Iophth   Online  Education Programs ( Education and Assessment)

Iophth Part B is Clinical and  focused  mainly on written  exams  .Doctors applied for frcs  exams can get benifit from iophth Clinical wirtten exams 

and can apply for the Iophth B.

Acknowledgment toward our reference  Prof Dr   Muthusamy Palanisamy, MBBS ( Madras), DO ( Lond), FRCSEd, FRCOphth, AM -Malaysia
   for his help correcting and guiding,  All questions discussed lead to pass mark

Most of the  questions were answered by Dr Walid Algorafi MBBS  DO  ICOphth .

Questions and anawers

Mrs   Jones, is a 40 year old school teacher.

She has developed chronic dacryocystitis of the left side.

You are one of the members of a team of ophthalmologists in a 10 days Eye Camp in a small remote town in Bangladesh.

How would you investigate and manage her?

Describe in detail your investigation, operation procedure

Introduction

I am glad to help in this camp and help the  people, The camp should  be supported with general anesthesia facilities  , The advanced investigations like dacryocystograph  and Canalicular endoscopy  is expected to not be available ,

History

Onset , previous attacks of acute dacryocystitis indicated the priority  to start with her , and previous failed surgery then I would try to make silicon tube .

Examination and Investigation

I would start  to measure the VA for the both eyes

Inspection to see if there is mucocel elevation because  this will plane to do silicon tubing

On slit lamp to press on the lt and Rt lacrimal sac and to see if there is tears with pus regurgitation to the eye .

Dye disappearance test   , put drop of fluorescein in the Rt and  Lt inferior conjunctival  fornix and after 5 minutes I will assess  the fluorescein remained in the lt  eye I suspect to see the most of the fluorescein remained  due to the obstruction of the nasolacrimal duct.   

And nearly disappeared in the Rt

1ry Jones test , I then place drop of fluorescein again in the both eyes and to put  cotton tiped appilicatior in the inferior  turbinate in both nose

No stain in the Lt applicator  

2ry Jones test , using a canula with normal saline to irrigate  an d thought the Lt inferior  canaliculus , if fluid appeared in the nose this means the obstruction is partial  and if complete obstruction the saline will recovered through the upper lt punctum    

 Preoperative  investigations by  internist , usually checking the blood pressure , Chest x ray , CBC

Surgery   ( DCR )  Dacryocystorhinostomy

The aim of the DCR is to create an anastmosis between the mucosa of the lacrimal sac and the nasal mucosa

The patient is asked to avoid aspirin ,

General anesthesia preparation 

In addition to the general anesthesia , Inject the site of the skin incision the superior and inferior canalicular area and the infratrochelar area with local anesthetic agent ( Lignocaine  2% and adrenaline 1:200000)

Pack the nose with vasoconstrictor  like cocaine ( eg Moffet ’s solution) after the patient were sleep and has a throat pack

Making the  incision ,,,, Make an incision about 2 cm long starting just above the medial canthal tendon and running straight down along the flat of the nose  

Locating the medial canthal tendon,,, Dissect down with blunt tipped scissors , Medial canthal tendon will appear as white structure , Cut the tendon with blade 15 along with the periosteum just in front the anterior lacrimal crest

Dissect the periosteum   working medially and do the four  traction suture with 4/0 silk

Diathermy the bleeding from the suture of notha

Locating the lacrimomaxillary suture and the anterior ethmoidal air cells

After stripping the periosteum  dislocate the lacrimo maxillary suture using the traquair’s periosteal elevator

Making the osteotomy

2by2 cm in size  , Remove the nasal pack , The osteotomy often starts from within an ethmoidal air cell , the easiest approach is to remove the thin bone first using up and then  down cutting bone punches

Deboning the medial wall of the nasolacrimal duct

Deboning the nasal mucosa

Creating nasal flaps , with ratio 2 anterior to 1 posterior by using  blade 11 and 6/0 vicryl suture 

Opening the lacrimal sac  which is defined by passing the probe through the inferior canaliculus , and vertical cut with ccissor

Making the anastomosis by suterint eh anterior flaps together and the posterior flaps together

Closure  by reforming the medial canthal tendon , suture the lateral stump to the nasal periosteum  , vicryl for subcutaneous suture and silk for skin subcutical  using one  continuous stitch .

Follow up

Prophylactic broad spectrum antibiotics , Nasal douching twice  a day for 2 weeks , skin stitch removal in 5-7 days , silicon tube removal  in 6weeks – 6 months

Mrs Nafisa Abu Bakar is a 60 years old retired school teacher. She is referred to you by her Optician because she has cataract in both the eyes. The best corrected vision in the right eye is 6/36 and left eye is 6/18. Her GP has confirmed that she is in perfect health.

 How would you manage her?

Introduction

The teacher is retired and the indication of  cataract surgery now is the patient’s desire for improved visual function to perform  desired activity , for temporary management  If the patient is having nuclear sclerosis the visual acuity may be improved by minus lenses try -2,-4 for both eyes   , Ask about if the vision improved  at night , the mydriasis by Tropicamide  may help to improve the vision ,   If no improvement I will decide to do cataract extraction  and IOL  implantation

History

The general health is ok,,

Usually in the general heath we are concern in close work with  the physician in managing the  diabetes , hypertension , Ischemic heart diseases , Chronic obstructive pulmonary disease,,,,,drug, sensitivity, if the patient is using anticoagulants  , musculoskeletal disease ( operating table abnormal lie), should be arranged with good posture , Ocular History   ,history of trauma , inflammation , amblyopia ,  glaucoma , optic nerve abnormalities ,  Retinal disease .

Examination& investigations

At first  I test the visual acuity  OD6/36 and OS6/18 (corrected) , and test for near , brightness acuity testing in dark and light room , contrast sensitivity ,  visual filed test

Simply by confrontation

 I take the ophthalmoscope to see the Pupil  the Pupillary light reflex which is usually not clear , black in the center in the Posterior sub capsular cataract , nuclear ,  and diffuse or black spikes  in the Cortical cataract, Swinging light test is important as it gives clue about the retina and optic nerve status, pupil size in the dim light if large should indicate to have large optic size IOL  External examination  to see if the patient is with tremor , Parkinson’s ,   cooperative  as this will determine the plane for the surgery as local or  General  anasesthesia ,     to see the texture of the eye lids ,ectropion , entropion , blepharitis should be treated before surgery , Epiphora , press on the lacrimal sac if reflux with pus this mans DCR should be performed before cataract

 Exam the eye motility  ,  bec. deviated eye means old amblyopia which is not going to be corrected with surgery , inform the patient with this  

The slit lamp examination , , Examine the Conjunctiva to exclude  filtering bleb , Conj..Scarring, Symblepharon ,  because this will indicate direct corneal approach

, Corena to exclude any haziness , degenerative changes,   see the endothelium to exclude guttata , measure the thickness of the  cornea with pachymeter if the thickness is more than 640micro.m ,this means bad prognosis for corneal clarity ,  If she had lasik she should have the keratomter reading kept before the lasik as this will help in measuring the IOL, AC  examination see the depth , is the cataract intumescent bec if the axial length of the lens is big I prefer to do ECCE rather than Phaco  and exam the angel to exclude  peripheral anterior psynechia or new vessels .

Iris examination  see the pupil margin to exclude psudoexfoliation , dilate and exclude the posterior psynechia , if the pupil is difficult to dilate I would plane for  sphinctrotomy,or iris retraction  Crystalline lens examination  focus with slit lamp beam , to see the posterior subcapsular  cataract  , nuclear sclerosis and pseudo exfoliation can be seen clearly after dilation Fundus Examination with direct ophthalmoscope to see the retinal condition , macula,optic disc , Measure the IOP

Special tests , Potential acuity meter and laser inferometry  can estimate the visual acuity prior to the cataract extraction  through projecting snellen chart

around the lenticular opacity, Macular function test by using the Maddox rod  ,l defect in the red lines if the macular lesion , and Photostress recovery test ,is average 27 seconds after shining pen light to the eye , Blue light entoptoscopy , back ground of blue light gives shadow of the WBCS in the perifoveal    the patient see this shadow means good macular function ,Purkinje’s entoptic phenomenon , ERG,VER

Biometry IOL calculation could be obtained by  measuring the axial length of the eye by  A scan and  measuring the K1 and  K2 by the Keratometer , 

Corneal Topography  in order to know how much astigmatism  and may to plane implanting toric IOL

Specular microscopy  to count the endothelial sells normally they are more than 2400 cells/mm2

Patient Preparation and Informed Consent  to understand the risk and benefits for the cataract  extraction  

Topical antibiotics like Choramphenicol   1*4  for both eyes

After Medical  check up the medical doctor usually write the patient is fit for the operation under the  local anesthesia

Treatment

Surgical removal  of the Rt cataract

1-      The pupil is dilated

2-      The eye and  eye lids are disinfected with povidone iodine 5%

3-      The eye and lids are anesthetized  and speculum is placed to open the lids

4-      An Incision is made into the anterior chamber

5-      A viscoelastic  is injected into the AC

6-       The anterior capsule is opened to gain access to the lens mass with a capsulotomy or cpsulorehexis

7-      The nucleus is removed manually or by phacoemulsification

8-       The residual cortex is removed

9-       An IOL is inserted

10-   The wound is sutured closed

11-  An injection of  sub conj antibiotics and Depomedrol    

12-   Cover the eye with eye cotton and eye shield

13-   Give the patient prescription of Voltarine  tabs  for pain after anesthesia

Follow up

The  second day to remove the cover and  prescribe the( pred forte) eye drops usually 3 bottels  the first is with   every two hours and the other bottles for tapering eg the second 3 times daily and the third 2 times daily  , eye ointment at bed time ( Maxitrol)  ,  

Advice not to reach the eye by the water while washing the face , and after one week to use boiled water  and let it cool   .using this method for one month 

Third day  to see the patient in the slit lamp and to exclude any complications , which should be treated &if the eye is quite the patient can go home and return if any pain or vision disturbance e is happened ,  Regarding the sutures I personally using the 0,10 nylon Alcon   and I put it embedded under the conj    and relaxed with minimum astigmatism , The suture of this type usually disappear after 6 months with out needing to remove it , I take care the patient is coming from distant area and his poor situation can not offer returning  back.

Any error of refraction can be treated by glasses  and if not using bifocal IOl glasses for reading should be prescribed

Plane to do Lt ECCE in the next month

A 4 year old boy was bitten by his pet dog.

He has sustained a tear in the upper lid rearing the superior canaliculous 4 mm medial to the punctum.

 How would you manage him?

Problem in this case is the age of the patient, a wound which is caused by the dog bite which is probably irregular.

I would first ask the parents for time since the dog bite. This is important since the lid repair can be delayed upto 48 to 72 hrs. I would also ask them the time since the child had last food, since probably he may need examination under anesthesia if he is not co-operating. Also about the vaccination status of the child against tetanus and that of the dog against rabies. Antirabies prophylaxis should begin immediately.

I will make the child lie down on the examination table and try to clean the wound with normal saline taking care to remove all the grit. The length of the lid tear and its thickness will be assessed at the same time. Levator function should also be looked for to rule out aponeurosis dissinsertion. Health of the wound will also become apparent at the same time i.e. if the wound is infected or it is still too early to comment about it.

