrowing of the palpebral fissure. Adduction may also be affected in type 2 or 3 Duane syndrome. B Myasthenia gravis Myasthenia gravis is incorrect. Myasthenia gravis may manifest as a sixth nerve palsy, and should be considered as a differential diagnosis. However, there is usually ptosis which is not present here. In view of the patient’s microvascular risk factors and absence of other neurological deficits, an isolated sixth nerve palsy is more likely. D Thyroid eye diseaseORY >» ID © PY .6 & 12:03 absence of other neurological deficits, an isolated sixth nerve palsy is more likely. D Thyroid eye disease Thyroid eye disease is incorrect. This may cause restriction of movement of extra-ocular muscles. However, the inferior rectus is more commonly affected with restricted upgaze. E Cerebral infarct Cerebral infarct is incorrect. There are no other neurological deficits, which makes the diagnosis of a cerebral infarct less plausible as a sixth nerve palsy is unlikely to occur in isolation. Rate this question: ©ORY >» ID © PY so & 12:04 Question 3 of 75 A 23-year-old woman presents to the Dermatology Department with a 6- month history of unilateral eyelid dermatitis. There are no other symptoms of allergy. Her serum IgE is normal. Which one of the following is the patient most likely to be allergic to? A Dermatophagoides B Egg white Cc Mascara D Nail varnish E PeanutORY >» IO! © GY 46 & 12:12 < Question 3 of 75 | | Nail varnish Unilateral dermatitis points to a focal cause (contact). Absent-minded contact between the nails and the lids causes this diagnostic conundrum. Mascara Mascara is incorrect. Mascara, or more commonly of late, fake eyelashes cause bilateral eyelid swelling. A Dermatophagoides Dermatophagoides is incorrect. Dermatophagoides causes a systemic reaction. B Egg white ECan wrhita ic innnrrart ECan wrhitacVv >} ID © PY wf OB 12:13 a < Question 3 of 75 Dermatophagoides Dermatophagoides is incorrect. Dermatophagoides causes a systemic reaction. B Egg white Egg white is incorrect. Egg whites cause a systemic reaction. E Peanut Peanut is incorrect. Peanuts cause a systemic reaction. Rate this question: © Previous Question Tag QuestionOo AY iD © W uA 0 2:53 OQ = @ mypastestpastestcom @ : < Question 4 of 75 A 22-year-old man with ulcerative colitis and chronic lower back pain complains of a red and painful eye. Which one of the following is likely to be present on examination of his eyes? A Purulent discharge B Cells in the anterior chamber Cc A dilated pupil D Profound visual loss E Retinal haemorrhagesMv ID! © W ué | 2:54 a < Question 4 of 75 Cells in the anterior chamber Patients with ulcerative colitis and possibly ankylosing spondylitis have a higher risk of anterior uveitis, due to the HLA-B27 association. Anterior uveitis on examination manifests as conjunctival injection, cells and flare in the anterior chamber and photophobia. There may or may not be keratic precipitates, fibrin, synechiae and a hypopyon. A Purulent discharge Purulent discharge is incorrect. Purulent discharge is a feature of conjunctivitis, usually bacterial. The eye may be uncomfortable but is not usually painful. Cc A dilated pupilOo AY (O' © W uA 0 2:55 Question 5 of 75 An 82-year-old woman presents with sudden loss of vision in her left eye. On further questioning, she complains of a left-sided headache over the past few weeks, associated with tenderness of her head when she brushes her hair. On examination, her vision is reduced to counting fingers in the left eye. A left relative afferent pupillary defect is present. Fundoscopy reveals a pale, swollen left optic disc with some flame-shaped haemorrhages. The right eye is entirely normal. An urgent erythrocyte sedimentation rate (ESR) is elevated at 72 mm/h. Which one of the following management options should be carried out first? A Temporal artery biopsy B Ophthalmic outpatient reviewOo AY (O' © W uA 0 2:55 < Question 5 of 75 erythrocyte sedimentation rate (ESR) is elevated at 72 mm/h. Which one of the following management options should be carried out first? A Temporal artery biopsy B Ophthalmic outpatient review Cc Administration of high-dose systemic steroids D Automated visual field assessment E Computed tomography (CT) scan of brain and orbitsOoeRmv iD! © W uf & 3:00 < Question 5 of 75 The symptoms and signs, coupled with an elevated ESR, are consistent with a diagnosis of giant cell arteritis (GCA) or arteritic ischaemic optic neuropathy (AION). GCA should always be suspected in a patient over the age of 50 who presents with a history of headache and scalp tenderness. Other systemic symptoms include scalp tenderness, jaw claudication, weight loss and fever. It is associated with polymyalgia rheumatica. ESR and C- reactive protein