Eye

Question 1

A two year old has been brought in because the parents think they can’t see as well and their eye seems sore. A red reflex in each eye rules out what pathlogy?

Answer 1

• large retinal detachment
• large vitreous haemorrhage
• dense cartaract
• large retinoblastoma

key is to look for symmetry in both eyes. Colour can change depending in skin colour (more orange than red in dark skinned children)
Dark dot in center of red reflex may represent a coreal FB

Question 2

In the abscence of trauma, an unequal pupil suggest whta pathology

Answer 2

Intraoccular inflammation such as uveitis

Question 3

An RAPD suggest damage/disease to which structures?

Answer 3

• optic nerve (CNII)
• retina
• visual pathway (eye to occiptal lobe)

Common causes
CNII - optic neuritis e.g MS, ischaemia e.g artery/vein occlusion
glaucoma
deteached retina
CVA

Question 4

Red flags for orbital cellulitis?

Answer 4

• systemic features of inffection
• concurrent sinusitis
• abnormal visual acuity or RAPD
• chemosis
• proptosis,
• diplopia
• pain on eye movement

sinusitis can be the source of infection
infection can spread to carvenous sinus causing throbosis, meningits, abscess, frank sepsis

Question 5

A patient presents with a painful eye. You instill topical anaesthetic drops and their pain resolves. What structures must be causing the pain?

Answer 5

• conjunctiva, or
• cornea

Question 6

A pt had a rock strike their eye. You are worried about a retrobulbar haemorrahge causing intraoccular compartment syndrome. What are signs and symptoms of this?

Answer 6

• IOP > 30mmHg
• reduced visual acuity
  -sluggish pupil and RAPD
• proptosis
• firm globe on palpation

Question 7

Your patient has a paiful red eye. There is no eyelid swelling. You instil topical anaesthetic but it doesn’t reduce the pain. What does this limit the differenials to?

Answer 7

• uveitis
• acute glucoma
• scleritis

Question 8

How do you perform a siedel test?

Answer 8

• instil 2% fluorescein above the lesion or superior fornix
• observe lesion under cobolt blue light with slit lamp
• ask pt to blink
• test positive if aqueous humour dliutes the fluorescein creating a green fuorescing ‘waterfall’
• indicated full thickness corneal or scleral defect

Question 9

How much fluid and how long do you irrigate a chemical eye injury before doing an examination?

Answer 9

2-4 L of 0.9% saline or hartmans or
30 minutes

Question 10

A pt has a chemical injury to their eye and a nurse has been irrigating it for 30 minutes. How long after irrigation do you have to wait before checking the pH?
What should the pH be?

Answer 10

Wait 5 minutes
pH 6- 8 = normal
Then check again in another 20 minutes to ensure STAYS normal

Question 11

A pt has a chemical eye injury and it has been irrigated for 30 minutes. What are features on examination of a severe burn that needs immediate referral to an opthamologist?

Answer 11

• significant epithelial loss
• chemosis
• corneal oedema or haziness
• blanching of conjunctival vessels or opacification

all occular burns get anbiotic drops and follow up with ophthalmology

Question 12

What is a complication of a hyphema?

Answer 12

Raised IOP as blood can block drainage from anterior chambler

• refer to ophthal
• they may want cycloplegics, antiemetics and advise sleeping partly upright

Question 13

What antibiotics are best for an open globe injury?

Answer 13

moxifloxacin or ciprofloxacin

Question 14

Which children should be given amoxycillin immediately for suspected bacterial otitis media?

Answer 14

• age < 2
• immunocompromised
• cochlea implant or hearing impairment
• indigenous
• high grade symptoms: high fever, vomiting, peforation

Otherwise review 2-3 days to see if improvement occurs. This can avoid 80% of children getting antibiotics. If you give a script and say to fill is not improved this avods 50% of children getting antibiotics

Question 15

What nerve should be assess when you are reviewing a
- eye injury/disease
- ear injury/disease

Answer 15

Eye = infraorbital nerve
Ear = facial nerve

Question 16

Managment of peritonsillar abscess

Resus
Specific treatment
Procedures
Disposition

Answer 16

• fluid rehydration 10ml/kg IV bolus, can repet
• IV benzylpenicillin 50mg/kg up to 1.8g IV 6 hrly and if not drainaged metronidazole 12.5mg up to 500mg IV BD
• Refer to ENT for drainged or could consider needle aspiration under ENT advise if remote and systemically well (aspiration is effective in 90% of cases)
• Ideally admit under ENT

Question 16

Management of post tonsillectomy bleed?