 If possible, the cornea, conjunctiva and anterior segment examination needs to be done, damage to these structures may need more immediate attention. If in doubt, a CT scan of the orbits should be done. If the margins of the wound are swollen or infected, surgery can be delayed for about 72 hrs and meanwhile systemic and local antibiotics may be given.

If it is possible I'll try to record his vision, which will be indirect evidence that the intraocular structures are not damaged.

I will arrange the OR for lid repair of the child.   Meanwhile I'll put antibiotic drops in the conjunctival sac or if there is corneal exposure, ointment may be used. Since it is potentially an infected wound I'll give an i.v. antibiotic Cefalexin 25 mg/kg.

In the OR, under general anesthesia after painting and draping, the lid should be sutured in two layers after protecting the globe using lid guard. Sac syringing also should be done to assess the damage to the lacrimal sytem. Tarsal plate is first sutured using 6-0 polyglactin suture from conjuntival side starting from lid margin side. The lid margin is apposed using 6-0 silk suture and long ends are left behind to be incorporated in the last skin suture so that it does not rub on the cornea. Skin is sutured with 4-0 silk suture. Upper canaliculus is marsupialised into conjuncival sac in the presence of well functioning lower canaliculus.

After putting antibiotic ointment, the eye will be patched. The patch should be removed the next day and surgical results assessed. Antibiotic drops and ointment to apply on the wound should be used. After 3 days i.v. antibiotics should be discontinued and oral antibiotics like Tab Cefixime 50mg b.d. should be started. There is no need to patch the eye for longer time since at this age there is always a danger of developing amblyopia. The skin suture can be removed after   a week. Child should be watched for fever and signs of preseptal and orbital cellulites. The dog should also be watched for signs of rabies like hydrophobia and rowdy behavior.

  Answered by Dr  Sudhir

Mrs Mary Smith, a 63yrs old school teacher, had a left Phaco + IOL done 3 year ago by your colleagues in your area.

 She has come to see you because she has developed irritation with photophobia of the left eye.

 Examination shows that the vision in the left eye is 6/36 with early Fuchs's Dystrophy. An anterior Chamber lens is sitting slightly decentred.

 The right eye has a vision of 6/6 with early cuneiform cataract.

 How would you manage her ?

Mrs Smith is most likely suffering from Psudophakic bullous keratopathy, RE?, which has been worsened by a pre existing Fuch's endothelial dystrophy, a
displaced AC IOL touching the corneal endothelium is possibly further contributing  to the problem.

Do not forget ( Hyphema, Uveitis , Glaucoma) syndrome

I would note the following points in her history:

h/o pain and redness: will indicate the severity of her problem. A rise in IOP would also be accompanied by pain. Pain and blurring in Fuch's endothelial dystrophy is worse in the morning. H/o recurrent corneal erosions occurs in Fuch's endothelial dystrophy.
Duration of symptoms,  any treatment  taken:  prolonged use of tear substitutes with preservatives may aggravate her symptoms by affecting her tear film.
I would ask her if she is taking any treatment for glaucoma. Open angle glaucoma is associated with Fuchs endothelial dystrophy.
H/o DM:  As she might need another operative procedure on her I would take this into account. Also post operatively after PKP persistent epithelial defects are more commo in diabetics, risk of endophthalmitis.

Examination:

VA of BE
RE = 6/36, LE 6/6
SLE:   try to present the examiner as an idiot , SLE   could be  systemic lupus erythematosus
Epithelial bullae,
Beaten metal appearance of the corneal epithelium.
Corneal guttae on specular illumination
Fluorescein staining of  ruptured bullae
AC depth, I will assess the AC depth (with the Redman smith method)
Position and type of IOL.
I will assess the posterior capsule, and the vitreous, to see  if the vitreous is touching the IOL or endothelium.
flare and cells , Blood in AC, Posterior segment  and retinal exam , Macula ( exclude CME)

Investigations:

Keratometry, Biometry  for the new IOL power
Pachymetry (normal pachymetry is 490 microns to 560 microns).
IOP BE
Specular microscopy, endothelial cell count : specular photomicrograph and Pachymetry for the other eye.

Ocular U/S
Management:
Sodium chloride 5% drops or ointment
Early morning drying the cornea with a hair dryer
Preservative free lubricants
Bandage contact lens
Anterior stromal puncture (away from the visual axis).
Antiglaucoma drops if the IOP is raised, eg alpha 2 agonists, b blockers or dorzolamide.

Treat the Uveitis if present
Surgery
Under subtenon's anesthesia, I would peform a PKP (given the stromal edema and the history of 3 years, DLEK, deep lamellar endothelial keratoplasty, which is now the treatment of choice for fuch's endothelial dystrophy,would not be possible ) and trial of IOL repositioning and if repositioning is not successful, I will perform  IOL exchange with vitrectomy if indicated intra operatively,  and replace with a sulcus fixation IOL.

 In the post operative period I will be alert to the development of any complications asso with PKP or IOL implant. Wound leak, shallow AC,  IOP rise, signs of epi/ stromal or endothelial rejection (and treat with topical/ systemic steroids if needed, I would consider ant uveitis in a graft patient as a graft rejection until proved otherwise) recurrent corneal erosions, endophthalmitis and astigmatism.

Follow Up:
I would follow up Mrs Smith for her RE every week for one month and then 3 monthly for 6 months and then yearly.
I would also keep a watch on the progression of her LE cataract and endothelial cell counts by specular photomicrographs,  to prevent the complications of  Fuch's endothelial dystrophy occurring in her left  eye.

 

Miss Hellene Dorundus, 26 has bilateral keratoconus.
Her optician has diagnosed acute hydrops of the left cornea and has referred her to you.
How would you mange?
What is the long term complications and management?
 

Introduction
The lady is suffering from bilateral keratoconus , Lt hdrope means low vison and hydration of the stroma due to rupture o tthe descmets memberane , the cause may be continuous rubbing as in vernal catarrh ,

History
Onset and history for chronic allergy like vernal catarrh , Chronic rubbing ,, pain , photophobia , Tearing , drug histroy in order not to dublicate the prescription ,
suergical histroy like keratoplasty

Examination
Measuring the visual acuity uncorrected and the best corrected Rt and Lt , the Lt would show low visual acuty
Exclude keratoconus by munson's sign by leting the pateint see down the lower lid margin showed trinagle excavation
Irregular astigmatism by the direct ophthalmscope showed dark line in the middle of the red reflex .
slit lamp would show rt clear cornea , exclude fleisher ring , vogts striae vertical tension lines in the descemets memberane

Inverstigation
Corneal topography showed red color more in the lt eye

Treatment
Cycloplegic eye drops , NACL eye drops , Eye patch , glasses , contacts

Cmplications Lomg term
persistent low vison due to corneal scarring

Long terma managment
advice for keratoplasty ,


 

A general ophthalmologist has received a 3 day old baby to you with bilateral congenital glaucoma.

How would you manage it?

If you would do a surgery, describe it in detail.

History

I would ask  about any other systemic abnormalities  , nevus flammus and port wine stain  is associated with sturge Weber syndrome and high IOP  in some cases , eye lid abnormalities and axillary  freckles  in neurofibromatosis ,  Rubella infection during pregnancy , Birth trauma..

Examination

Under GA if the child is not accepting bottle feeding to be quite ,,,

The eye globes are usually look  big ,because the high IOP expands the eye and bec  the sclera at this age is more elastic    

The diameter of the cornea is usually more than 12 mm horizontally  , Using the pen tourch to see   Corneal haziness  ,

Tearing,

Measuring the IOP by  tonopen or the schiotz tonometer because  they are portable and easy to use while the patient in supine  ,  , dilate the pupil and exam the fundus by the  direct ophthalmoscope    to see the optic disc    (   cup disc ration ) normal is less than 0,4   , and I will suspect more than 0.5 ,,,,retinoscope  for refraction ,, use portable slit lamp to see the habbs striae which is horizontal lines in the descemts membrane due to their rupture  , which confirms the presence of congenital glaucoma

, Perform gonio exam to see the angel ,

Investigation 

U/S  to see any  other intraocular abnormalities , and  to measure by the A scan the antroposterior diameter which is usually  17 mm in 40 gestational week  because myopic shift is suspected ,

Treatment

The initial treatment is surgical but using medical till surgery appointment taken

  B blockers  Timolol 0.5  B.D   and  Carbonic anhydraze inhibitor Topical drops  dorzalamide   B.D,

Surgery in detail

I will speak about the goniotmy , and trabeculotomy,,,, 

Under GA ,

Apply pilocarpin drops to protect the lens from the procedure

The anterior chamber is filled with the viscoelastics  ,  With a goniotomy a needle knife   is passed across the anterior chamber , and superficial incision is made in the anterior aspect of the trabecular mesh work , under the gonioscopy control , the cornea should be clear to perform m goniotomy . if the cornea is haze I would prefer to do trabeculotomy , in which an incision  done over the  canal of schlem    and trabeculotme is inserted to  rotate inside   the  canal of schlem  , breaking the trabeculm to the anterior chamber , and other way is to insert praline or nylon  suture   to rotate inside the canal of schlem    the hall  360  and to  open the hall angel 

Follow up   to exclude Complications , like hyphema, stripped descemts , cataract , uveitis ,  and to measure the IOP  weekly till the IOP stabilize… 

A 9 year Old  is referred to you from the accident and emergency department having  sustained an airgun pellet injury . A CT scan shows a pellet lying in the  orbit adjacent to the optic nerve  . The vision in the eye is  Hand Movement .

Describe the likely findings how you would manage the case and what you would say to the child’s parents ..

The likely Findings

The Child may be crying , Preorbital   edema due to preorbital  hemorrhage , Peribulbar hemorrhage , Retrobulbar  hemorrhage ,  Bleeding wound , The site of entry either form the globe or form the eye lid skin ,   Rupture Globe , Corneal or Scleral Perforation , Vitreous hemorrhage , IOFB ,   

 My management

History

I would ask about the time of the injury , If more that two days I suspect associated infection like Endophthalmitis , 

The composition of the pellet , air gun usually 80%  lead and  20 % iron  bec. this will associate with retina toxicity if delayed   removal.

Examination

Test the visual acuity in both eyes and record the best corrected visual acuity ,  Hopefully the patient is with out sever preorbital edema , Because This will make the examination difficult ,

Inspect for any skin entrance ,   Test with the direct ophthalmoscope to see the papillary red reflex , May be absent in this case due to  media disturbance ,   Slit lamp to see the cornea  exclude injury, Conj   and exclude sub conj. Hemorrhage

AC   exclude Hyphema, Exclude Cataract  , Lens dislocation  , Mesure the IOP usually hypotony  if the globe penetrated  ,  

Dilate and  by 90+ exclude vitreous hemorrhage,  exclude optic disc edema  

If the eye globe is not penetrated by the pellet  and it is inside the orbit adjacent to the optic disc  in the Cone , the globe is intact and the preorbital edema is the likely finding   , the Optic disc may show swelling if injured

Investigations

CT scanning  showed  pellet adjacent the optic disc

I would order   Ocular B scanning to exclude the pellet inside the eye ball , Exclude vitreous hemorrhage , PVD , Retinal detachment ,   

IF suspect infection , Culture to the site of entrance would help in giving the appropriate antibiotics

Treatment 

 Hospitalization , Tetanus prophylaxis , Place a protective shield ,

  ,  IV   Vancomycine  500mg  12 h  , and    Syru[p  Ceftrixone  250 mg   12 h  

Surgical removal of the pellet .  