are typically raised, and ocular examination reveals a relative afferent pupillary defect, optic disc swelling and impaired colour vision. To avoid visual loss in the contralateral eye, high-dose systemic steroids should be commenced immediately.OoeRmv iD! © W uf & 3:01 < Question 6 of 75 A 34-year-old man comes to the clinic with deteriorating night vision. It is thought that he has an inherited defect in the retinal protein responsible for light perception in low-light conditions. Which of the following proteins is most likely defective? A Cone opsin B Melanopsin Cc Panopsin/Opsin-3 D Rhodopsin E Vertebrate-Ancient (VA) opsinOo mv iD © W i U 3:03 Question 6 of 75 Rhodopsin Rhodopsin is a cell membrane protein present in rod photoreceptors, and is responsible for initiating visual phototransduction, the conversion of light energy to an electrochemical response. Rhodopsin is responsible for enabling light in low-light conditions. Defects in rhodopsin are responsible for the condition retinitis pigmentosa manifesting as deteriorating night vision. A Cone opsin Cone opsin is incorrect. Whilst rods are responsible for dark adaptation, cones are responsible for light adaptation. The photosensitive pigment in rods and cones is rhodopsin and opsin respectively. There are three types of cone opsin that respond differently to tha cama vasavpoplananth nf linhkt vwarithOo mv iD © W i U 3:03 < Question 6 of 75 the same wavelength of light, with peak sensitivities to blue, red and green portions of the visible light spectrum. Defects lead to varying degrees of colour blindness. B Melanopsin Melanopsin is incorrect. Melanopsin is a photopigment detected in retinal ganglion cells, of which there are five types with different functions, including regulation of circadian rhythms and pupillary responses. Cc Panopsin/Opsin-3 Panopsin or Opsin-3 is incorrect. This is a protein encoded by the Opsin-3 gene. This is largely expressed in tissues outside the eye, including the liver, testis, brain and pancreas.Oo mv (O © ¥ 4 O 3:05 < Question 7 of 75 A patient is examined in the diabetic clinic and is found to have a vitreous haemorrhage, which is precluding a view of his fundus. He is admitted for bed rest. After 3 days the fundus can be visualised. What is the most likely diagnosis? A Normal fundi B Background retinopathy Cc Maculopathy D Pre-proliferative retinopathy E Proliferative diabetic retinopathyOo@onmnv iD! © W 46 U 3:07 < Question 7 of 75 Proliferative diabetic retinopathy Vitreous haemorrhage in diabetic patients is commonly caused by bleeding of fragile new vessels of the retina, consistent with neovascularisation in proliferative diabetic retinopathy. 8 | Background retinopathy Background retinopathy is incorrect. Micro-aneurysms consistent with background or mild non-proliferative diabetic retinopathy would not cause a vitreous haemorrhage. A Normal fundi Normal fundi is incorrect. A diabetic patient with vitreous haemorrhage is axtramelyv unlikely to have a norma]Oo mv iO © ¥ 4 O 3:08 < Question 7 of 75 Classification of non-proliferative diabetic retinopathy (Note this differs from the diabetic screening service criteria e¢ Mild non-proliferative (background) diabetic retinopathy: at least one micro- aneurysm. Screening criteria include exudates. ¢ Moderate non-proliferative diabetic retinopathy: intra-retinal haemorrhages or micro- aneurysms Carotid Doppler ultrasound Asymmetric diabetic retinopathy should raise a suspicion of ocular ischemic syndrome (COIS) on the side affected worse. OIS is usually due to atherosclerosis, in those aged 50 or over. It is frequently under-diagnosed as it has non-specific signs involving the anterior and posterior segment. It manifests as visual loss with or without pain, with signs including raised intraocular pressure, rubeosis iridis, anterior chamber cells, cataract, retinal haemorrhages, neovascularisation of the disc and retina, cotton-wool spots and micro-aneurysms. Typically, veins are dilated but non-tortuous, unlike in central retinal vein occlusion. Fluorescein angiography and carotid Doppler ultrasound are the investigations of choice, the latter typically showing >90% obstruction of the carotid artery. Cardiovascular riskORY iD! © 4S ug 5:01 typically showing >90% obstruction of the carotid artery. Cardiovascular risk factors should be identified and optimised. A Chest X-ray Chest X-ray is incorrect. Ocular ischaemic syndrome does not have respiratory manifestations, and a chest X-ray would not provide relevant diagnostic information. B Electrocardiography Electrocardiography is incorrect. An ECG (electrocardiogram) may show atrial fibrillation, or other arrhythmias which need to be identified and treated, but this is not diagnostic of