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A 75 y/o F comes in for her annual check complaining of reduced vision and increased intolerance to glare. She has had a myopic shift and has cataracts. a) What factors should you consider when referring for cataract surgery? - ✔✔ b) Cataract Cause of visual complaint Compromising Lifestyle Driver Anisometropia Visual Acuity Other Ocular Pathology General Health and Medications Patient wants to have operation b) What type of cataract is most likely from the above description? - ✔✔Nuclear Sclerotic c) Describe a cataract op in laymans terms - ✔✔Outpatient Basis Before surgery seen by a specialist doctor 30 - 40 minutes on local anaesthetic The Surgeon will make a tiny cut in your eye to get to the lens High-frequency ultrasound device that breaks up the cloudy lens into small pieces Small pieces gently removed from the eye with suction. Cloudly lenses replaced by a clear plastic one d) What are the post op drops (names and concentration) and common post-op complications you would look out for weeks after? - ✔✔Postoperative regimens of topically applied antibiotics, corticosteroids, NSAIDs, and oral analgesic agents vary among practitioners.
From Incision - wound leak Corneal Astigmatism Keratopathy IOP rise Endopthalmitus IOL disslocation Sunset syndrome Iris epithelial ingrowth Pupil Capture CMO Retinal Detachment Signs of Glaucoma - ✔✔Disc Signs: Asymetric Cupping, Disc Haemorrhage , Increased cuppping, RNFL changes, PPA, NRR thining. Visual field loss characteristic to ONH changes, notching, superior arcuate defect. How is glaucoma diagnosed. - ✔✔Progression analysis, visual fields and RNFL scanning using OCT Medisoft plot, RE: false +ve 3% fixation losses 7/10 Le: false +ve 7% fixation losses 2/10. What is the reliability of the fields? - ✔✔Fixation loss higher than about 20% is deemed unreliable. A false positive rate around 20% or higher is considered to indicate low patient reliability Medisoft plot showing a right homonymous hemianopia with macular sparing. What is the full name and classification of the condition?
Prism Fogging Strabismus surgery 64 y/o F complains of pain on chewing and headaches 2 weeks. Loss of vision in one eye today. a) What is your diagnosis and immediate response? - ✔✔Refer as emergency for systemic steroids e.g prednisolone 64 y/o F complains of pain on chewing and headaches 2 weeks. Loss of vision in one eye today. you suspect Arteritic AION. What are likely systemic causes and tests required? - ✔✔ESR (erythrocyte sedimentation rate), high then indicated inflamation CRP (C reactive protein) - produced by liver with inflamation platelets temporal artery biopsy Describe two types of Blepharitis. - ✔✔Anterior marginal blepharitis (seborhoric- disorder of the ciliary sebaceous glands of Zeis or bacterial - staphylococal exotoxin reaction) Posterior marginal blepharitis (MGD) - abnormal meibomian secretion. What is the management of Blepharitis? - ✔✔Lid hygiene Warm compresses avoidance of cosmetics, especially eye liner and mascara Weak evidence to suggest antibacterials help.
Eye lash growing in touching cornea but lid not turned in. What is the diagnosis and management (pros and cons)? - ✔✔Trichiasis Removal with forceps (simple, not painful but may return) Electrolysis (time consumigng and painful) Cryosurgery (complications include corneal ulcers visual loss and lid notching) A 12 y/o is brought in by their mum with red watery eyes following a cold, it started in the RE 4 days ago followed by the LE 2 days ago. Examination shows conjunctival hyperaemia, follicles and infiltrates in the stroma. What is the most likely diagnosis? What is the treatment and prognosis for this condition? What other factors would you discuss in the management of this patient? - ✔✔Viral conjunctivitis Advise self limiting, should self ressolve in 1-2 weeks. Advise not to share towels to avoid spreading. If sight-threatening corneal involvement, unless already visual loss and severe pain then refer to Ophthalmology RGP patient. Current lens is 7.4/10.00/-4.00, OR shows - 0.75DS. There is dimple veiling was more central and the RGP extends at least 1.5mm past corneal limbus on either side. What changes would you make to the lens? What is the new specification? - ✔✔Flatten lens and reduce TD as this will reduce the tear prism. Reducing TD by to 8.00mm is a 0.1mm = 0.5D