Follow up 

 Observe the patient daily for  the sign of infection or inflammation  and observe the other eye  Exclude    sympathetic ophthalmitis..

?

Mr. Abdul Salad, a 42 years old manual laborer has developed mild redness and tenderness of the right eye for the passed 2 weeks.

He has developed slight blurring of vision with photophobia in this. He was started on treatment for tuberculosis 3 weeks ago  

,What are the ocular complications of tuberculosis?

How would you manage him

What are the ocular complication of the TB

42 years , 2 weeks ,RT  red and tenderness , blurred vision , photophobia , 3 weeks ttt

The  Ocular Complications of the TB

Anterior  uveitis ,

Retinal periphlebitis

Mutifocal Choroidits ,

Choroidal Granuloma

Introduction

The TB cause chronic  granulomatous  uveitis ,  Caused by tubercle bacilli   ,

Bovine  ( Mycobacterium Bovis or Human  Mycobacterium tuberculosis ) 

  The patient is suffering form  Anterior Uveitis   , May be associated with Posterior Uveitis  .

 History

The patient is with TB under treatment ,  IS the redness and tenderness get worst or is he  improving

I  would ask about his general feeling is there anorxia , sleep  sweats , fever,  

IS there cough is it stained by blood

Drug History what treatment he is taking  , Previous history of  red eye , Old  BCG vaccine

Examination

VA    in the Rt and Lt eye

Slit lamp examination RT and LT eyes,

  Rt eye  Conjunctiva  showed  circumcorneal congestion. Conjunctivitis   , Corneal  Endothelial deposits , KPS  more inferiorly,Mutton fat precipitates  ,  Corneal edema if  raised IOP , Anterior chamber ,  Flare and cells ,  The iris may showed koppe nodule on the papillary margin and bussaca nodule on the surface ,  small pupil , posterior psynechia , Lens may be clear or starting posterior subcapsular cataract ,  Measure the IOP ,  dilate and see the Fundus  exclude Mutifocal Choroidits , periphlebitis,  Choridal  Granuloma ,

 Investigations

Sputum Examination for the acid fast bacilli

Chest X ray  , Tuberculous cavity

Tuberculin Test      –ve result exclude TB

 Anticore factor antibody

Ocular  US to exclude Choroidal Tubercle , Vitorues floaters in vitritis  , Chorioretinal  thickening in posterior Uveitis 

Treatment

Treatment of Rt anterior Uveitis 

Topical Drops   -  Predforte ( Prednisolone acetate) every two  hours   -means6 times  at day time and tapering one drop every one week  , - Dexamethazone Ointment  at night befor sleep till completing the oint

Cyclplegic eye drops like Tropicamide 4 times daily  

If the anterior uveits is sever I advice  Anterior Subtenton injection of long acting steroid like Depomedrol   1 ml or B metahsone 0.5 ml

I will try to avoid  systemic  oral steroids in order to not exacerbating  the  systemic  TB infection

Systemic drugs for the TB

The patient is under  three drugs

Isoniazide , Rifampicine , Ethambutol

1-A  50 year old woman is admitted to the medical word with pyrexia , general malaise  , mouth ulcers and non healing ulcer on her lower leg , You are asked to see her because her right eye is red and painful with reduced vision

Discuss the differential diagnosis  , investigations , and management of this patient.

I have answered this question in my  way , I diagnosed the patient as diabetic and the rt eye is with neovascular glaucoma

I understand that systemic disease with red eye goes more with anterior uveitis  

Differential diagnosis

Crohn disease , with glossitis and Pyoderma gangrenosum

Ulcerative colitis

2ry sjogren syndrome

Stevens Johnson Syndrome

Long standing Diabetes with complicated proliferative diabetic retinopathy and neovascular glaucoma 

History

About general  heath  , Abdomianl Cramps ,  Is the patient diabetic   ,  

I would ask  about  treatment she is using   , did she had laser in her eyes for  ( diabetic retinopathy )  ,

Is there chronic  abdominal pain and diarrhea , blood with stool  , to exclude  ulcerative colitis   or crohn disease

Is she has dry eye dry mouth to exclude sjogrn syndrome

Did she use  sulpha  tabs one month befor to exclude stevens Johnson

Examination

  Rt eye  Conjunctiva  showed  circumcorneal congestion . Conjunctivitis   , Corneal  Endothelial deposits , KPS  more inferiorly,Mutton fat precipitates  ,  Corneal edema if  raised IOP , Anterior chamber ,  Flare  and cells ,  The iris may show koppe nodule on the pupillary margin and bussaca nodule on the surface ,  small pupil , posterior psynechia , Lens may be clear or starting posterior subcapsular cataract

Dilate both eyes and exclude diabetic retinopathy

Schirmer test  for both eyes I suspect  lower then 5 mm in 2ry sjogren

Investigations

For the systemic disease I advice the internist  to do  barium enema and abdominal X ray to exclude strictures and  Rose thorn ulceration in Crohn disease , He may prefer endoscopy ,

Fasting blood sugar 

Treatmnt

Control the fever with cold compress , antipyretic

Treat the anterior uveitis

Topical Drops   -  Predforte ( Prednisolone acetate) every two  hours   -means6 times  at day time and tapering one drop every one week  , - Dexamethazone Ointment  at night befor sleep till completing the oint

Cyclplegic eye drops like Atropine 3 times daily 

Aquess supressors if raised IOP  due to  trabculitis  or neovascular glaucoma

Systemic Steroids , Prednsiolone 1-2mg /kg  with tapering would improve the condition in crohn dis , Ulcerative colitis , Stevens Jhonson ,  Sjogren syndrome ,  

If the case due  to neovascular glaucoma add  Pan retinal photocoagulation , filtration surgery with adjunctive antimetabolites , or shunting  surgery with tube    

Follow up the patient

    - A 32 year old man has a 10 history of ankylosing spondylitis and associated uncontrolled bilateral chronic anterior segment inflammation .He attends your clinic with vision reduced to 6/24 right and 6/36 left and he ahs  developed secondary cataracts with band keratopathy in both eyes . the intraocular pressure is raised  in each eye and he is having difficulty continuing with his work  as a manager in a warehouse .

Discuss the short and long term management of this patient .

 Chronic uveitis, low VA, Band keratopathy, raised intraocular pressure  , manager

Short term management

History about the general health, Treatment of the arthritis (systemic drugs) ,

Chronic use of Topical steroids , any antiglaucoma medications contraindications , previous operations , difficulty in working , facilities to change work

Examination For Rt and Lt Eyes  , VA and with dilated drops ,  Slit lamp , cornea ( band keratopathy) , Kps , AC flare and cells  ,IOP, Gonioscopy ( exclude  PAS , Pupil ( Posterior Psynechia) Lens ( cataract ), Fundus ( dilate )  ( CME) associated with  intermediate uveitis , Snow banking inferior to the vitreous , vitritis, Retinal Bl. vessels sheathing  , Optic disc cupping ..

Investigations:  CBC ESR , Chest X ray,   PPD , ACE , FTA ABS , HLA B27

 Treatment :    Topical  Steroids , Pred forte   start with 1by 6 and then 1by 4  

Dexamethasone eye oint at night , Cycloplegics ( Mydriaticum 5 % ) 1 by 4

Sub tenon  Depomedrol ,  Systemic Steroids , NSAID, Immunosuppressive if the case non responding

Antiglaucoma mediations e.g. B Blockers ,  add Dorzalamide if the IOP still high ,aim to decrease the IOP less than 20mmhg ,Xalatan at bet time ,Systemic acetazolamide , Laser PI if  Pupillary block

Treat the band keratopathy with the  EDITA

Treat the   CME  with   NSAID drops like acular

Follow up the patient in  daily basis look for the AC flare , Measur the IOP

Long term management

Plane for   ECCE with IOL ( phako)  although we prefer to delay the operation to avoid the  complications  and prefer to do the operations after the eye is quite for  6 months

  If the IOP is no responding to the treatment  plane for the  Trabeculectomy and in the same time ECCE,

 The  medications that can be continued is the Acular   three times daily till the CMO subside

 Return to work if vision improved  .

60 years , Rt ptosis , diplopia , 3 days duration

Introduction

The patient is suffering form  the Rt 3^rd nerve palsy

History

General health  if he is suffering form diabetes , hypertension ,     History of  Head trauma, previous attack of diplopia , headache bec the diabetic 3^rd nerve palsy is usually  painful , if there is tremors or weakness in the  lt hand  to exclude benedikt or weber

Drug history , is he using medication as prescribed for diabetes or hypertension or poor compliance. 

Examination

 Note if  he has lt hemitremor , LT hemi paresis to exclude benedikt or weber syndrome associated with rt 3^rd nerve palsy.. 

Measuring the V/A in the Rt and Lt  eye, Corrected if needed  ,Usually the patient have to elevate his rt upper eye lid with his rt hand  ,

  Usually the visual acuity of the patient would be normal  unless he is suffering form cataract or diabetic Retinopathy  .

Testing the pupil size with torch ,  if the pupil dilated more then the lt pupil  usually means there is pressure on the third nerve in its basilar course( tumor or an aneurysm)

If the pupils are equal in size which is predicted means vasculopahty in the main trunk  of the third nerve .

Ocular movement, note abduction in primary position , normal abduction  , defective  adduction ,elevation  and depression , Intortion ,

 Slit lamp exam to the anterior segment for both eyes , Dilate and examine the both Fundi

If the patient is diabetic  with long history diabetic retinopathy  may be noted , hypertensive arteriosclerosis changes , ARMD. Exclude papilloedema .

Hess chart testing  for rt and lt ocular movement , Rt Hess showed restricted upper  , lower , nasal movements ,   LT restricted nasal movement .

Investigations

Exclude diabetes by  fasting blood sugar , Measuring the Bp , Usually I refer the patient to an internist to exclude  the diabetes of hypertension ,  

Neurosurgical consultation and brain CT with angiogram if the  Rt pupil is dilated.

Treatment

Rt ocular occlusion to   avoid diplopia , usually I prefer Plano glasses and to cover the rt glass ,  Fresnel  prism  with  base in  if the angel of deviation is small , Botulinum toxin injection to the Lt lateral rectus  to prevent its contracture ,  Tonics like TRI B  tabs BD and Injections IM for one  months

Follow up the patient

Every  2 months  to evaluate ocular movement by Hess chart

Strabismus surgery after 6 months

Mr. Richard Burton is a 36-year-old Scottish gardener. He developed headache, vertigo, nausea,  vomiting, and low-grade fever 3 days ago.
He was admitted to the neurology ward.
He developed rapid loss of vision in both the eyes while he was being managed.
The neurologist has found that there was loss of hearing, and loss of hair (alopecia) and skin color along, with poliosis.
You have been asked to assess the patient and if necessary to manage the patient.
What would you do?