ocular ischaemic syndrome. {~~ —Mmrnraniilatinn orrannORY iD! © {$4 5:01 < Question 11 of 75 Electrocardiography is incorrect. An ECG (electrocardiogram) may show atrial fibrillation, or other arrhythmias which need to be identified and treated, but this is not diagnostic of ocular ischaemic syndrome. Cc Coagulation screen Coagulation screen is incorrect. This should form part of the cardiovascular work-up in someone identified as having OIS, but again is not diagnostic. E 24-hour urinary protein 24 h urinary protein is incorrect. An abnormal result would not signify OIS, although it may signify diabetic renal disease. Rate this question: eoORY iO! © {$4 i 5:04 Question 12 of 75 A 26-year-old man presents with sudden-onset headache and double vision. The doctor in the Emergency Department diagnoses a Illrd Coculomotor) nerve palsy and notes a dilated pupil on that side. Which one of the following is the most likely cause? A Posterior communicating artery aneurysm B Acoustic neuroma Cc Diabetes mellitus D Extradural haematoma E Ophthalmoplegic migraineID © 48 46 @ 5:07 Question 12 of 75 Posterior communicating artery aneurysm The Illrd (oculomotor) nerve emerges in the interpeduncular fossa, passes between the posterior cerebral and superior cerebellar arteries and pierces the dura at the lateral clinoid process to enter the lateral wall of the cavernous sinus. Causes of palsy include: e Posterior communicating artery aneurysm - sometimes associated with headache and usually involving pupillary fibres causing an ipsilateral dilated pupil e Patients with a new onset, pupil- involving, isolated oculomotor nerve palsy require urgent investigation for an aneurysmORY iD! © 4 ug) @ 5:07 Question 12 of 75 which may require urgent treatment to prevent sub- arachnoid haemorrhage B Acoustic neuroma Acoustic neuroma is incorrect. An acoustic neuroma does not typically affect the oculomotor nerve given its location. Cc Diabetes mellitus Diabetes mellitus is incorrect. Diabetes mellitus causes a microvascular infarct of the nerve, and is more commonly painless and associated with sparing of the pupillomotor fibres. D Extradural haematoma Eytradiiral paamatnma ic inrnrrartORY iD! @ fia) Hi 5:08 Question 13 of 75 A 30-year-old man, under investigation for abdominal cramps and passing blood rectally, presents with an acutely painful, red and photophobic eye. What is the most likely sign on ocular examination? A Conjunctival purulent discharge B White corneal stromal infiltrate Cc Mydriasis of the affected eye D Hypopyon E Swollen optic discit © Ht ua) @ 5:10 Question 13 of 75 a Hypopyon Passing blood rectally is a symptom of inflammatory bowel disease. There are many causes of ared eye but, in this context, iritis (anterior uveitis) should be suspected. The classical symptom of iritis is photophobia. A cardinal sign of iritis is the presence of inflammatory cells in the anterior chamber of the eye, visible with a slit lamp. In cases of severe iritis, the degree of inflammation in the anterior chamber is enough to cause settling of inflammatory cells inferiorly to form a level - a hypopyon. While a hypopyon may imply infective endophthalmitis (eg following cataract surgery), a sterile hypopyon can occur in cases of severe iritis. A Conjunctival purulent dischargeORY Dt © Ht ug 5:11 Question 13 of 75 A Conjunctival purulent discharge Conjunctival purulent discharge is incorrect. Bacterial conjunctivitis causes purulent discharge but is very unlikely to cause severe pain and photophobia. lritis does not cause a discharge. B White corneal stromal infiltrate White corneal stromal infiltrate is incorrect. Microbial keratitis, causing a white corneal infiltrate, is more likely if there is a history of contact lens wear or trauma, such as a corneal abrasion or a corneal foreign body. Cc Mydriasis of the affected eye Mydriasis of the affected eye isORY Dt © Ht ug 5:11 Question 13 of 75 Cc Mydriasis of the affected eye Mydriasis of the affected eye is incorrect. lritis often causes pupillary miosis, because the pupil becomes adherent to the lens owing to the inflammation. While acute angle closure, an ophthalmological emergency, causes mydriasis in a red, painful eye, it is also less likely ina patient as young as 30. E Swollen optic disc Swollen optic disc is incorrect. Cerebral metastases from colorectal carcinoma can cause raised intracranial pressure and papilloedema, but this is unlikely in a young patient, and would not cause conjunctival injection Cie a red eye). RAT OREINT OUCH S Erne enRv iD @ 4% ye O 12:25 Question 14 of 75 A 32-year-old woman presents as an emergency with sudden, painless loss of vision in her right eye. She has been a type 1 diabetic for the past 16 years. On examination, her