A 68-year-old man with a history of type 2 diabetes mellitus presents with worsening eye sight. Mydriatic drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. A referral to ophthalmology is made. Later in the evening whilst driving home he develops pain in his left eye associated with decreased visual acuity.
What is the most likely diagnosis?
Correct Answer C: Mydriatic drops are a known precipitant of acute angle closure glaucoma. This scenario is more common in exams than clinical practice.
Acute angle closure glaucoma:
Glaucoma is a group disorders characterized by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognized that a minority of patients with raised IOP do not have glaucoma and vice versa.
In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow.
Factors predisposing to AACG include:
Features:
Management:
A 71-year-old with a history of type 2 diabetes mellitus and hypertension presents due to the sensation of light flashes in his right eye. These symptoms have been present for the past 2 days and seem to occur more at the peripheral part of vision. There is no redness or pain in the affected eye. Corrected visual acuity is measured as 6/9 in both eyes.
Correct Answer C: Flashes and floaters - vitreous/retinal detachment.
Flashes and floaters are symptoms of vitreous detachment. The patient is at risk of retinal detachment and should be referred urgently to an ophthalmologist.
Sudden painless loss of vision: The most common causes of a sudden painless loss of vision are as follows:
Ischaemic optic neuropathy:
Central retinal vein occlusion:
Central retinal artery occlusion:
Vitreous haemorrhage:
Retinal detachment:
Differentiating posterior vitreous detachment, retinal detachment and vitreous haemorrhage:
A 67-year-old man presents as he has developed a painful blistering rash around his right eye. On examination a vesicular rash covering the right trigeminal nerve dermatome is seen. Currently he has no eye symptoms or signs.
Which one of the following is most likely to predict future eye involvement?
Correct Answer A: This is Hutchinson's sign which is strongly predictive for ocular involvement.
Herpes zoster ophthalmicus: Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles.
Complications:
Each one of the following is a cause of a mydriatic pupil, except:
Correct Answer D: Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis and is often said to be the prostitute's pupil - accommodates but doesn't react. Another mnemonic used for the ArgyllRobertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA).
Causes:
Mydriasis Causes of mydriasis (large pupil):
Drug causes of mydriasis:
A 45-year-old woman with Graves' disease comes for review. She has recently been diagnosed with thyroid eye disease and is being considered for radiotherapy. Over the past three days her right eye has become red and painful. On examination there is proptosis and erythema of the right eye. Visual acuity is 6/9 in both eyes.
What complication is she most likely to have developed?
Correct Answer A: Thyroid eye disease affects between 25-50% of patients with Graves' disease. It is thought to be caused by an autoimmune response against an autoantigen, possibly the TSH receptor, which in turns causes retro-orbital inflammation. The patient may be eu-, hypo- or hyperthyroid at the time of presentation.
Thyroid eye disease: Prevention:
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