Introduction
This case is Voct koyanagy harada with meningio- encephalitis

Examination
Complete neurological examination ,and examination of the cranial nerves
Visual acuity for both eyes ,
Examination with the portable slit lamp for the Anterior chamber to exclude anterior Uveitis , dilate and see the fundus exclude haziness caused by vitritis , papilloedema which indicates increased in the intracranial pressure due to the meningeal adhesion in associated with meningitis , Exclude retinal multiple spots of CSCR ( central serous chorioretinopathy ) ,

Investigations
FFA , which usually showed early hypofluorescent spots and late multiple pooling sites scattered around the macula
Brain MRI with enhancement showed multiple hot spots which indicated inflammation ,

Treatment
Long term steroid therapy 80-100 mg day as initial therapy for several weeks with tapering
With minimal dose ranitidine to avoid peptic ulcer.

Follow up the patient every one week and checking the fundus




A 57 year old man presents with a history of severe headache of 1 week duration
Patient is aware of field defects in both his eyes He is suffering from atrial fibrillation and is on Warfarin.His vision is 6/9 and 6/18 He has possible RAPD in his left eye How would you investigate and manage this patient

The possible differential diagnoses I would think of in this patient
1) Post chiasmal involvement of the visual pathway possibly an optic tract lesion
2)  Glaucoma
3) GCA

I would like to take history in this patient
Is the patients field defect more in upgaze or downgaze
Altitudinal defects respecting horizontal meridian more likely to be in glaucoma or non ischemic optic neuropathy
If the patients says in lateral aspect more likely to be a visual pathway lesion
Does the patient have any symptoms suggestive of stroke or weakness in limbs
How long the patient is on Warfarin and what is the dosage patient is taking right now
Any bleeding in the gums or any inadvertent bleeds anywhere in the body
Examination:
Visual acuity Mentioned as 6/9 and 6/18
and recording the best corrected  visual  acuity
Pupils RAPD in left eye has been mentioned Recheck and confirm the RAPD by doing swinging flash light test
IOP  measurmnet
Red target test to see any color desaturation if optic neuropathy is present
Gonioscopy to evaluate the angles

Dilated fundus examination for
1)Any glaucomatous cupping
2)Examine the fundus for scctoral disc edema in the left eye or evidence of disc pallor in the right eye for NAION
3)Any evidence of branch retinal artery occlusion or any emboli in the retinal arterioles, or Ischemic  CRVO

Visual field analysis : automated perimetry
1) Homonymous hemianopic fields is in optic tract lesion with Wernickes hemianopic pupil( RAPD left eye)
2) Arcuate scotoms coming on to fixation in glaucoma
3) Hemi field defects in Non arteritic optic neuropathy

In this patient the most likely diagnoses is a cortical hemorrhage [patient is on warfarin] or an infarct if an emboli has dislodged because of AF more so if the visual fields show homonymous hemianopia

Additional CT imaging with contrast and a neurologists opinion is advised

 

Mr James Cameron is a 25 years old Scottish school teacher.
There days ago, he noticed blurring of the right vision.
It has deteriorated to the extent he cannot recognize the faces of his students with the right eye.
Their red uniform also looks dull when he closes the left eyes.
How will you mange him?

Mr. James Cameron has developed acute right optic neuritis.
I would evaluate him to identify the etiology of this condition from the following possibilites.

a. Multiple sclerosis
b.Compressive optic neuritis
c. Anterior ischemic optic neuritis
d. Syphilis
e. Leber hereditary optic neuritis
f. Toxic or nutritional optic neuritis
Amongst them Multiple sclerosis is the most likely etiology.

History

I would look into following matters in history taking.
a. Present of ocular pain: because retrobulbar neurtits presents with pain on ocular movement.
b. Uhthoff phenomenon: visual loss is exacerbated by heat or exercise- indicates demyelinating disease.
c. Pulfrich phenomenon: objects moving in a straight line appearing a curved trajectory- indicates asymmetric conduction between the optic nerves.
d. History of preceding viral illness: often associated with optic neuritis and multiple sclerosis
e. History of previous episode of reduced vision in the same or the fellow eye: Multiple sclerosis associated optic neuritis often recurs.
Sequential reduced vision refers to Leber hereditary optic neuritis.
f. An episode of numbness of face or extrimities suggests multiple sclerosis
g. Family history of Multiple sclerosis. Leber hereditary optic neuritis may have a history of vision loss in maternal uncles.

Physical examination

1. Visual acuity: I'll check and record the visual acuity both eyes separately for future reference.

2. Visual field analysis: central scotoma commonly seen on optic neuritis.
There may be altitudinal, arcuate defects or nasal steps.

3. Color vision testing: by Ishihara color plates to detect color vision defects; I expect red-green deficiency in this case.

4. Pupil examination: Pupillary reaction to light may be sluggish because of conduction defect in optic neuritis.
Swinging flash light test: to elicite Relative Affarent Pupillary defect; I expect positive in this case which signifies the dilatation produced by withdrawing the light from the left eye outweighs the constriction produced by stimulating the right eye.

5. Ocular motility test: to elicite any restriction or pain.
6. Dilated funduscopy: fundus may appear normal since 2/3rd of optic neuritis are retrobulbar.
Swollen optic disc indicates papillitis.

The presence of segmental changes, altitudinal swellings, pallor, arterial attenuation and splinter haemorrhage suggest anterior ischemic optic neurtis.
7. Indirect ophthalmoscopy: to exclude retinal peripheral degenerative conditions like retinal detachment.

Investigation:
a. Complete blood count: to get any information of infection/inflammation.
b. Erythrocyte sedimentation rate, C-reactive protein: to exclude anterior ischemic optic neuritis.
c. Serum B-12 level to exclude nutritional cause.
d. Red cell folate levels to evaluate general nutritionalo status.
e. Urinalysis: to exclude toxic neuropathy
f. Rapid plasma reagin test to exclude syphylis
g. Magnetic resonace imaging of brain and orbit:
to visualize inflammation of the optic nerve.
to rule out structural lesions
to predict future development of multiple sclerosis.
H. Visual evoked potential: if MRI findings are normal.

Management:
a. Consultation with neurologist for complete evaluation of the case.
b. Admission to hospital for Mega dose of Steroid according to ONTT.

Follow up:
a. Vision may improve within few weeks in optic neuritis.
b. counseling that visual loss may be permanent.


 
Describe how you would manage an 18 year old woman with a divergent squint of 20
degrees and a marked V phenomenon who complains bitterly about the cosmetic
appearance and intermittent diplopia .
She is moderate hypermetrope (+2.5 BE).
If you decide to operate what preoperative tests would be necessary, precisely what
surgery you would perform and say what risks you would explain her?
 

History:

Age of onset- here patient presented at the age of 18 years. I have to know the age of onset, because age of onset can give an indication as to the aetiology of a squint. The earlier the onset, the more probable the need for surgical correction. The latter the onset, the greater the likelihood of an accommodative component. Inspection of previous photographs may be useful for the documentation of strabismus.

Variability- is significant because intermittent strabismus indicates some degree of binocularity. An alternating deviation suggests symmetrical visual acuity in both eyes.

H/o trauma or illness, general health, developmental problems, diplopia are significant.

Family history- is important because strabismus is frequently familial, although there is no definitive pattern. It is also important to know what therapy was necessary in other family member.

Examinations:

VA- I will check visual acuity unaided, aided and with pinhole. If poor vision in strabismic eye does not improve with refraction indicates strabismic amblyopia.

Hirschberg test- this gives a rough estimate of the angle of a manifest strabismus.

Cover test - By far the most accurate assessment of a deviation is with the cover tests. This test allow the examiner to differentiate tropias from phorias, assess the degree of control of a deviation, and note fixation preference and strength of fixation for each eye. These tests are based on the patient's ability to fixate.

1. Cover-uncover test - it should be performed both for near (using an accommodative target) and for distance to detect a deviation.

2. Alternate cover test - interrupts binocular fusion mechanisms and reveals the total deviation (phoria plus tropia).

3. Prism cover test - precisely measures the angle of deviation.

Ocular motility

1. Versions- towards the eight eccentric positions of gaze are tested by asking the patient to follow a target, usually a pen or pen-torch.

2. Ductions- are assessed if reduced ocular motility is noted in either or both eyes. A pen-torch should be used with careful attention to the position of the corneal reflexes. The fellow eye is occluded and the patient is asked to follow the torch into various positions of gaze.

Dissimilar image tests (Maddox wing, Maddox rod) and fusional amplitudes test should be performed.

Slit lamp examination- slit lamp examination should be performed to detect any pathology in the anterior segment.

Fundoscopy- It should be emphasized that dilated fundoscopy is mandatory in the context of strabismus, to exclude any underlying ocular pathology such as macular scarring, optic disc hypoplasia or retinoblastoma.

Investigation: Patient has intermittent diplopia. So Hess test and Lees screen should be performed to exclude paralytic squint. The Hess test and Lees screen plot ocular position of the extraocular muscles and enable differentiation of paretic strabismus caused by neurological pathology from restrictive myopathy such as in thyroid eye disease or a blow-out fracture of the orbit.

Treatment:

Refraction- Refractive error should be corrected. Strabismus is often secondary to refractive error. Here patient is moderate hypermetrope (+2.5 BE). I will prescribe the maximum amount of 'plus' (+2.5 BE) that can be tolerated.

Orthoptic treatment- diplopia awareness, improvement of fusional convergence may be useful.

Treatment of diplopia- here patient complains of intermittent diplopia. Intermittent does not require any treatment. If diplopia is annoying then it can be treated by the use of Fresnel prism or by uniocular occlusion.

Surgical treatment: I will do operation.

Preoperative tests-

1. Botulinum toxin chemodenervation test to determine the risk of postoperative diplopia. For example, in an adult with a left divergent squint and good vision in both eyes, the left lateral rectus muscle can be injected so that the eyes will either straighten or converge.

2. Prism test- placing a corrective prism in front of the deviating eye offers a simpler, and perhaps more accurate method of determining the risk of postoperative diplopia. If either of the above indicates the likelihood of diplopia, the patient can then be advised preoperatively of this diplopia.

Surgery- I will do bilateral lateral rectus recessions and upward transposition. If inferior oblique muscle overaction is present, the inferior oblique muscles should be weakened.

Risks I would explain her- There may be diplopia after operation. Such diplopia almost invariably resolves spontaneously. There may be overcorrection or undercorrection. A temporary overcorrection of up to 10Δ-15Δ is desirable after lateral rectus muscle recessions. Persistent overcorrection (beyond 3-4 weeks) may require treatment with base-out prism or reoperation. Reoperation should be delayed for 4-6 months because spontaneous improvement is common. Mild to moderate residual exodeviation is often treated by observation alone. Base-in prism can be given. Reoperation may be needed.


A 21-year-old apprentice decorator is assaulted and has a finger poked into his left eye.
The following day he presents with slight epistaxis and dipopia on down gaze.
Describe your management of this case.



Introduction
Usually the finger force of injury affects the eye its self and the surrounding adnexa without doing fracture for the orbital bones , the patient is suffering from epistaxis which means bleeding from the conjunctival wound and watery eye due to the irritation of wound which lead to epistaxis , diplopia is due to inferior rectus or superior rectus contusion ,periorbital hematoma .