vision is reduced to hand movements in the right eye. Pupil reactions are normal. Dilated fundal examination reveals a vitreous haemorrhage with limited fundal view. Which of the following would be the most likely causative retinal abnormality? A Microaneurysm B Cotton-wool spot Cc Hard exudates D Neovascularisation at the optic discAv iO! @ 23 46 OE 12:25 Question 14 of 75 Neovascularisation at the optic disc Neovascularisation is a feature of proliferative diabetic retinopathy, and may occur at the optic disc or elsewhere along the vascular arcades. Neovascularisation can lead to vitreous haemorrhage, which can take several weeks to self-resolve. The patient requires urgent panretinal photocoagulation once fundal view is sufficient. A Microaneurysm Micro-aneurysm is incorrect. Micro- aneurysms are a feature of mild diabetic retinopathy. They would not cause a deterioration in visual acuity to hand movements. B Cotton-wool spotRv iD @ 46 ye O 12:26 Question 14 of 75 B Cotton-wool spot Cotton-wool spot is incorrect. Cotton- wool spots are a feature of diabetic and hypertensive retinopathy, signifying ischaemia of the retinal ganglion cells. They would not cause such deterioration of vision. Cc Hard exudates Hard exudates is incorrect. Hard exudates in the fundi may occur in diabetic and hypertensive retinopathy. They may also occur in the macula as a feature of diabetic maculopathy. However, they would not cause an abrupt loss of vision as seen in this patient. E Venous beading Venous beading is incorrect. Venous Lo. be tn ae ke be kn keAv i! @ 23 44 OE 12:28 Question 15 of 75 A patient is examined in the Diabetic Clinic and found to have circinate hard exudates in both fundi, with reduced visual acuity. On examination of both retinae these are within one disc diameter of the macula. What is the most likely diagnosis? A Normal fundi B Background retinopathy Cc Maculopathy D Preproliferative retinopathy E Proliferative retinopathyAv i! @ f$ i OE 12:30 Question 15 of 75 Maculopathy Diabetic maculopathy may occur at any stage of retinopathy. It is classified as either clinically significant or non- clinically significant macular oedema. Clinically significant macular oedema (CSMO) requires hard exudates within 500 um of the fovea with adjacent retinal thickening, or retinal thickening within one disc diameter of the fovea, which is itself at least one disc diameter in size. Non-clinically significant macular oedema refers to macular exudates with no macular oedema, or to macular exudates and oedema not meeting the definition of CSMO. In this scenario the patient has maculopathy, but it may be clinically or non-clinically significant depending on the extent of retinal thickening, which is not mentioned here. Circinate exudates refer to exudates arranged in a ring surrounding an area of capillaryRv iD @ 46 ye @ 12:30 Question 15 of 75 exudates refer to exudates arranged in a ring surrounding an area of capillary leakage. These may be treated with macular laser or anti vascular- endothelial growth factor agents. | | Preproliferative retinopathy Pre-proliferative diabetic retinopathy is incorrect. See answer for Option B. A Normal fundi Normal fundi is incorrect. Hard, circinate exudates are an abnormal fundal finding. B Background retinopathy Background retinopathy is incorrect. Retinopathy and maculopathy are both diabetic changes with their own classifications. This patient may haveRav ir @ 4 ug) @ 12:31 Question 15 of 75 2 exUdd fundal finding. B Background retinopathy Background retinopathy is incorrect. Retinopathy and maculopathy are both diabetic changes with their own classifications. This patient may have maculopathy and any stage of retinopathy, but it does not mention retinopathy changes in the scenario. E Proliferative retinopathy Proliferative diabetic retinopathy is incorrect. See answer for Option B. Rate this question: ©96 2 iD © Pu & 10:53 < Question 1 of 64 A patient presents with a fourth episode of painful reduction in visual acuity in one eye. The acuity is 6/60, ocular movements produce pain and the optic disc is pale. Which one of the following investigations suggests that her optic neuritis is due to multiple sclerosis (MS)? A Abnormal visual evoked potentials (VEP) in the contralateral eye B Abnormal nerve conduction studies Cc Xanthochromia in the CSF D Normal MRI brain scan E Bilateral spike and waveOOo 8 iD © @ ud & 10:54 < Question 1 of 64 Lesions are disseminated in space and time in patients with MS. The presence of a lesion on the other side (as evidenced by an abnormal VEP makes the diagnosis more likely. B Abnormal nerve conduction studies Abnormal nerve conduction studies is incorrect. Peripheral nerves (and hence nerve conduction studies) are