Why would Ishihara not work for identifying a tritan defect? - ✔✔identifies proton/deuteron anomalies Other than the D15 what could you use to screen for a tritan defect? - ✔✔Nagal Anomaloscope (lantern) Describe Adies Pupil - ✔✔one or both pupils to be abnormally dilated with delayed constriction disorder of the parasympathetic nervous system innervation to the iris sphincter and ciliary muscle Causes include viral infection, trauma, vasospasm due to migraine, ocular surgery, tumors, and possibly chronic cough Hypersensitivity to pilocarpine Describe Horners - ✔✔Constricted pupil due to sympathetic disorder Also may have ptosis Causes could be lung tumor, carotid artery dissection, or even a congenital malformation Associated with decreased sweating on the effected side Constricted pupil Will not dilate to cocaine A px comes in to the store, he got cement in his eye 10 minutes ago. Outline your work up of this patient On examination you decide he needs immediate referral. What details would you include in the referral letter? - ✔✔NaFl examination of the cornea to determine extent and depth of alkaline injury Palpebral fissure checks Initial PH
IOP
Details in referral letter should include - chemical, duration since initial incident, initial PH, IOP, however immediate emergency attention is required and irrigation. What are potential treatments for diabetic retinopathy? - ✔✔laser photocoagulation anti vegf vitrectomy How quickly would you refer a patient with proliferative diabetic retinopathy (PDR) or diabetic macula oedema (DMO)? - ✔✔Urgent to Ophthalmologist (within 4 weeks) unless under review Describe the management of GPC in a silicone hydrogel contact lens wearer. - ✔✔improve lens hygeine Increase lens replacement frequency DD if possible Reduce modulus of lens material (Swap to hydrogel lens, be aware more difficult to handle) Manage lid margin disease If sever - topical Mast cell stabalisers 28 y/o overweight female has 6/6 vision and IOPs are normal. On examination, she has bilaterally woollen optic discs that are hyperaemic and with flame haems. a) What optometric tests would you perform b) What non-optometric tests would you perform c) What is your primary concern? - ✔✔Visual fields Pupils Colour Vision Motility Stereo Disc images
Px attends asking for an appointment complaining of flashes & floaters started yesterday when do you see her? A) appt today b) tomorrow c) within the next week d) within the next 4 weeks - ✔✔A) appt today A mum wants to collect her 20 year old daughters rx what do you do? A) give it b) give it and then inform daughter c) request consent from daughter d) refuse - ✔✔c) request consent from daughter How often should you calibrate Goldman? A) daily b) weekly c) monthly d) yearly - ✔✔c) monthly (if under 2 years old, otherwise twice-yearly) List what is used to diagnose optic neuritis? - ✔✔acute unilateral decrease in vision, eye pain-especially with movement RAPD decreased color vision/contrast/brightness sense documentation of a visual field defec (young, female 3:2, MS 75%) Sudden onset eso, what do you suspect? out of duanes and browns? - ✔✔Duanes Px c/o waking up with soreness - not pain - and red eyes for the last two days with associated mucopurulent discharge. All tests are normal but the eye does look red and sore. What is your diagnosis? A) Allergic conjunctivitis b) chlamydial conjunctivitis c) viral conjunctivitis d) bacterial conjunctivitis - ✔✔d) bacterial conjunctivitis A CL multifocal rep asks for the contact details of all your px over 45 to tell them about a new CL available on the market. What do you do?
A) give it to him b) refuse C) give address but not names - ✔✔b) Refuse
- which of the following breaks patient confidentiality? A) showing px the photos of their eyes B) calling their name in the waiting area C) leaving the px with their notes alone in the room - ✔✔D) showing px records to another OO outside of the practice An elderly lady (70s) comes in complaining o glare and haloes around lights with a gradual change in vision. Vision last time was Re: 6/6 LE 6/7.5 and rx RE: +2.00 LE: +2. IOP: 21mmHg R&L What is differential? A) normal change rx, dry ARMD, cataracts B) Cataracts, ACG, optic neuritis C) CRAO, optic neuritis, AMD - ✔✔A)normal change rx, dry ARMD, cataracts Why is FDT more sensitive to early glaucoma? - ✔✔Early glaucomatous nerve damage is thought to be due to loss of large-diameter retinal ganglion cells (in magnocellular layer) These cells are responsible for a small proportion of the total retinal ganglion cells and have minimal functional redundancy, making them a good target for detecting early glaucoma damage. What disease will have worse field results with a blue-yellow field test? A) Ret Pig B) Optic Neuritis C) Glaucoma - ✔✔Blue yellow best for picking up early glaucoma, unspecific question? A px has been prescribed drops by his ophthalmologist and advised to shake them. Why is this?