History
Onset of the injury , history of bleeding after the injury , pain ,blurred vision , medication used , foreign body sensation ,

Examination
Visual acuity in Rt and Lt eye , Examine eye movements in all cardinal directions , test with cover uncover test as well , Forced duction test , Inspect for chemosis in the conjunctiva, any perforation in the sclera , any cut wound in the lower lid and inspect for the lower and upper punctum contour , slit lamp for testing the cornea for abrasions, Put Na fluorescein for staining , Inspect conj. for lacerations , and AC hyphema, iridodyalisis, lens subluxation , , dilate and examine the Fundus with the +90 diopter exclude vitreous hemorrhage , RD , macular edema , Use the exophthalmometer to test proptosis if suspect retroblubar hemorrhage ,


Investigations
Orbital Ultrasound
Hiss chart testing


Treatment
Antibiotics eye drops , I will use strong wide spectrum antibiotics like Choramphenicol eye drops 1 * 4 and Erythromycin eye oint at bed time bec finger nail dirty wounds needs careful care ., Eye Shield
Systemic antibiotics Augmentine 625 1*3
Prepair for surgery under General anaesthesia , dissect the conjunctiva and expose the torn rectus muscle and Repair ( either Superior rectus or inferior rectus repair ) Exclude any perforation in the sclera if happerned do suturing

If lower lid is cut , suturing the tarsus and the skin and putting the note of suture out side the lid margin ,
If hyphema is present add anti glaucoma like Betagan eye drops 0,5 twice daily , Vitamine C eff one tab daily to accelerate blood clearing ,
Complete bed rest

Follow up
with hiss chart exam

I will draw the hiss chart findings , Lt eye recatngel is limited inferiory

 

Blow out fracture

1- Introduction
 
  ,
History : I would ask about pain around the eye ,or pain during movement of the eye which suggest soft tissue and muscle entrapment in the floor fracture ,
History of blurred vision indicates eye globe injury , difficulty in opening the lids due to ecchymosed and lid Oedema , more swelling with blow out the nose indicates medial wall fracture , History of double vision which can be due to Orbital hematoma and soft tissue swelling in the right orbit or due to entrapment of the inferior rectus in the fractured site or direct injury to the nerve supply , Also ask about the gaze in which diplopia is maximum…what do you expect in blow out fracture
Whether diplopia is binocular or monocular…How will you find that?
Numbness in the lower eyelid and cheek is expected…should ask?and history of any associated head injury , Past history of any previous trauma,
medical history to exclude diabetes , hypertension , heart disease and drug allergy Why?
Examination at first I would examine the patients Visual acuity OD and OS , then exam the face to exclude any laceration , test the sensation of the infraorbital nerve bec. it is usually damaged in the orbital floor fracture and compare it with the other side , the orbit examination to exclude the impure fracture which involves the orbital rim , Exclude surgical emphysema (crepitus by palpation) which means its presence medial wall fracture ,,,
Examination of the eye globe OD and OS and to look for corneal reflexes to see if squint is present , Ocular movements test douple diplopia restrictions in the up and down gaze and By forced duction test I expect restriction of up gaze OD movement bec. of the muscle entrapment , Exophthalmometer to measure the degree of the enophthalmos , OD and OS exam by Slit lamp to exam the anterior segment ,AC, Cornea ,Pupil, iris , crystalline lens ,
Dilate to exam the Posterior segment


2 - Investigation
Radiological investigation
X ray Orbit ( PA) showing tear drop sign which is the tissue entrapment into the maxillary sinus
Ct Scanning Coronal to assess bony orbit and Axial view to assess eye ball
Routine preoperative blood investigations and ECG, X-Ray Chest as pt may have to be taken for surgery

Hiss Chart to monitor diplopia

3- Indication of surgery
- Persistent diplopia after 10 days after injury (There should be radiological evidence of fracture of the floor of the orbit with persistent diplopia
- Enophthalmos more than 2 mm
- Half of more than half of the orbital floor fracture
4- Timing of surgery
Most probably in this case after examination and investigation, it will be established that there is floor fracture with incarceration of soft tissue- so I will go for surgery as soon as haemorrhage and oedema is resolved i.e., within 2 weeks because if I delay this, the result will be less satisfactory because of secondary fibrotic changes.
5-SURGICAL MANAGEMENT:
During the preoperative period the patient should receive systemic antibiotics to avoid secondary infection
The surgery usually with incision in the inferior fornix , Lifting the periosteum , reposition the entrapped part of the muscle and the soft tissue , close the defect with supramid which fixed in the floor of the orbit and the orbital margin
6-COMPLICATIONS:
With proper timing and appropriate management , the results can be excellent and I will be able to minimize the complications .
Early complication like peribulbar haemorrhage , Oedema , compression of the optic nerve ,Globe injury , Orbital cellullitis .
Late Complication like persistent diplopia due to fibrosis , Enophthalmos due to fat atrophy , Lower lid ectropion due to scar of the incision , Optic nerve atrophy due to Inadvertent injury .

NB I may draw in this answer the water view , Surgical steps ….., Hiss chart results



Miss Lin Xioo Feng, 24 year College student has developed severe twitching of her lower lids for the past 1 month. She is very worried because she has a final exams in a month.
How would you manage her?



Introduction
The student since one month thinks in the exams , She is in stress , She is studying hard and may doesn't sleep well , She may use many cups of tea or coffee with caffeine,
All of these factors play major role in eye lid muscle twitching , also dry eye from working or studying with the computer stairing long time toward the screen , and also to her books, stress , fatigue and eye irritation would be the major cause of her lower lid twitching . ..

History
History of the present illness ,onset of lower eye lid twitching , intermittent or constant, reliving factors, worsening factors , if associated with pain , if twitching involves only the eye lid or extended to the Jaw, facial , limp ,
foreign body sensation , photophobia, previous similar condition , old trauma to the face .
How many cup of tea or coffee she is drinking , ask about sleep ,
general health , medication if she is using antipsychotic drugs , any eye drops .

Examination
Visual acuity OD and OS , inspection for the twitches , Confrontation test , Slit lamp examination searching for dry eye , we may put Rose Bengal dye drops to detect dryness , look for blepharitis , evert the eye lids to see if there's an foreign body , Fundus exam to exclude papilloedma , neurophtalmic examination to exclude any accompanied abnormalities , taping over the seventh nerve path way may lead to more twitching in electrolyte imbalance such as hypocalcaemia,

Investigation
MRI to exclude posterior fossa tumor because it may cause 7th nerve irritation ,
CBC and electrolytes

Treatment
At first reassuring the patient , decrease or stop drinking caffeine , treat underlying cause ,lubricant eye drops for the dry eyes ,treat the blepharitis , anti anxiety drugs : Clonazepam tab once daily may help ,

Follow Up
If the blepharospasm persists after she passed her exam consider botulinum toxin injections


Mr. James Watson has rubeois in both the eyes. He has developed Glaucoma in both the eyes. The pressure in the right eye is 18 with latanaprost and left eye is 28 with latanaprost and acetazolamide.
How would you manage him?
 

Introduction
The most common cause of developing nonvascular glaucoma in both eyes is the retinal ischemia in diabetic retinopathy , the patients visual acuity will determine the kind of management ,, the lt eye is more affected as multi drugs used and still with high pressure ,
Other causes which are rare like chronic uveitis , CRVO,CRAO,Ocular ischemic syndrome

.

The history is better to start with the Presenting complaint ,specific questions : flashes floaters field loss, flashes of light possible retinal detachment , new onset floaters possible vitreous hemorrhage ,field loss means optic nerve damage., Previous Ophthalmic history , like does the patient wearing glasses ,previous surgery ,Previous Medical Diabetes , Hypertension ,,Medications Any eye drops currently, Tablets ,, Family history Glaucoma

First I like to ask some questions.
Is there any pain in either eye? It is important for management options.
Is he diabetic or hypertensive? The most frequent cause of neovascular glaucoma (NVG) is central retina vein occlusion (36%) in which hypertension is one of the risk factors. Proliferative diabetes retinopathy is 2nd (33%) common cause of NVG.
Is there any history of transient loss of vision.? carotic artery occlusion is also a cause of NVG.
Is there any history of ccular disease? chronic intraocular inflammation like chronic uveitis,chronic RD and intraocular tumour can cause NVG.So i like to find out these problem from history.
I also like to know any problem with drugs which he is using for glaucoma.
If he is diabetic and hypertensive ,I like to consultant with physician for proper control of his glycaemic state and to treat any complication of diabeties and to control for thypertension.
Examinaion
I like to measure his visual acuity,and if there is adequate visual acuity I like to do visual field to get a record for his visual function.
Then I will examine thoroughly under slitlamp for any sign of congection,cornea oedema,anterior chamber reaction,rubeosis iridis .
I will measure intraocular pressure and examine fundus with 78 or 90 D indirect lens. I like to check for media clearity ,any sign of proliferative diabetic retionpathy and hypertensive retionpathy. I will look for any residual features of central retinal vein occlusion or ,central retinal artery occlusion,and retinal detachment and any trace of ocular tumour.
After fundus examination .I will do gonioscopy to check the state of angle. Angle may be still open in early open angle glauma stage of NVG.
I like to palpate carotic artery pulsation and listen carotic bruit .Absent pulsation and bruit will be heard in part
ial carotic artery occlusion.
Investigations ??
Treatment
If media is clear, ( if the media is clear and there is no PL are you going to do it)I will do panretina argon
laser photocoagulation in both eyes. Laser setting is 500 um spot size, 0.2 sec duration ,gentle white burn ,3000 to 5000 burns divited in 3 or 4 sections in both eye according to patient pain threshold and concentration. With adequate laser treatment new vessel will regress but it doesn't influence on fibroblastic component.
If media is not clear adequately,cryo or transclera diode laser photo coaguation can be tried.Before and after laser , I like to give apraclonidine eye drops to prevent post laser rise of IOP.
I will also give atropine 1% drop daily and topical steroid (dexamethalone or predford) QID..These drugs will reduce the inflammation and make the patient comfort and lessen the pain.
I will continue ocular hypotensive agent to control the IOP.Although latanoprost can reduce the IOP 25 to 35 %,convenient for once daily dosing ,it can provoke the ocular inflammation and has risk to get cystoid macular oedema.so in my point of view ,I like to give nonspecific B blocker after excluding the asthma, COPD ,2nd or 3d degree heart block.If necessary I will add topical acetazolamide eye drop both eye after checking the sulpha allergy.
I also like to give topical NSAID (ketorolac) to reduce congestion and make the patient comfort.
If visual acuity is hand movement or more ,angle is closed ,I will consider surgery after laser.
Trabeculectomy with mictomycin c or artificial filteration shunt should be done.
If there is any detached retina,I will try to reattach retina by pars planna viterectomy,gas fluid exchange and endo laser photocoagulation .
If he suffer pain and visual prognosis is not favourable,I like to do transclera diode laser cycloablation.27 burns applied 1.4 mm posterior to the limbus.1500 to 2000mw energy and 1.5sec duration should be done.cryo can be used if laser is unaviailable.
Another option for pain control is retro bulba alcohol injection. It can induce ptosis and congestion may persist.
I will do follow up 3 monthly .
\
 

Diana Arthur is a 4 years old girl.
When she was playing in her play school, a friend accidentally poked her right eye with a sharp pencil.
She is IN agony and is unable to open her eye.
How would you manage her?