unaffected. Cc Xanthochromia in the CSF Xanthochromia in the CSF is incorrect. The CSF shows lymphocytosis and oligqaclonal handecOOo 8 iD! © @ ud & 10:55 < Question 2 of 64 A 45-year-old woman is found by her optometrist to have band keratopathy and is referred to the Eye Clinic. Which one of the following investigations is likely to be helpful in determining an underlying cause? A Cholesterol B Ferritin S U&E D Gamma GT E Serum calciumID © Wu O 10:56 Question 2 of 64 a Serum calcium Band keratopathy is caused by calcium deposition in Bowman’s layer of the cornea. It can result from the degenerative phase of chronic eye diseases or from hypercalcaemia. Patients who present with band keratopathy should have a serum calcium and phosphate level drawn unless the deposition has been documented previously and a known underlying cause exists. Parathyroid hormone levels should be checked in otherwise idiopathic cases. A Cholesterol Cholesterol is incorrect. The presence of corneal arcus can be related to hypercholesterolaemia, and is a white encircling band around the cornea.OOo 8 iD © @ ud & 10:58 < Question 2 of 64 B Ferritin Ferritin is incorrect. No specific corneal signs are directly related to low ferritin levels, although anecdotally it can cause ocular irritation. lron levels found on corneas are also called Hudson and Stahli lines, and are not related to plasma serum levels of ferritin. S U&E U&E is incorrect. Patients with chronic kidney insufficiency who have a corneal finding are usually fortuitous. D Gamma GT Gamma GT is incorrect. Liver dysfunction can cause problems such as dry eyes, from dysfunctional tear production.OOo 8 iD © @ ud & 11:00 < Question 3 of 64 A 78-year-old woman presents with sudden-onset double vision. On examination she has a normal range in up- and downgaze in both eyes. On left gaze the left eye fails to abduct, while the right eye appears normal. On right gaze the right eye appears to abduct normally but the left fails to pass the midline. Her visual acuity and pupil reactions are normal. You also notice that she has a left facial weakness with sparing of the frontalis muscle. What is the likely site of the lesion? A Cerebello-pontine angle B Brainstem Cc Cavernous sinus D Frontal cortexIDO © WP ua OB 11:01 < Question 3 of 64 Brainstem The clinical scenario is difficult as there are several problems: e Inability to abduct the left eye. This movement is mediated by the lateral rectus muscle under the control of the VI cranial nerve, the Abducens. Therefore, there is a left-sided VI cranial nerve lesion. e Left-sided facial weakness with frontalis soaring. Remember, ‘upper spares upper’, meaning that the upper facial muscles retain movement due to cross- innervation in upper motor neurone lesions. Therefore, there is also a left-sided VII cranial nerve lesion.OOo 8 iD © @ ua & 11:02 < Question 3 of 64 e Lastly, the left eye fails to cross the midline (medial rectus, III cranial nerve) when the right lateral rectus abducts (VI cranial nerve). We know there isn’t a Ill cranial nerve palsy - all other eye movements are intact. This is an internuclear ophthalmoplegia CINO). The lack of abnormality in pupillary reactions and vision localise the lesion to the area of the VI cranial nerve nucleus, horizontal gaze centre, medial longitudinal fasciculus and the facial colliculus. The brainstem is the only unifying affected area. Orbital apex Orbital apex is incorrect. Cranial nerves Il, I, IV, and VI all travel through theOOo 8 iD © @ ua & 11:02 orbit into the eye. Tumours of the orbit classically create oculomotor dysfunction with loss of vision due to optic neuropathy. A Cerebello-pontine angle Cerebello-pontine angle is incorrect. Cranial nerves V, VIl and VIII palsies are the classic syndrome here. Cc Cavernous sinus Cavernous sinus is incorrect. Cranial nerves Ill, lV, V and VI travel in the cavernous sinus. Consider this diagnosis in pregnancy and acne when cavernous sinus thrombosis risk is higher. D Frontal cortexOo KR ID © WP ua O 11:06 < Question 4 of 64 A diabetic 46-year-old man is found in the Diabetic Clinic to have reduced visual acuity. During a telephone referral to the eye clinic, the ophthalmologist asks whether the patient has any risk factors for macular oedema. Which one of the following should the referring physician bring to his attention? A Background diabetic retinopathy B Low glycosylated haemoglobin Cc Previous myocardial infarction D Recent conjunctivitis E Perioheral vascular diseaseOo KR iD © 4 11:08 < Question 4 of 64 Background diabetic retinopathy The Wisconsin Epidemiological Study showed that the incidence of macular oedema was 2-6% in background diabetic retinopathy (DR), 20-63% in preproliferative DR and 70-74% in