Dr Bhatia Medical Institute

Case Based Questions for Ophthalmology

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1. What is the your diagnosis of the following examination of the fundus?

(A) Diabetes retinopathy.

(B) Optic atrophy

(C) CRAO

(D) Retinal detachment

1. Ans. (D) Retinal detachment It is a cause of retinal detachment appears as an elevated sheet of retinal tissue with folds. In this patient the fovea was spared, so acuity was normal, but a superior detachment produced an inferior scotoma. Retinal Detachment This produces symptoms of floaters, flashing lights, and a scotoma in the peripheral visual field corresponding to the detachment. If the detachment includes the fovea, there is an afferent pupil defect and the visual acuity is reduced. In most eyes, retinal detachment starts with a hole, flap, or tear in the peripheral retina (rhegmatogenous retinal detachment). Patients with peripheral retinal thinning (lattice degeneration) are particularly vulnerable to this process. Once a break has developed in the retina, liquefied vitreous is free to enter the subretinal space, separating the retina from the pigment epithelium. The combination of vitreous traction on the retinal surface and passage of fluid behind the retina leads inexorably to detachment. Patients with a history of myopia, trauma, or prior cataract extraction are at greatest risk for retinal detachment. The diagnosis is confirmed by ophthalmoscopic examination of the dilated eye.

2. What is your diagnosis of the following examination of the fundus?

(A) Diabetes retinopathy.

(B) Optic atrophy

(C) Acute glaucoma

(D) Optic disc drusen

2. Ans. (C) Acute glaucoma Glaucoma results in "cupping" as the neural rim is destroyed and the central cup becomes enlarged and excavated. The cup-to-disc ratio is about 0.7/1.0 in this patient. Glaucoma Glaucoma is a slowly progressive, insidious optic neuropathy that usually is associated with chronic elevation of intraocular pressure. The mechanism by which raised intraocular pressure injures the optic nerve is not understood. Axons entering the inferotemporal and superotemporal aspects of the optic disc are damaged first, producing typical nerve fiber bundle or arcuate scotomas on perimetric testing. As fibers are destroyed, the neural rim of the optic disc shrinks and the physiologic cup within the optic disc enlarges. This process is referred to as pathologic "cupping." The cup-to-disc diameter is expressed as a ratio (e.g., 0.2/1). The cup-to-disc ratio ranges widely in normal individuals, making it difficult to diagnose glaucoma reliably simply by observing an unusually large or deep optic cup. Careful documentation of serial examinations is helpful. In a patient with physiologic cupping the large cup remains stable, whereas in a patient with glaucoma it expands relentlessly over the years. Detection of visual field loss by computerized perimetry also contributes to the diagnosis. Finally, most patients with glaucoma have raised intraocular pressure. However, many patients with typical glaucomatous cupping and visual field loss have intraocular pressures that apparently never exceed the normal limit of 20 mmHg (so-called low-tension glaucoma).

3. What is your diagnosis of the following examination of the fundus?

(A) Optic atrophy

(B) Papilledema

(C) Acute glaucoma

(D) Central retinal vein occlusion

3. Ans. A. Optic atrophy

This is a case of Optic atrophy. Optic atrophy is not a specific diagnosis but refers to the combination of optic disc pallor,

arteriolar narrowing, and nerve fiber layer destruction produced by a host of eye diseases, especially optic neuropathies.

Toxic Optic Neuropathy

This can result in acute visual loss with bilateral optic disc swelling and central or cecocentral scotomas. Such cases have

been reported to result from exposure to ethambutol, methyl alcohol (moonshine), ethylene glycol (antifreeze), or

carbon monoxide. In toxic optic neuropathy, visual loss also can develop gradually and produce optic atrophy without a

phase of acute optic disc edema. Many agents have been implicated as a cause of toxic optic neuropathy, but the

evidence supporting the association for many is weak. The following is a partial list of potential offending drugs or

toxins: disulfiram, ethchlorvynol, chloramphenicol, amiodarone, monoclonal anti-CD3 antibody, ciprofloxacin, digitalis,

streptomycin, lead, arsenic, thallium, d-penicillamine, isoniazid, emetine, and sulfonamides. Deficiency states induced by

starvation, malabsorption, or alcoholism can lead to insidious visual loss. Thiamine, vitamin B12 , and folate levels

should be checked in any patient with unexplained bilateral central scotomas and optic pallor.

4. What is the your diagnosis of the following examination of the fundus?

(A) Retinoblastoma

(B) Optic atrophy

(C) Papilledema

(D) Retinal detachment

4. Ans. (C) Papilledema

It is a cause of papilledema means optic disc edema from raised intracranial pressure. This obese young woman with

pseudotumor cerebri was misdiagnosed as a migraineur until fundus examination was performed, showing optic disc

elevation, hemorrhages, and cotton-wool spots.

This connotes bilateral optic disc swelling from raised intracranial pressure.

Visual field testing shows enlarged blind spots and peripheral constriction (Fig. 28-3F ). With unremitting papilledema,

peripheral visual field loss progresses in an insidious fashion while the optic nerve develops atrophy. In this setting,

reduction of optic disc swelling is an ominous sign of a dying nerve rather than an encouraging indication of resolving

papilledema.