The most likely Diagnosis in this case is Penetrating ocular injury of the right eye .or could be superficial corneal scratch.
Thus my work up would be directed to exclude globe rupture as well as other associated ocular injuries. I would proceed with primary repair as soon as possible if the dx is to be confirmed, in the anticipation of salvaging the globe and ocular structures.
Therefore my work up would include a detailed hx from the carers in the play school,
Stressing on the nature and time of the trauma as well as last meal. I will enquire from the parents about tetanus immunization.
Then I would proceed with both general and ophthalmic examination. However, if penetrating injury is to be dx, I would defer further examination till the time of sx under GA for the hope of protecting ocular structures.
Thus, I would interfere with primary repair as indicated. However, I would postpone 2ry repair according to the situation.
Then, I would follow up the pt POP for vision assessment and hinder the possibility of development of amblyopia.
Detailed work up:
I History:
I would take a detailed hx from the parents and carers regarding the following points:
Nature and time of trauma
Time of last meal for possibility of sx intervention
Tetanus immunization
Previous vision in this eye
Sudden or gradual DOV post trauma to assess the prognosis
POH: previous ocular problems and treatment
PMH : if any
Allergies and drug hx
II Examinatin:
1... General: state of consciousness
2... Ocular:

put   drop of anesthesia  and  Na fluorescein for detecting  if superficial scratches
VA: BCVA (bilat)
Pupils for light reflex and RAPD
I would use a pen torch or portable slit lamp to look for:
Entry site, identify location& integrity of the wound
IOP: digital (avoid applanation or tono pen at this stage)
Iris: for iris hole (TI)
Lens for traumatic cataract/dislocated or subluxated lens
Vitreous hge
Retina for retinal hge if possible view
I would look for accompanying signs of globe rupture as: subconj he, deep or shallow AC compared with the CL eye, hyphema, peaked or irregular pupil,
Low IOP
NB: once I dx penetrating ocular injury, I would defer further examination till the time of sx repair. This is to avoid placing any pressure on the globe and risking extrusion of IO contents.


I would take the following measures:
protect the eye with a shield
admit with no food or drink
I would give the pt sys antibiotics within 6 hrs of injury: cefazolin 25-50 mg/kg/d IV in 3 divided doses + Gentamicin 2 mg/kg IV q8hrs+_ topical antibiotics
tetanus toxoid if needed
place the pt on bed rest with bathroom privileges
I would request a CT scan(axial and coronal views) of the orbit and brain +- gentle B scan US to localise posterior rupture
I would liaise with the anaesthetist for GA, request ECG/ bloods (if needed)


III SX management:
I would assess the situation under GA for 1ry repair:
Wound: I would debride contaminated non viable tissue
I would carefullt maintain the AC to avoid expulsion of IO contents
Corneal wound : if small and self sealing : I would observe with bandage CL& antibiotic cover
If non sealing corneal wound: reposit viable tissssue, excise non viable iris tissue and directly close corneal wound with 10-0 nylon(bury knots to avoid irritation)
If limbus is involved: I would expose sclera to determine full posterior extent of wound. I would start closure at limbus and proceed post.
I would drain any hyphema
Scleral wound : I would do conj peritomy and explore sclera/ reposit viable uveal tissue/ cut prolapsed vitreous flush to the wound then direct scleral closure

Secondary repair:
I would plan for 2ry repair if indicated 4 – 10 days after initial injury
Lensectomy :if cataract, IOL deferred
Vitrectomy for vit hge
Encircling buckle if retinal breaks
NB: if the eye is very severly traumatizedwith no chance of restoring useful vision, I would cousel the parents for enucleation, to prevent the rare occurrence of sympathy ophth.
IV Follow up:
I would follow up the child POP with assessingof VA, refraction to hinder the possibility of amblyopia. I would assess the angle 4 weeks post trauma for angle recession.
I would inform the parents for the importance of yearly assessment of IOP for angle recession glaucoma . Finally, I would advice the parents for protective goggles during contact sports.



Mrs Agnes Smith has been undergoing treatment for hyperthyroidism for the past 10 years. She has developed disfiguring proptosis of both eyes. She has come to you for cosmetic surgery.
How would you manage her?

Mrs Smith is a known case of hyperthyroidism, and is on treatment.
Since she has disfiguring proptosis, my main concerns will be diminution of vision (due to exposure keratopathy, compressive optic neuropathy and increased IOP) and diplopia.
I would take a detailed history, perform thorough examination, and investigate the patient to asses and advise her of the need for cosmetic surgery.
History:
I would ask her the treatment that she has received so far, steroids, carbimazole, propythiouracil, azathioprine, radiations as the side effects of these drugs need to be taken into consideration.
Ocular pain: suggesting exposure keratopathy, EOM hypertrophy.
Diplopia: maxiumum in which position ? I would expect it to be maximum on upgaze.
Field defects: Scotomas, colored vision defects point to a compressive neuropathy.
History of tremors, restlessness, lack of sleep, cardio vascular problems (atrial fibrillation) are symptoms that can be present in thyrotoxicosis.
Examination
I prefer to start with Ocular exam
I would check for the following
GPE
Pulse:rate could be high
Temp: May be febrile.
Fine tremors
Ocular ex:
Visual acuity in both eyes.
Proptosis : Axial, examine the proptosis from above and from behind??? How u would examine it form behind I think u mean form above the fore head . Thrill or bruit over the proptosis and the thyroid
Measure the amount of proptosis with Hertels exophthalmolometer (normal values 22 mm, a difference of > 2mm is considered +ve.
Lid retraction (Dalyrymple’s sign),lid lag (Von graefes sign)
Lower lid lag on upgaze (Griffith’s sign)
Weakness of convergence: Moebius sign.
Color vision on Ishara’s charts
Visual fields : central or pareacentral scotomas may be present
Lagophthalmos and Bell’s phenomenon
EOM. Restriction esp in Upgaze
IOP in primary position and in Upgaze.
Fundus
Optic disc pallor, cupping, swelling or choroidal folds.
She his thyrotoxic , Would u like to inspect the neck, the thyroid gland during swallowing ( water ) , and palpate to make sure that the thyroid is enlarged
Investigation
CBC,TSH and T4 levels TSH is low , T3 is high ( I have been asked in this in glasgow 2006 and the examiner would failed me if I did not answer it correct ))
CT to detect fusiform enlargement of muscle in TED without tendon involvement.
Hess Chart for diplopia
Treatment
Lubricating drops/taping of the eye/ lateral tarsorrhaphy: depending on the extent of corneal involvement.
My main concern is the diminution of vision from the proptosis, which is due to compressive optic neuropathy, for this I will liaise with the internist and start the patient on I/V methylprednisolone
She has come to you for cosmetic surgery
Try to go with the question order
in the dose of 0.5g in 200ml of isotonic saline in 30 mts. This can be repeated after 48hrs. depending upon the response. I would monitor pulse, B.P., serum electrolytes at regular intervals.
This is followed by oral steroids 60-80mg/Kg. body weight in tapering dosage for 6-8 weeks. During steroid therapy I will monitor IOP at regular intervals.
If there is no response with above treatment, I will go for surgical decompression of the left orbit, and then the order of surgery would be Orbit  Squint  Eyelid. I will refer the patient to an oculoplastic surgeon, he would perform the orbital decompression according to the following parameters :
Mild proptosis : 21 – 23 mm, 2 wall decompression (floor and posterior part of MW)
24-27mm, 3 wall decompression (above + lateral wall).
>27 mm, 4 wall decompression (above + sphenoidal bone at apex). By decompression the orbital tissue and fat move partially into the sinus spaces, orbital fat can also be removed.
If there is a squint, I would wait till the condition is stable for a period of six months, and control the squint with prisms in the interim. I will perform IR recession (and if required MR recession) with adjustablel sutures, with suture adjusting on the next day. IR recession will take care of the diplopia as well as the lid retraction, as the overaction of the SR and LPS will now be reduced.
For the lid retraction, she may need recession of the superior and inferior lid retractors, however if the retraction is significant, spacers may have to be used, hard palate for the lower lid and fascia in the upper lids.
If there is excessive loose lid skin following decompression, then blepharoplasty may also have to be done.
Follow up:
I will follow her up regularly to assess the results of the surgery eg worsening of diplopia, development of fresh diplopia and complications of surgery like infraorbital hypoestheia following decompression, infection and Hge, in addition, to an overall monitoring of her ophthalmopathy status and side effects of drugs.

Mrs Yourona Putin is a 49 years old school teacher. She has been treated by her GP for Diabetes Mellitus Type II for the past 9 year.
She has developed vitreous haemorrhage of her right eye and the vision is only Hand movement. How will you manage her?
I will proceed to manage Mrs Putin as follows:

History:
How is the vision in the affected (right) eye ( big patch or just a hazy vision) ?
What was the vision prior to the vitreos hge? So I would know what VA should be my target for treatment.
Vision in the other eye, any similar episodes in the left eye.
Any signs of clearing : if there are, then probably I would be conservative in my approach.
Past history of similar vit hges or any h/o laser in that eye would signal poorer prognosis.
Who has been treating her , so I can access old records and fundus pictures.
Treatment history : Any medicines for associated diseases eg HTN, renal disease, glaucoma. Treatment for DM II: oral (sulfonylureas, biguanides, glitazone or acarbose etc ) or Insulin.
Examination:
Visual acuity for BE
RAPD
SLE:
Neovascularisation of Iris.
Gonioscopy to look for neovascularisation of the angles.
Anterior vitreous cells
LENS : cataract
IOP
FUNDI: Examination under mydriasis with + 90 lens, I would look for a Weiss ring (PVD), status of the diabetic retinopathy. I would examine both eyes
Investigations:
CBC (for hyperviscosity states), ESR
FBS,PPBS
FFA and fundus photograph of the RE (if retinal view is possible) and of the LE.
B Scan in the B scan u would see vitreous floaters , exclude PVD , Retinal detachment
TREATMENT
wait for two months for spontaneous resloutuion
I will formulate a treatment plan as follows:
1. I will proceed to perform PRP of the affected eye if the retinal details are visible and the patient has PDR or HRC (high risk characteristics). HRC in this case will be considered to be present if he has NVD >1/4 DD, NVD < 1/4 DD or NVE > 1/2 DD. I would use a Mainster lens, and Argon green laser settings of a spot size of 200 microns, 0.1 s and 0.1 w. Beginning at the inferior disc border and along the inferior arcade, protective barrier along the temporal border of the macula, superior border of the disc, the superior arcade, nasal border of the disc and then peripheral treatment till 1500 to 2000 burns have been put in 2-3 sittings at least 4 days apart. I will counsel him about the peripheral vision loss and diminution of night vision.
2. If CSME (retina thickening with or without hard exudates within 500u from the centre of the macula or retinal thickening 1500u which is 1500u from the centre of the macula) is also present along with PDR/HRC, I would perform a grid laser if retinal thickening is present > 500u from the centre of the FAZ and 500u from the temporal margin of the disc., spot size of 100 u and exp of 0.1 s, one burn width apart. If micoaneurysms are present 500- 3000u from the FAZ, I would use focal laser aiming at the microaneurysms, spot size may be variable from 50-100u with exp of 0.1 sec.
I will top this up after 6 weeks with PRP,all thickened and ischemic areas upto the aracade. Can be followed up by OCT.
3.If VH is dense and interferes with the retinal view, I will counsel the patient for a vitrectomy and endolaser and if TRD is present, intraocular gas tamponade.
4. If cataract is also present along with a dense VH, I will opt for phacoemulsification with a large (6.0mm optic) lens for a better view in case PRP is required in the future. After 1-2 weeks after the eye has become quiet, I would perform pars plana vitrectomy and endolaser.
5. If the patient has NVG, I would assess his IOP after PRP, if not controlled I would consider trabeculectomy with MMC, and even if this does not produce desirable levels of IOP, I would refer him for a shunt procedure to a glaucomatologist.
6. I would keep the option of intravitreal bevacuzimab (Avastin) and intravitreal triamcinolone open, however this will be reserved, only if the patient has had repeated failures of PRP and recurrent VH.
7. I would also treat the left (contralateral) eye, on the same guidelines.
8. Finally I would refer the patient to an internist for control of DM and
HTN and nephropathy, if present.
Follow up:
I would follow up the patient at 2-3 months interval and assess him for recurrence of VH, improvement/ worsening of retinopathy, NVI and


Mr. Arnold Smith is a 22-year-old University student. He went to see his GP because he developed blurring of vision in the left eye 2 days ago. The GP found that his vision has dropped to 6/60 and there are no other neurological signs or symptoms.
How would you manage him?