proliferative DR. The prevalence increased with greater duration of diabetes, higher glycosylated haemoglobin and greater proteinuria levels. B Low glycosylated haemoglobin Low glycated haemoglobin is incorrect. Glycated haemoglobin, also known as HBA\Ic, is representative of the average plasma glucose concentration over three months and is an indicator of glycaemic control. Low HBAIc is not arisk factor for diabeticOo nw iD © Pu & 11:25 OQ @ mypastest.pastest.com : < Question 5 of 64 A 30-year-old man is referred to the Dermatology Clinic and found to have café au /ait spots. Which one of the following features subsequently found in the Eye Clinic suggests a diagnosis of neurofibromatosis? A Busacca nodules 8 | Lisch nodules Cc Brushfield spots D Koeppe nodules E Heterochromia iridisOo KR ID © Wu OB 11:26 < Question 5 of 64 je | Lisch nodules Lisch nodules are iris nodules, and are the most common clinical sign described in individuals with Neurofibromatosis type 1. A Busacca nodules Busacca nodules is incorrect. Busacca nodules are seen in ocular sarcoidosis cthis is an inflammatory nodule, but the eponym need not be memorised for the MRCP exam). Cc Brushfield spots Brushfield spots is incorrect. Brushfield spots are a finding described in people with Down syndrome, although they have also been found in normal individuals.Oo KR ID © WP wf OB 11:26 < Question 5 of 64 spots are a finding described in people with Down syndrome, although they have also been found in normal individuals. D Koeppe nodules Koeppe nodules is incorrect. Koeppe nodules are seen in ocular sarcoidosis Cthis is an inflammatory nodule, but the eponym need not be memorised for the MRCP exam). E Heterochromia iridis Heterochromia iridis is incorrect. Heterochromia iridis is seen in a variety of conditions including congenital Horner’s syndrome, pigment dispersion syndrome, Sturge-Weber syndrome and Waardenburg syndrome. Rate this question: eOo KR ID © WP .é O 11:27 < Question 6 of 64 A 70-year-old woman with a history of rheumatoid arthritis comes to the Emergency Department with sudden, painful loss of vision in her left eye. She has a history of hypertension, which is managed with ramipril 10 mg daily and amlodipine 5 mg, and she has type 2 diabetes, which is controlled with metformin. She is taking hydroxychloroquine for her rheumatoid arthritis, aspirin over the counter for intermittent headache and amitriptyline for depression. On examination her BP is 152/92 mmHg; there is increased intraocular pressure, more marked in the left eye than the right; fundoscopy is difficult due to the likely presence of inflammation; both pupils look partially dilated. Which one of the following drugs is the most likely cause of these problems?Oo KR ID © PW ua OB 11:28 < Question 6 of 64 mmHg; there is increased intraocular pressure, more marked in the left eye than the right; fundoscopy is difficult due to the likely presence of inflammation; both pupils look partially dilated. Which one of the following drugs is the most likely cause of these problems? A Amitriptyline B Hydroxychloroquine Cc Metformin D Aspirin E RamiprilOo R ID! © Wud @ 11:29 < Question 6 of 64 Amitriptyline Drugs that cause acute closed-angle glaucoma include tricyclic antidepressants (including amitriptyline), antihistamines, anti- parkinsonian agents, antipsychotics and sulphonamides. Treatment involves a combination of acetazolamide, B-blocking eye drops, a-adrenergic eye drops and pilocarpine. The causative medication should be stopped, although around one third of patients require permanent therapy to lower the intraocular pressure despite discontinuing the responsible medicine. a Hydroxychloroquine Hydroxychloroquine is incorrect. This toxicity mimics open-angle glaucoma, and prednisolone is a cause of chronicOo KR ID © Wu OB 11:30 < Question 6 of 64 and prednisolone is a cause of chronic open-angle glaucoma. Cc Metformin Metformin is incorrect. This is associated with B,. deficiency, which could contribute to a toxic optic neuropathy. D Aspirin Aspirin is incorrect. This has no significant association with glaucoma. E Ramipril Ramipril is incorrect. Administration at night can increase nocturnal hypotension, which can worsen glaucoma. Pate thie aiiectinn <*>Oo KR iD © WP wé @ 11:31 < Question 7 of 64 A 35-year-old woman is found to have aortic regurgitation. She is wearing aphakic spectacles. Which one of the following diagnoses in the Eye Clinic sheds light on the cause of her valvular disease? A Cataract B Glaucoma Cc Kayser-Fleischer rings D Ectopia lentis E IritisOo KR ID © WV wé O 11:32 Question 7 of 64 Ectopia lentis Ectopia lentis is not a disease but refers to subluxation or dislocation of the lens within the eye. Dislocation of lens can be