Resus
Specific treatment
Procedures
Disposition

Answer 16

• PIVC, ideally 2 then 10-20ml/kg 0.9% sodium chloride then if ongoing fluid resus give PRBC 10-20ml/kg IV
• Tranexamic acid 15m/kg IV and spray co-pheynlcaine to oropharynx then if pt allows forceps to hold 1:10,000 (1mg in 10ml) adrenaline soaked gauze onto tonsillar bed. Push laterally not posteriorly. Hold until bleeding stops or help arrives
• Intubate with most experienced intubated if massive haemorrahge
• Admit ENT/ICU

Allow pt to sit up and forward to spit blood out
ENT may advise antibiotics

Question 17

Complications of peritonsilar abscess?

Answer 17

• dehydration - common
• extension to retropharyngeal space - rare
• haematogenous spread, sepsis - rare
• airway obstruction - rare
• aspiration causing pneumonia - rare

Question 18

You diagnose your patient with peritonsilar abscess. Do they need a CT scan?

Answer 18

Only if diagnosis is uncertain or you suspected deep neck infection

For children use this rule. For adults may be more liberal with CT scan

Question 19

Signs of peritonsillar abscess?

Answer 19

• cervical lymphadenopathy
• unilateral tonsilar erythema
• bulging of superior aspect of tonsil
• uvula deviation to opposite side

differential is peritonsillar cellulitis where there is no abscess collection but clinically its hard to distinguish the two

Question 20

Symptoms of a peritonsillar abscess that help you distinguish it from uncomplicated tonsillitis

Answer 20

• muffled “hot potato” voice
• ipsilateral ear pain
• trismus

Question 21

Complications of GAS (strep pyogenes) pharyngitis?

Answer 21

Suppuative complications
- peritonsilar abscess
- sinusitis
- otitis media
- necrotising fascitis

Non-suppurative complications
- rheumatic fever
- glomerulonephritis
- autoimmune associated neuropsychatric disorder associated with GAS

All very rare in Australia and antibiotics should only be for high ris individuals: Indigenous, immunocompromises, severe symptoms
Treatment with phenoxymethylpenicillin BD for 10 days or IM benzathrine benzylpenicillin

Question 22

A strike to the chin from a fall especially in children can be associated with what fracture?

Answer 22

manidublar condylar fracture

Question 23

How long can an avulsed tooth survive in
- milk
- saliva or saline

Answer 23

• milk = 6 hours
• saliva/saline = 1 hour

reimplantation within 15 minutes allows for best surival
if tooth is soiled rinse very briefly with saline (less than 10 seconds)
Water is bad for the tooth
dont handle the root - need cells here to surival to reimplantation to be successful

Question 24

symptoms of a retropharyngeal abscess

Answer 24

- sore throat - odynophagia - torticollis or reduced neck movement ## Footnote late: drooling, voice changes, systemic toxicity, chest pain, trismus, obstructed breathing

Question 25

While there is poor sensitivity and sensitivity, what may a lateral neck xray see for suspected retropharyngeal abscess?

Answer 25

- prevertebral swelling - gas - foreign body - air fluid level - bony erosion - evidence of alternative disease

Question 26

Management of retropharyngeal abscess with sepsis ## Footnote Resus Specific treatment Procedures Disposition

Answer 26

- IVF 10-20ml/kg 0.9% sodium chloride - cefazolin 50mg/kg up to 2g IV 8 hrly + metronidazole 12.5mg/kg up to 500 mg IV BD - CT neck with contrast - consider intubation - refer to ICU ## Footnote same regimen can be used for non-shocked but could also chose augmentin 25mg/kg IV up to 1/0.2g IV 6 hrly If at high risk of MRSA add on vancomycin If penicillin allergy clindamycin 15mg/kg up to 600mg IV 8hrly

Question 27

Antibiotic for orbital (post-septal) cellulitis

Answer 27

Cetriaxone 50mg/kg IV 24 hrly or BD if needing ICU + flucloxacilin 50mg/kg IV 6 hrly ## Footnote + vancomycin is MRSA risk factors

Question 28

Antbiotic for periorbital (pre-septal) cellulitis with risk factors for haemophilus influenzae B?