INTRODUCTION
From the information available, I fell that patient has left eye optic neuritis. However, I will keep in mind the other causes sudden decreased vision in this age group for my work-up.
The causes of sudden decreased vision in one in young adult include:
-optic neuritis
-multiple sclerosis
-uveitis
-retinal detachment
-vitreous hemorrhage
-acute hydrops of keratoconus
CSCR Central Serous Chorioretnopathy
History
I will take the history from Mr Smith about:
Pain on ocular movements
Previous episode of decreased vision
Diplopia
Muscle weakness
Urinary frequency
Electric sensation on neck flexion
Photophbia
Floaters
cough
joint pains
pet animals like cat
Flashes of light

Feeling of a curtain in front of visual field
Glasses—high myope/high astigmatism
Ocular examination
Both eyes Of... Examination
Visual functions
Visual acuity
pin-hole
refraction
gross colour vision
confrontation test
brightness sensitivity
Amsilr Grid
pupil examination
anisocoria?
RAPD?
ocular motility...limitation/ diplopia/ nystagmus
anterior segment examination...both eyes
cornea ..shape...cone shaped? acute hydrops, munson sign, oil droplet reflex
cells, flare in AC
K.P's....size/distribution
Iris..nodules..size & distribution
lens clarity
IOP
vitreous...dense homogenous/cells/pigments/degeneration/PVD?/hemorrhage
.. fundus examination
red reflex...normal / dull.. compare with fellow eye
optic disc
colour...pink/pale
margins... regular/blurred/raised
cd ratio
vessels crossing optic disc
hemorrhages on / around disc
macula
retinal vessels..calibare/ colour/ tortuosity
peripheral retina ....lattice degeneration?
Systemic examination
CNS examination
sensations; nunbness or tingling sensation in the limbs, trigeminal neuralgia.
motor; leg weakness, spasticity
cerebellar functions; ataxia, diplopia, intention tremors,vertigo, decreased memory, dementia, aphasia, epilepsy., depression.
interneuclear ophthalmoplegia/ bilateral INO
cranial nerves examination;
usually involvement of ;
optic nerve....optic neuritis
trigeminal.... trigeminal neuralgia
abducent nerve.. abduction deficit
Musculoskeletal system and CVS exam , if RD due to Marfan synd.
INVESTIGATIONS:
CBS and ESR to exclude inflammatory disorder
MRI Brain...typical periventicular and corpus callosum plaques of demyelination.
CSF Examination... lymphocytosis, Ig-G levels greater 15 percent and oligoclonal bands on CSF protein electrophoresis.
VEP ... DECREASED AMPLITUDE and increased LATENCY.
Perimetry ....central scotoma, enlarged blind spot.
HLA DR2
corneal topography if clinically seems keratoconus.
FFA Fundus Fluorescein Angiography
CONSULTATION with neurophysician
TREATMENT;
Methyl prednisolone 1G/24 hours, i/v ...decreases recurrences, for 3 days,followed by
Oral prednisolone 1G/kg body wt. for 11 days.
Beta Interferon....Avonex: ...
30 mcg IM qwk.... can decrease relapse rate.
for spasticity..beclofen 15-100 mg /day or diazepam 2-15 mg /day
for urgency in micturation oxybutynin
for retention .. intermittent cleaning/ catheterization.
topical sreroids and cycloplegics, if uveitis
RD surgery if retinal detachment
IF CSCR follow up till 6 months and then if no improvment do laser
PROGNOSIS
Generally good, with improvement in visual acuity. However, there is residual impairment in colour vision, contrast sensitivity , light brightness appreciation and mild RAPD.
optic atrophy may occur in patients with recurrent attacks.



 Mr Allan Brown, a 48 year old school teacher, went to see an optometrist because he had difficulty reading fine prints. He had no other symptoms or signs.
The Optometric found that he was presbyopic. His corrected vision for distance and near were normal.
The optometrist referred him to you because he found that the left optic disc was elevated.
How would you manage him?
Introduction
The teacher is with normal vision for distance corrected ( the hypermetropia show elevated small optic disc and the teacher may be more hyperopic in the LT ) , The Lt optic disc elevation if pathological the vision usually deteriorated ,
Terms:Optic disc swelling is for unilateral optic disc elevation , Papilloedma is for both optic discs elevation..
If I saw the patient , I would make sure of his glasses numbers and make sure of this elevation using the stereovision of the 90 + Dioptirc lens ,and the result may be Physiological ( normal) , If abnormal I would suspect optic neuritis , Ischemic optic neuropathy , usually non arteritic , bec. arteritic affecting ages more than 55 ,
 History
history and physical examination is required including blood presure, diabetes,inquiry about medications,any previous episode of loss of vision,any pain with movment ,weight,
,refractive errors ,cheak the eye glasses.
Eye examination
copmplte ocular examination including pupillary assesment ,intraocular pressure,colour vision evaluation,dilated fundus examination by using indirect ophthalmoscopy and slit lamp biomicroscopy .optic nerve assessment of both eyes.
Differential diagnosis
Pseudopapillodema
1. Disc drusen
2. High hypermetropia
3. Mylinated nerve fiber
True pailloedema
1. Idiopathic Intracranial Hypertension
2. Malignant hypertension
3. Diabetic papillitis
4. Centeral retinal vein occlusion
5. optic neuritis
6. Anterior ischemic optic neuropathy
7. Tyroid ophthalmopathy
8. Infiltration of the optic disc
9. Carotid cavernous fistula
10.leber optic neuropathy
Invistigation
Urgent CT scan and MRI of the orbit and brain
if normal the patient should have a neuro-ophthalmic evaluation including a lumbar puncture procedure to determine the opining pressure and to rule out other causes of papilloedema.
Visual field test ,preferably automated is useful.
Ultrasound B scans may be helpful .
Fluorescine angiography to check for autof louresince or leakge from the disc head.
OCT can be useful .
Check blood presauure
Consider blood test for thyroid ,blood sugar
Treatment
1. Any underlying problem revealed by the workup should be treated.
2. The treatment range from reasurance of the patient to surgical intervention such as optic nerve fenestration and lumpoperitoneal shunts .
3. Discontinuation of any causative medication.
4. Regular perimetry is essential to detect visual field loss .
5. Regular ophthalmic assessment is invaluable.
6. Diuritcs such as acetazolamide and systemic steroids may be used according to the final diagnosis paying attention to the potential complication of long use of steroids.
7. Shared care with other specility is often necessary.

1. A 72 year old man is referred by his optician complaining of severe glare when driving at night and difficulty in reading. He has a history of closed angle glaucoma and has bilateral PI's performed in the past. On examn he has cortical and posterior subcapsular cataracts in both eyes but with corrrection of +5.0 in each eye improves to 6/6 p in each eye. There are posterior synechiae in both eyes from preeious surgery.
How would you manage this patient and explain the risks and difficulties with any ttreatment and how would you deal with them ?

Introduction
The sever glare the patient is suffered is due to the immature cataract , and the difficulties in the pupil to dilate due to the posterior psynechia , In addition to the position of the PI ,
Because the vision still in 6/6 , I will advice to stop driving at night ,

History
Medial history ( current topical treatment eg Pilocarpine will increase the restricted visual field and glare at night and it is may be the cause of the glare and the problem can be solved if we change the medication , history of filtration surgery ,

Examination
Visual acuity for far and near , Ophthalmoscope to see the Pupillary light reflex , Fundus exam to see the optic disc C:D ratio and try to avoid the dilating drops to avoid the angle closure attack although the PI are present , Slit lamp to see if cornea is oedematous , AC if shallow , PI in iris if patent , Angel exam with the ziess contact lens , Pupillary margin ( posterior psynechia ) , Crystalline lens to see the cataract , measure the IOP in both eyes ,


Investigations
Visual field exam by Humphrey perimeter
Ocular Ultrasound and IOL calculation if you arrange for the cataract extraction ,

Treatment
Risk and difficulties

We are dealing with patient with 6/6 vision and the problem is glare only at night with driving , My advice is to stop driving and to delay any surgery for the cataract extraction till his vision deteriorated to for example 6/24

If patient insist to do the surgery , Corneal incision is advised to be away form the bleb of the previous Trabeculectomy , Using Phaco ,
The patient is at risk of blocking the bleb from debris , vitreous , and inflammation . , High pressure may return , in this case if the IOP is high repeat the trabeculectomy if the medication alone not effective

The incidence of the ocular inflammation will be high post operatively due to the old trauma ( previous operation ) – Sympathetic ophthalmitis , adviced to give subtenon depomedrol ( methyl prednisolone acetate ) after the operation , Intensive topical steroids , Systemic steroids

2. A 45 year old lady is known to have thyrotoxicosis and is on treatment. She presents to her physician witrh severe periorbital swelling on the right side, reduced visison of 6/18 in the eye and diplopia. You are asked for an opinion.
What is the DD and how would you manage this case in the long and short term?
Introduction
The patient is suffering from Thyroid ophthalmopathy , The problem know is the priorbital swelling and reduced vision which means optic nerve compression , diplobia means restrictive myopathy

History
Duration of the priorbital swelling, reduced vision , diplobia , bec the recent onset means the good management outcome, medications ,
Examination
Visual acuity in Rt and Lt , Color vision may be affected in the Rt eye bec the compressive optic neuropathy , Measure the degree of the proptosis with the Hertel exophthalmometer , and as well from the above fore head and for asymmetry in the proptosis , test the eye movement in all cardinal directions
Make note for the diplobia in which direction , use the force duction test .
Dilate and see the optic nerve and see if optic disc swelling is a feature in the rt Fundus and compare to the lt Fundus using the 90 + D lens ,
Measure the IOP in the both eye
Corneal testing by Na fluorescein to exclude exposure keratopathy,

Investigations
Thyroid Function test , Suspect Low TSH and HIGH T3 and T4
Visual field testing suspect constricted visual field defect in the rt
Hiss chart test

Short term management
Endocrine counseling for good management for the thyrotoxicosis
Give Systemic steroid with tapering , and test in 3 days basis the color vision and the visual acuity ,
Give eye lubricants drops for the exposure keratopathy , Sunglasses

Long team management
For the compression optic neuropathy , Decompression surgery by removing the medial and orbital floor , Correcting the diplobia by extra ocular muscle surgery( recession,, resection ) , correcting the ptosis .
3. A 7 year old boy brought to you by his parents with a painful red left eye. On examination th vision is counting fingers in the eye with severe antrior uveitis. Fundoscopy is difficult but suggests a large exudative retina detachment.
How would you manage and investigate this case ?