seen in Marfan’s syndrome. Cin contrast, aphakia refers to having no lens seen at all.) Dislocated lenses are a feature of Marfan syndrome, as is aortic regurgitation. Aphakic spectacles are prescribed if the dislocated lenses have disappeared entirely from the pupil aperture (a kind of spontaneous cataract extraction) or after they have been surgically removed. A Cataract Cataract is incorrect. Cataract is one of the most common eye conditions, although it has no known direct correlation to aortic problems.Oo KR ID © PV we OB 11:34 < Question 7 of 64 B Glaucoma Glaucoma is incorrect. Glaucoma is associated with increasing age and chronic medical conditions such as diabetes mellitus. It isn’t associated with aortic regurgitation. Cc Kayser-Fleischer rings Kayser-Fleischer rings is incorrect. Kayser Fleischer rings are an ocular feature associated with Wilson’s disease, where a dark ring is seen to encircle the whole corneal edge. E lritis lritis is incorrect. Chronic iritis is not associated with spontaneous aphakia, but can cause cataract in recurrent disease.Oo KR ID © WP 26 O 11:35 < Question 8 of 64 A diabetic patient with diplopia is found to have a Illrd nerve palsy. Which one of the following clinical features suggests that urgent neuroimaging should be carried out? A Impaired adduction B Impaired elevation Cc Nystagmoid jerks D Ptosis E Pupil involvementOo KR ID © Ww OB 11:36 < Question 8 of 64 Pupil involvement The third cranial nerve has motor fibres to the levator palpabrae superioris, superior, medial and inferior recti, inferior obliques as well as pupillomotor fibres to the iris sphincter. Depending on the cause of IIIrd cranial nerve palsy, the function of the iris sphincter can either be spared or affected. If the pupil is soared, an ischaemic cause is more likely (check the individual’s likely cardiovascular profile, in this case diabetes makes this more likely). If the pupil is involved, a compressive lesion must be suspected, particularly if there is associated pain. This warrants urgent intracranial scan and, if appropriate, onward referral to neurosurgery. A Impaired adductionoo K ID © V 26 OB 11:38 < el dlela me mem or) A 64-year-old man with a history of Type 2 diabetes and hypertension comes to the clinic. He awoke from sleep unable to see the top half of the visual field in his right eye. His diabetes is poorly controlled, a recent HbAIc was 76 mmol/mo admission to the (9.1%), and his BP on Emergency Department is 165/105 mmHg. Pulse is 80/min and regul focal neurologica What is the most ar. There is no other deficit. likely cause of this visual field defect? A Age-related macular degenerat ion B Retinal vascular disease Cc Parietal lobe infarction D Optic chia sm compressionOo KR ID © PF we OB 11:42 < el dlela me mem or) Age-related macular degeneration is incorrect. Age-related macular degeneration typically causes loss of central vision, manifesting as a central scotoma. This is usually a gradual process although wet ARMD may cause sudden loss of vision. It would not cause an altitudinal defect. Cc Parietal lobe infarction Parietal lobe infarction is incorrect. Parietal lobe lesions cause an inferior homonymous quadrantanopia, although this may progress to a homonymous hemianopia. D Optic chiasm compression Optic chiasm compression is incorrect. Lesions or compression of the optic chiasm would cause a bitemporal hemianopia.Oo KR ID © PF we OB 11:42 < Question 10 of 64 A 45-year-old man with syncopal episodes is found to have a heart block and is referred to the eye clinic because the doctor in the Emergency Department found limited eye movements. On further questioning he admits to decreased night vision, such that he no longer drives at night. Which one of the following retinal findings might be related to the cardiac problem? A Myopic degeneration B Papilloedema Cc Old chorioretinitis D Retinitis pigmentosa E Macular degenerationoOo iD © FW uf & 11:44 Question 10 of 64 o Retinitis pigmentosa The combination of heart block, ocular myopathy and pigmentary retinopathy is known as Kearns-Sayre syndrome. This mitochondrial cytopathy occurs sporadically. People with this syndrome can also have ptosis, deafness, dementia and raised cerebrospinal fluid protein levels. Patients with ocular myopathy have limited eye movements but usually no diplopia because the eyes are symmetrically involved. A Myopic degeneration Myopic degeneration is incorrect. Myopia (short-sightedness) can be associated with degeneration at the macula, but is not associated with cardiac problems.Oo KR ID © WP uf OB 11:46 < Question 10 of 64 B Papilloedema Papilloedema is incorrect. Papilloedema is not associated with night vision problems, and more frequently causes transient, posturally