Answer 28

Amoxycillin + clavulanic acid 22.5mg/kg ## Footnote risk factors for Hib age < 5 and not immunised

Question 29

Causes of amaurosis fugax

Answer 29

- thromboembolic (carotid artyer) - giant cell arteritis

Question 30

Possible causes vision loss + headache

Answer 30

Giant cell arteritis elevated intracranial pressure

Question 31

Causes of binocular diploipa | binocular means present when both eyes are open

Answer 31

- cranial nerve palsy from intracranial patholgy e.g aneurysm of PCA, mass - giant cell arteritis - myasthenia gravis - thyroid eye disease - periorbital fracture ## Footnote Keep it simple by working through the following questions: * Is it only present with both eyes open? * Is it present if one eye is closed? If so, which eye? If double vision is only present with both eyes open, consider whether: * the two images are side-by-side, on top of each other, or vertically displaced * the double vision resolves if the patient looks in a particular direction * the double vision gets worse (greater separation between the images) in another direction.

Question 32

Symptoms concerning for giant cell arteritis

Answer 32

- abrupt painless vision loss in one or both eyes - brief transient vision loss in hours or days prior - double vision - headache - classically frontotemporal - jaw or tongue claudication (worse chewing, talking) - discomfort brushing hair over temples - weight loss - anorexia - polymyalgia rheumatic symptoms - pain and stiffness in hips, shoulders

Question 33

Why could an eye injury cause bradycardia?

Answer 33

Oculocardiac reflex ## Footnote more common in children. An eye fracture entraping the inferior rectus could cause severe bardycardia

Question 34

What are three reasons not to dilate a pupil?

Answer 34

- will prevent RAPD assessment - may precipitate acute angle closure glaucoma - prevents neuro observations of head injured patient ## Footnote RADP is a very useuful sign. always check before dilation

Question 35

During the start of your eye exam you see the globe is ruptured. What are your next two steps?

Answer 35

Cover with a clear cover or other makeshit cover (cup) Call opthamology Do not assess any further ## Footnote Do not clean the eye, don' assess further. Do not put pressure on the eye

Question 36

What nerve palsy has - ptosis - eye is down and out

Answer 36

3rd nerve palsy ## Footnote pupil may also be dilated

Question 37

What nerve palsy is present when - eye is misaligned medically - can't abduct

Answer 37

Cranial nerve 6

Question 38

what conditions can cause a relative afferent pupillary defect?

Answer 38

- large retinal detachment - central retinary artery or vein occlusion - optic nerve ischaemia, compression - optic neuritis - gluacoma

Question 39

Acute angle closure gluacoma treatment

Answer 39

- acetazolamide 500mg IV then 250mg PO 4 hlry Every 15 minutes give 1 drop of - timolol 0.5% (beta blocker) - brinzolamide 1% (carbonic anhydrase inhibitor) - brimonidine 0.2% (alpha-2 agonist) - laser therapy by opthal ## Footnote Do not give prilocarpine 2% (miotic) while IOP > 40mmHg, can exaccerbate some types of angle closure gluacoma. DW opthal first. Avoid eye patches avoid dim lighting lay patient supine treat pain treat nausea Acetazolamide CI in severe renal/hepatic impairment, Low K or Na, sulphonamide sensitivity, sickle cell disease

Question 40

You patient doesn't have a red reflex in one eye. What conditions could cause this?

Answer 40

- retinoblastoma - cataracts - vitreous haemorrhage - retinal detachment ## Footnote most useful thing you can do with an opthalmoscope is check for the red reflex Don't dilate unless you have carefully assess the pupil and done an RAPD. Don't dilate if you think pt needs urgent transfer to opthal - it will exclude them from being able to check pupils/ RAPD themselves

Question 41

When looking for fluoroscein uptake, which light do you use - green - blue

Answer 41

- cobalt blue ## Footnote green light filter is not for fluorscein uptate. It used to help see red cells by opthamologist Blue light is at the end of the height adjustment nob - turn once more than 8mm (max height) and it clicks to blue Green light is by filter dial

Question 42

Treatment iritis

Answer 42

topical predisolone mydriatic (dilate) eg topical cyclopentolate or homatropine

Question 43

What visual acuity is needed for - private licence - commerical licence

Answer 43

private 6/12 in best eye commerical 6/9 best eye and 6/18 bad eye ## Footnote Other: if monocular vision, need 3 months to adjust before able to drive with conditional licence (if you give your pt an eyepatch they can't drive) visual field defects: none ok for commercial, some peripheral ones ok for private