Introduction
This case could be due to -- trauma ( blunt or IOFB) which lead to uveitis , commetio retina ,
-- Inflammation: Sympathetic ophthalmitis due to old surgery or trauma which is associated with anterior and posterior uveitis and may be in Panophthlmitis
--Infection : Hypopyon ulcer and Endophthalmitis
-- Tumor like retinoblastoma ,Exophytic type is associated with the

History
History of trauma ,eye surgery , medication , Onset and duration of the red eye and the low vision , Joint pain to exclude Juvenile Rheumatoid arthritis
General health

Examination
Test the VA in RT and LT eye , RPD , Slit lamp to see if the cornea is intact , the anterior uveitis signs is glaucomatous with mutton fat , Bussaca nodules or kopee nodules in iris , hypopyon if sterile indicating sever uveitis , Measure the IOP if high associated with trabeculitis , Posterior psynechia , cataract , try to dilate and exam the vitreous , vitritis ,vitreous hemorrhage , and see the Fundus and check for snow ball and exudates in the inferior retina in pars palnitis , see exudative retinal detachment is associated with shifting fluid indicating posterior scleritis and
Check the optic nerve if involved ,

Investigations
Ocular A B scanning , to exclude retina detachment , IOFB , and to exclude hidden tumor exophytic retinoblastoma
CT scanning to exclude calcification
Blood , CBC , ESR , ANA , WBCS direct and differential
Lt orbital X ray to locate the site of the IOFB


Treatment
IF the cause is Uvitis due to trauma , Sympathetic ophthalmitis , : I will prescribe topical steroid eye drops eg ( Tobradex ) every two hours , and Topical steroid oint at night , If the IOP is more than 20mmhg B blocker eye drops , I will give Betagan 0.5% bd , Cycloplegics like Mydryacil one drop 4 times daily
Systemic Steriod , Prednison 1mg/Kg with tapering in two weeks , Posterior subtenon steroid - methyl prednisolon acatate( depomedrol)

If the cause is Tumor like retinoblastoma , Enuclation of the eye globe , the media is unclear and the history suggests big tumor to affect the anterior segment
If IOFB , Consult retinal department and
arrange to remove it through pars plana vitrectomy

Mr. Ford  is a 49-year-old schoolteacher. He is wearing glasses with a prescription:
RE: -8.00/-2.00X180=6/6 LE: -7.50/-1.50X16=6/6 Near Vision-With Add of +2.00=N5
He is interest in a refractory surgery.
How would you counsel him?
How much you manage him?
What are the problems he would have after a successful surgery?


Counseling
Mr Hosni is 49 years old and is high myopic with degree of +2 presbypoia , The counseling with the refractive surgeon here is for the best king of refractive surgery for him , Lasik , Phakic IOL , or Refractive Lens Exchange (RLE ), The patient can choose the one He preferred and the complications of each can be explained to him as mentioned in the answer later on and as well can be asked if he prefer to keep the reading glasses after the surgery Or using the monovion method which can let him see clearly for reading by one eye and the other eye is clear for far ,RLE which is removing the crystalline lens and implant an IOL is permanent procedure that may be preferred because he may suffer from cataract in 10-20 years , In the same time Multifocal IOL can be used which helps vision for far and near,...
Managment
In the history I will ask about if he has stable eye prescription for at least one year , Any eye disease or old eye injury , Any medications he is using that affects the vision , General health if he is diabetic bec all factors mentioned can affect the real measurement of the refractive error . Examination To test his visual acuity eith the prescription glasses bec if is for example amblyopic and has 6/12 viison he will have the same after successful refractive surgery ( no more ) , Do Autorefractometer again to make sure his prescription is ok and to exclude Progressive myopia
, and by slit lamp , exclude Keratoconus ,Herpetic keratitis ,
Corneal disease
Glaucoma also use applantation tonometer, See the angel and do Fundus exam for the optic disc ,
Exclude Cataract ,
Any other preexisting pathology of the cornea or anterior segment, including scarring, lagophthalmos, dry eye by using shirmer test or rose Bengal dye and blepharitis
Investigation
Blood test for fasting blood sugar
Corneal topography to to exclude ectasia
Pachymtery ( optical or ultrasonic ) to measure the thickness of the cornea, If the the cornea is thin the lasik is not preferred bec usually 25mMicromter should be left after the flap cut
In case of the phakic IOL , special measurement applied by A scan and K1, K2
In RLE the calculation is as PC IOL measurement in cataract extraction A scan , K1 ,K2 with using SRK formula
Treatment

The first idea is to correct the far and prescribing +2 for reading in both eyes , Or 2nd idea correcting one eye to be 6/6 for far and the other eye we left -2 in order to help for reading and this method called monovision , Or 3rd idea Bec he is a teacher and his work for reading is more important we can correct the reading eg we left -2 in both eyes and he can use the -2 spectacles for far ( I preferred monovision)
-Lasik laser in-situ keratomileusis is currently the most frequently performed refractive surgery which can help Mr Hosni bec it works up to 12 D myopia and up to
5 D astigmatism ,The way here is by using suction ring and making very thin flap either by microkeratome or laser cut using phemtosecond , Excimer laser applied and then flap is repositioned ,
- Phakic IOL is by inserting through small corneal wound an IOL in to the PC in front the crystalline lens.
-RLE by Phacoemulsification and foldable IOL .

Complications of lasik
- Keratoectasia
- Dry eye
- Infectious keratitis

Miss Clarice Mikimoto is a 22 years old College student. She has been wearing contact lenses for about 4 years. Two days ago she developed redness of the right eye.
She has come to see you because the eye has become redder, very painful and blurring of vision. She has notices a white spot in the middle of the cornea.
How will you manage Miss Mikimoto?

HISTORY
regarding type of contact lens
no of hrs a day of CL wear
When was the CL lens changed last
purpose of her contact lens -Refractive error/high astigmatism/cosmetic
H/O swimming with CL
Whether she uses tap water to clean her lenses
any history of trauma with nail
Has she been continuing her lenses inspite of the redness
Recent history of Conjunctivitis/or contact with person who had conjunctivitis
Examination
Visual acuity
S/l examination
Conjunctiva
careful documentation with diagram of the corneal lesion with measurements
level of lesion
look for other lesions in surrounding areas
corneal oedema
Stain the lesion
AC for reaction
IOP with TONOPEN
Fundus examination
Examination of other eye
D/D
Any infiltrate in the cornea in a CL wearer should be considered as infectious unless proved otherwise
pseudomonas
acanthamoeba
other bacterial ulcers should be kept in mind
Viral keratitis-adenoviral with nummular lesion
herpes
allergic reaction (tends to be peripheral and will have less pain)
dry eye with SPKS/filamentary keratitis
Acute hydrops in a keratoconus pt
Recurrent corneal erosion
Management
Pt to be told not to wear CL
infiltrate should be scrapped and sent for grams/KOH/calcoflor white with evans blue counter stain if Acanthamoeba suspected culture with blood/choclate/nutrientagar with e.coli overlay/
As lesion is central start on fortified antibiotics fortified tobra/genta1/2 hrly along with fortified cephazolin 1/2 hrly along with topical cycloplegic .eye should not be patched
pt reviewed next day.If acanthamoeba start on PHMB and diamidines alternating every 1/2 hr along with cycloplegicsTopical lubricants should also be prescribed
oral NSAIDS for pain
Review the pt the next day and see for improvement ,if improving CST
if pt not improving then consider changing antibiotic based on C&S report after checking compliance
Allergic infiltrate will usually subside with Cl discontinuation and lubricants after ruling out infectious cause
Dry eye can be treated with lubricants and reassessed after the condition subsides
Acute hydrops requires patching along with lubricants .Keratoplasty only after acute condition subsides.


This answer reminds of my MS exam where one short note was on MPS and finding time short ( Those days it was 2 long questions and 4 short notes 3hs/day for 3days ! + the impression was, write all you know !) I wrote 4 points as one word answers for the manifestations. Our professor after the exam would discuss our performance whether passed or failed. When I met him, the first thing that he told me was, MPS , only 4 words on manifestations , big professor ? I had passed ( I got the gold medal for best performance ! ) and he knew it was the last question on the paper, the points were right but it struck him as a very casual attitude.
So the lesson is that you may write the right answers but the person correcting it in addition to checking the contents forms an impression about the author ; casual ? overconfident ? lazy ? I know in an online course one tends to take shortcuts and the above adjectives DO NOT reflect my impression about the author but it is better to be aware than sorry.
Lastly the English are proud of their language and probably will not appreciate answers SMS style. So write sentences , you may surprised how difficult it is , to make sense plus be attractive. Practice now so that in the exam it will be smooth sailing.
Another major shortcoming of this answer was, what and why ? If you asked a particular history then you have to write why, if you looked at a particular structure, then why. A negative finding is as important as a positive finding. If you start doing this then in the clinicals also it will be helpful because there is no place for assumption. In the clinicals they just watch you and you need to explain each and every thought and action, the positive and the negative.
Excellent contents but poor packaging.
One major point missed, any case of CL infection , culture the lenses & the case.
IOP with Tonopen ? In a painful eye ? Why not digital estimation ? Would have impressed me since it indicates your clinical experience.
Would have appreciated a few points on how to identify bacterial or fungal or acanth infection clinically. Here is why it's important to explain each of your actions during examination.
You forgot systemic exam for any disease which may be a cause , RA, Dry eye, etc.
"Eye should not be patched". I am aware of this recommendation though this practice was mandatory in the "old " days. However in a painful eye one of the dictums of management is rest. And we know that even if a FB gets into eye the first reflex is to close the eye – give rest. So the point I want to highlight is, should we say "the eye should not be patched" or that "the eye need not be patched".
Need not – indicating that patching is not mandatory but if there is severe photophobia and pain you could patch the eye ; if the patient is going to keep his eye closed then its as good as patching ! In short the practice of patching or not to, did not alter the course of response so that is why it was not recommended. Somehow along the way 'need not' became 'should not' and ended up becoming a dictum ! Forget the reasons, of collection of discharge & temp rise ; anyway you are instilling drops hrly so if the eyepad is too soiled it can be changed plus even without the eyepad, collected discharge in the fornix can re-infect, if that's the argument. Anyway hrly antibiotics is there to control infection unless it's not sensitive in which case either way will not make a difference. Temp rise, well, even without eyepad the patient will keep it forcefully closed, so temp will still rise. In short why make him suffer, give the choice to the patient.
And lastly , just 24 hrs to decide response before you change the antibiotic ? How long would it take your culture & sensitivity report to reach your hands 24hrs, 48hrs, 1wk,2wks?
Do include an introduction and in the end a note on prognosis and finally a summary of the case.
Dr Muthu asked will I pass you ? Yes but I will need you to present it better in the other questions.