induced visual obscurations. Cc Old chorioretinitis Old chorioretinitis is incorrect. Chorioretinitis is not typically associated with cardiac or ocular motility problems. E Macular degeneration Macular degeneration is incorrect. Age-related macular degeneration is the most common cause of blindness in the Uk, but is not associated with cardiac problems and night vision is typically spared.Oo KR ID © PF wf OB 11:48 < Question 11 of 64 A 40-year-old woman with rheumatoid arthritis takes oral steroids. She presents with watering of both eyes associated with intermittent blurred vision when using a computer. What is the most likely diagnosis? A Cataract B Diabetic retinopathy iS Dry eyes D Glaucoma E Transient ischaemic attackOo KR ID © PF wf OB 11:48 < Question 11 of 64 Rheumatoid arthritis is associated with dry eyes. Tear-film integrity on the corneal surface is required both for comfort and to provide an optically smooth surface for refraction. Therefore, in dry eye, when the tear film cannot provide adequate wetting of the corneal surface between blinks, grittiness and intermittent blur occurs. A reflex response to irritation of the corneal surface is epiphora, or watering. Symptoms will be worse when tear-film evaporation is greater, for example in windy or in warm, dry (air-conditioned air) environments, or when the blink rate declines (as is likely when concentrating on computer work). The setting and recurrent nature of the intermittent blurring points towards ocular surface dryness as opposed to other forms of transient victial lose ctich as transient ischaemicOo KR ID © PF wf OB 11:48 < Question 11 of 64 visual loss, such as transient ischaemic attacks (TIAS). 0 | Glaucoma Glaucoma is incorrect. Occasionally, topical or systemic steroid use results in raised intraocular pressure, with subsequent progressive damage to the optic nerve and peripheral vision (secondary open-angle glaucoma). However, any visual symptoms due to peripheral visual field loss would not be intermittent. (The rise in intraocular pressure usually reverses when steroid treatment is stopped. Any damage to the optic nerve and visual field, however, would not be reversible). A Cataract Cataract is incorrect. Systemic or topical steroid treatment can cause ocular side-effects. Steroid use is aOo KR ID © PW we OB 11:52 < Question 12 of 64 A 21-year-old man presents to the Emergency department. He has double vision on looking to the left. There is no past medical history of note. On examination his BP is 110/70 mmHg, pulse is 70/min and regular. Upon examination of ocular movements, the patient is unable to abduct his left eye. Diplopia with horizontal separation of images is evoked when attempting to look left, and is worse when looking into the distance. Upon covering the left eye, the outer image disappears. Weakness of which of the following muscles is most likely responsible for his symptoms? A Left lateral rectus B Left medial rectus Cc Left superior obliqueOo KR ID © WP we OB 11:52 < Question 12 of 64 examination of ocular movements, the patient is unable to abduct his left eye. Diplopia with horizontal separation of images is evoked when attempting to look left, and is worse when looking into the distance. Upon covering the left eye, the outer image disappears. Weakness of which of the following muscles is most likely responsible for his symptoms? A Left lateral rectus B Left medial rectus Cc Left superior oblique D Right lateral rectus E Right medial rectusOo KR ID © Wu OB 11:55 Question 12 of 64 a Left lateral rectus Loss of unilateral abduction is consistent with a sixth nerve palsy, which innervates the lateral rectus muscle. Additionally, it is important to remember 3 rules: double vision is maximal in the direction of gaze of the affected eye, the false image is the outer image, and the false image arises in the affected eye. Therefore, an isolated sixth nerve palsy leading to paralysis of the left lateral rectus is by far the most likely diagnosis. The most common cause in an adult is microvascular, however with this patients’ young age and absence of medical history other causes such as a neoplasm, raised intracranial pressure and infection become more likely, although it may simply be idiopathic. B Left medial rectusOo KR ID © Wu OB 11:56 < Question 13 of 64 A 20-year-old woman presents with gradually reducing vision in her left eye of 2 weeks’ duration. Visual acuity is 6/4 (right eye) and 6/36 (left eye). The left pupil reacts sluggishly to light and the consensual pupillary reaction in the right eye is also sluggish. Optic discs are normal. What is the most likely diagnosis? A Cerebral tumour B Holmes-Adie pupil Cc Factitious visual loss D Parinaud syndrome E Retrobulbar neuritis