5. Which of the following most likely cause of the color photo given below.

(A) N. gonorrhoeae (B) Fungal infection (C) Adenovirus (D) E. Coli

5. Ans. A. N. gonorrhoeae N. gonorrhoeae causes conjunctivitis, pharyngitis, proctitis or urethritis, prostatitis and orchitis. Conjunctivitis is common in neonates (newborns), and silver nitrate or antibiotics are often applied to their eyes as a preventive measure against gonorrhoea. Neonatal gonorrheal conjunctivitis is contracted when the infant is exposed to N. gonorrhoeae in the birth canal and can lead to corneal scarring or perforation, resulting in blindness in the neonate.

6. What is your diagnosis of the color photo given below:

(A) Retinoblastoma (B) Cataract (C) PHPV (D) Coats disease

6. Ans. (B) Cataract This is the case of congenital cataract. Classification of cataract by etiology

Age-related cataract Cortical senile cataract Immature senile cataract (IMSC): partially opaque lens, disc view hazy Mature senile cataract (MSC): completely opaque lens, no disc view Hypermature senile cataract (HMSC): liquefied cortical matter: Morgagnian cataract

Senile nuclear cataract Cataracta brunescens Cataracta nigra Cataracta rubra

Congenital cataract Sutural cataract Lamellar cataract Zonular cataract Total cataract

Secondary cataract Drug-induced cataract (e.g. corticosteroids)

Traumatic cataract Blunt trauma (capsule usually intact) Penetrating trauma (capsular rupture and leakage of lens material—calls for an emergency surgery for

extraction of lens and leaked material to minimize further damage)

7. What is treatment of choice of the classical sign shown in the fundus photo given below:

(A) Control of systemic disease

(B) Laser

(C) Vitrectomy

(D) Enucleation

7. Ans. (B) Laser It is a case of diabetic retinopathy. Best treatment for this is LASER. Lasers In Ophthalmology Argon laser - It is absorbed by Hemoglobin - Used for PDR, neovascular glaucoma, capillary hemangioma Nd: YAG laser - For posterior capsulotomy, iridectomies, iridotomies, cutting vitreous bands (vibriolysis) Sec. Glaucoma, after cataract, tumors Excimer / UV laser - In refractive surgeries like LASIK (For T/t of Myopia, Astigmatism and Hypermetropia) Also used for photorefractive keratectomy (in Band Keratoplasty) Diode laser - Retinal photocoagulation, for glaucoma drainage Argon Laser is used in - RD

Retinal Vein Occlusion Eale's ds

Lasers used for retinal photocoagulation are---Diode laser, krypton red laser, double frequency Nd: YAG

8. What is your diagnosis for a patient having following fundus examination?

(A) Diabetic retinopathy

(B) Hypertension retinopathy

(C) Optic atrophy

(D) Central retinal vein occlusion

8. Ans. (B) Hypertension retinopathy This is case of Hypertensive retinopathy with scattered flame (splinter) hemorrhages and cotton-wool spots Hypertensive retinopathy Patient with systemic hypertension has frequent headaches. Vasoconstriction of the retinal arterioles is primary response to the raised blood pressure. Grading of hypertensive retinopathy (Keith and Wegner) Grade I - Consists of mild arterial attenuation, broadening of the arteriolar light reflex. Grade II - Marked generalized narrowing and focal attenuation of arterioles associated with deflection of

Veins at arteriovenous crossings (Salus sign) Grade III - Grade n + Copper wiring of arterioles flame shaped hemorrhages. cotton wool spots, hard exudates. Grade IV - Grade Ill + Silver wiring + papilloedema.

9. What is your diagnosis of fundus examination finding of the photograph given below?

(A) Diabetic retinopathy

(B) Hypertension retinopathy

(C) CRAO

(D) Central retinal vein occlusion

9. Ans. (D) Central retinal vein occlusion Central retinal vein occlusion can produce massive retinal hemorrhage ("blood and thunder"), ischemia, and vision loss. Impending branch or central retinal vein occlusion can produce prolonged visual obscurations that resemble those described by patients with amaurosis fugax. The veins appear engorged and phlebitic, with numerous retinal hemorrhages. In some patients venous blood flow recovers spontaneously, whereas others evolve a frank obstruction with extensive retinal bleeding ("blood and thunder" appearance), infarction, and visual loss. Venous occlusion of the retina is often idiopathic, but hypertension, diabetes, and glaucoma are prominent risk factors. Polycythemia, thrombocythemia, or other factors leading to an underlying hypercoagulable state should be corrected; aspirin treatment may be beneficial.

10. What is the diagnosis?

A. Epicanthus B. Microblepharon C. Cryptophthalmos D. Coloboma of the lid

10. Ans. A. Epicanthus a. This is a semilunar fold of skin, situated above and sometimes covering the inner canthus . b. It is usually bilateral and gives the appearance that the eyes are far apart and have a convergent squint and the

bridge of the nose is flat. It may disappear as the nose develops. It is normal in mongolian races, and deformity can be remedied by plastic surgery.

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