What is the least suitable management for GPC? A) Cease lens wear b) change to different modulus c) use of mast cell stabilisers d) increase wear time - ✔✔d) increase wear time
- which of these is a contraindication for soft DD wear? A) wanting to wear for sport B) occasional use C) planning to sleep in lenses D) wanting toric lenses - ✔✔C) planning to sleep in lenses A 45 year old male with an unremarkable rx and a low Add wants CLs to wear when practising martial arts a few days a week. What is the most suitable lens choice? A) Daily single vision B) Daily monovision C) monthly multifocal D) monthly single vision - ✔✔B) Daily monovision What is the best way to confirm the diagnosis of keratoconus? a) Munson's sign b) Topography c) Keratometry D) Slit lamp examination - ✔✔b) Topography A prescription of - 4.00/-2.00x90 is dispensed. Which of the following is true? a) Rimless frames are most suitable for this patient
b) The lens is thickest at the O.C c) The lens is thickest along the horizontal meridian - ✔✔c) The lens is thickest along the horizontal meridian A teenage is complaining of headaches worse when waking and coughing. Visual fields show a quadrantanopia. What is the most suitable management of this patient? a) Urgent referral to an ophthalmologist b) Urgent referral to a neurologist c) Urgent referral to a paediatrician d) Urgent referral to their family doctor - ✔✔b) Urgent referral to a neurologist What test is used to confirm ankylosing spondylitis? a) Angiotension enzyme level b) HLA-B c) ESR level - ✔✔b) HLA-B What is the most common cause of unilateral proptosis? a) Graves b) lacrimal gland tumour c) orbital cellulitis d) - ✔✔a) Graves You saw a px last month who had a myopic shift bilaterally so you referred to GP, they return to tell you their HBA1c is 6.5% What does this tell you a) Blood sugar has been raised for the last week b) Blood sugar has been raised for the last three months c) Blood sugar normal for the last week d) Blood sugar normal for the last three months - ✔✔b) Blood sugar has been raised for the last three months A middle aged man with well controlled but longstanding type 2 diabetes attends to practice. On examination has background retinopathy, vision is 6/6 R&L and macula is unaffected. What recall do you give him?
An elderly px presents with white fluffy deposits on the anterior lens capsule. Which is least indicated? a) full threshold fields b) gonio c) IOPs d) Pachymetry - ✔✔d) Pachymetry Which of the following causes recurrent corneal erosions? a) epithelial basement membrane dystrophy b) schnyder's c) crocodile shagreen - ✔✔a) epithelial basement membrane dystrophy What corneal layer do the follwoing happen? schnyder's and crocodile shagreen - ✔✔Stroma An elderly lady complaining of a reduction in vision and affected optic discs tells you she had raised ESR when it was tested. What diagnosis is more likely because of this? a) Papilloedema b) Retrobulbar optic neuritis c) AION c) NAION - ✔✔c) AION An overweight middle aged lady who takes meds (she is not sure why but says it's to do with being too fat) has an golden glistening obstruction at a bifurcation. What further investigations are required? a) investigation of the carotid artery b) full blood work up with GP c) ESR checked - ✔✔b) full blood work up with GP What is Sheard's criterion? - ✔✔Prism needed = 2/3 (phoria) - 1/3 (compinsating fusional vergence) eg: pt has 6 XP and BO to blur is 6, the prism needed is 2/3 (6) - 1/3 (6) = 2 BI What is Percival's criterion? - ✔✔Prism needed = 1/3 (greater limit of BI or BO range) - 2/3 (lesser limit of BI or BO range) eg: pt has 6 XP and BO ranges of 6/10/8 and BI range of 21/26/22, prism needed = 1/3 (21) - 2/3 (6) = 3 BI An elderly man in his 90s who is aphakic following cataract surgery (so a high + rx of +12.00 ish) has had a reduction in vision and is struggling to read his paper. What LVA is best? a) bifs with +8.00 add
b) stand mag c) mounted telescope - ✔✔b) stand mag 5 year old boy, both siblings wear a 'thick glasses', failed the school screening. Vision RE: 6/6 LE: 6/ Has a L sot Dry ret R: +0.75 LE: +4.00/-2.00x Cyclo R: +1.50 LE: +6.00/-2.00x What rx do you give? a) RE: +0.75 LE: +4.00/-2.00X b) RE: +1.50 LE: +6.00/-2.00X c) RE+ +0.75 LE LE: +5.25/-2.00X180 - ✔✔c) RE+ +0.75 LE LE: +5.25/-2.00X A 40y woman comes for her first sight test c/o difficulty threading a needle. She has been using +1. ready readers. You find +1.00 R&L for her distance vision. What add do you prescribe? a) +0.75 b)+1.25 c) +1.75 d) +2.00 - ✔✔b)+1. A 60y/o comes in for a routine check with difficulty reading. Their current rx is R: +1.75/-0.50x20 L: +2.25 Their add is +1. Today you find R: +2.00/-0.50x20 L: +2.00. What add do you expect to find? a) +1.75 b) +2.00 c) +2.25 d) +2.50 - ✔✔b) +2. How long do you wait after putting drops in before CL insertion? a) 5 minutes b) 10 minutes c) 30 minutes d) 1 minute - ✔✔a) 5 minutes Putting in steroids and ocular lubricants what advice do you give?
- A px has a P.D of 68mm, they select a frame which is 56-18. What blank size is required? - ✔✔63mm
