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Interactive Ophthalmology Quiz Mr Behrooz Golchin Consultant Ophthalmic Surgeon
10 minutes Section 1 Section 2 Spot diagnosis • Case presentations
Please participate • Don’t be embarrassed • Shout out the answers
Section 1 Case presentations
Case 1 • 35 year old man • C/O watery Rt eye • Eye becoming progressively painful • Photophobic • The vision is a little blurred
O/E VA is 6/12. • His right eye is photosensitive. • The redness is diffuse but more pronounced around the cornea. • The cornea appears a bit hazy and his pupil is miosed.
If you dilate the pupil, you will notice that the pupil now has a scalloped appearance. • What is the diagnosis?
Anterior Uveitis • Anterior uveitis refers to inflammation of the iris and/or ciliary body and • Usually presents with a painful, red eye. • Patients often c/o decreased vision and a watery discharge.
Anterior Uveitis • Photophobia is 2’ to spasm of inflamed iris and ciliary muscles. • Visual acuity varies depending on the severity of the inflammation.
Anterior Uveitis • The pupil is often miosed • if untreated, the pupil margin may adhere to the lens due to the formation of posterior synechiae.
Anterior Uveitis • Corneal precipitates may occur on the endothelium • hypopion (pus in the anterior chamber) may be present in severe cases.
Treatment • Dilating drops • relieve ocular discomfort by reducing ciliary muscle spasm • prevent the formation of posterior synechiae. • Topical corticosteroid drops to treat the inflammation • Periocular steroid injections or even systemic corticosteroids may be required in more severe cases.
Case 2 • 30 y.o lady • 5 day Hx of FB sensation and redness Lt eye. • c/o reduced vision and watery • No previous eye Hx
O/E VA is 6/9 • Mild diffuse conj injection. • A whitish area seen in the pupillary zone • What would you do next?
Instillation of 2% fluorescein shows a branching ulcer on the lateral side of the cornea. • What is the Dx?
Herpes simplex Keratitis • Dendritic ulcer • Confined to epithelium but deeper tissues may become involved. • Stained with fluorescein and rose bengal • Rx topical aciclovir
Geographic Epithelial keratitis • Dendritic ulcers coalesce and enlarge to form this larger ulcer. • Can occur as a result of inappropriate steroid use. • Do not treat a red eye with steroid unless HSK is ruled out.
Case 3 • A 9 y.o. boy c/o sever itching in both eyes. • his mother says that he is constantly rubbing his eyes. • The eyes water a lot and bright light hurts them. • Not sticky, no discharge. • He is currently on treatment for asthma.
O/E , his VA is 6/9 in both eyes • He is very photophobic. • His eyelids are red. • The conjunctiva is mildly injected. • His corneas are clear and do not stain with fluorescein. • What do you do next?
Upon everting his upper eyelids, you notice several raised, fleshy lesions on the conjunctival surface of the upper lids. • What is the diagnosis?
Vernal keratoconjunctivitis • Vernal keratoconjunctivitis • most commonly occurs in young boys • often have a history of atopy. • Symptoms include • severe, chronic ocular itching • photophobia, • blepharospasm, • mucoid/watery discharge • blurred vision also occur frequently.
Vernal keratoconjunctivitis • Signs include giant papillae under the upper eyelid • they have a typical cobblestone appearance.
Vernal keratoconjunctivitis • Limbitis • a fleshy, gelatinous ring around the limbus, • contains whitish spots called Trantas dots.
Treatment • Mild cases respond to: • topical antihistamines and artificial tear drops • topical mast cell stabilisers • oral antihistamines is often required in cases of moderate severity. • Severe cases frequently require: • short courses of topical corticosteroids, such as fluorometholone or dexamethasone • intraocular pressure need to be monitored. • In very severe cases • topical immunomodulatory drugs, such as cyclosporine or tacrolimus, may be needed to control the inflammation.
Case 4 • A 32 y.o. female c/o redness and increasing pain in her left eye x 3/7. • The eye is painful to touch • The pain has woken her from sleep over the last two nights. • Eye is a little watery but there is no significant discharge • visual acuity has not changed.
O/E VA is 6/6 and her eyelids are normal. • large area of redness, temporal to the cornea. • The eye is very tender to touch. • looking at the eye in natural daylight, the underlying sclera has a purplish hue. • The rest of the examination is unremarkable. • What is the likely Dx?
Scleritis • Scleritismay be either diffuse or nodular. • Pain is a prominent feature. • Often wakes the patient from sleep during the night. • Visual acuity is often not affected in the early stages.
Scleritis • Etiology: Collagen vascular disease RA, SLE, gout, syphilis • Complications: • Peripheral ulcerative keratitis with corneal perforation • Secondary glaucoma • Scleral melting and perforation • Exudative retinal detachment
Treatment • Scleritis often responds adequately to oral NSAIDs. • > 50% of patients with scleritis have an associated systemic disease. • They require specialist referral for systemic workup • May need potent immunosuppressive therapy.
Section 2 Spot Diagnosis