Question 44

Fundoscopy findings central retinal artery occlusion

Answer 44

- retinal pallor - cherry red spot ## Footnote will have sudden painless vision loss RAPD poor prognosis Order ESR/CRP as can sometimes be due to vasculitis but often are embolic from carotid

Question 45

signs and symptoms optic neuritis

Answer 45

- vision loss over hours to days - pain, that worsens with eye movement - impaird colour vision - RAPD

Question 46

fundoscopy central retinal vein occlusion

Answer 46

- extensive retinal haemorrhage "stormy sunset" - dilated turtuous veins - cotton wool spots ## Footnote sudden to gradual, often painless vision loss

Question 47

normal intraoccular pressure?

Answer 47

10 - 21mmHg ## Footnote be careful not to put pressure on the globe if you need to open the eye lids - it will raised the pressure erroneously

Question 48

Slit lamp examination anterior uveitis

Answer 48

- cells/flare in anterior chamber or hypopyon - hazy cornea - peri-limbal injection (ciliary injection) ## Footnote topical anaesthetic doesn't work as inflammation is deeper

Question 49

What is not a treatment for acute angle closure glaucoma? - timolol 0.5% - pilocarpine - acetazolamide - homatropine

Answer 49

Homatropine ## Footnote after DW opthal use pilocarpine to cause miosis to increased aqeuos fluid drainage. Homeatropine will cause dilation and make things worse

Question 50

signs and symptoms of a retrobulbar haematoma

Answer 50

- severe eye pain - vision impairment - opthalmoplegia - chemosis - RAPD - hard to palpation or raised IOP - proptosis - peri-orbital ecchymosis ## Footnote when lateral canthotomy is needed IOP is often > 40mmHg

Question 51

signs and symptoms orbital blowout fracture

Answer 51

- impaired movement esp upwards (trapped inferior rectus) - diplopia - sunk or protruding eye - crepitus - subconjunctival haemorrhage that you can't see end of - inferior orbital nerve neuropraxia

Question 52

max dose oxybuprocaine eye drops in adult or child | is same dose for both

Answer 52

6 drops ## Footnote duration of action 20 minutes

Question 53

acceptable pH range after chemical burn to eye

Answer 53

6.5 to 8 ## Footnote compare to other eye wait 5 min after irrigation has stopped

Question 54

A patient has an traumatic eye injury. What useful things can be seen on a CT orbit?

Answer 54

- retrobulbar haematoma - retained foreign body - orbital fracture

Question 55

4 most important parts of visual exam for traumatic eye injury

Answer 55

- visual acuity - RAPD - red reflex (loss suggest retinal trauma/detachment) - slit lamp with fluoroscein + cobalt blue (seidel test)

Question 56

Managment of open globe injury

Answer 56

- shield eye - ondansetron 8mg IV - analgesia 2.5mg IV morphine - IV antibiotics broad spectrum e.g ciprofloxacin 400mg BD - no eye drops - tetanus prophylaxis - consider CT orbit for retained foreign body - strict bed rest, sit up 30 degree - NBM - refer ophthamology urgently

Question 57

Managment orbital fracture

Answer 57

- analgesia - no nose blowing - cough/sneeze with open mouth - broad spectum Abs e.g augmentinDF - refer maxfax for immediate surgical repair if occulocardiac reflex triggered. Otherwise done at day 7-14. Observation only if minimal or no diplopia ## Footnote 30% have associated orbital injury medial wall blows out first but rare needs surgical intervetion. Floor is 2nd most common, often distrubs eye position. Lateral wall and roof are strong and only fracture with high force injury

Question 58

Steps of canthotomy and cantholysis

Answer 58

- topical oxybuprocaine to eye and inject lignocaine with adrenaline lateral - artery clamp to lateral canthus a few seconds - cut laterally 1-2cm - hold lower eyelid taught with forceps, cut lateral canthal tendon - ensure lower eye lid now lax - apply chloramphenicol ointment and dressing

Question 59

cranial nerve III palsy appearance

Answer 59

- ptosis - pupil may be dilated - eye looks down and out ## Footnote emergency conditions associated with this are - giant cell arteritis - raised intracranial pressure other urgent conditions: pituitary apoplex (bleed), PCA aneurysm, thyroid eye disease, myasthenia gravis, horner syndrome, compression neoplasm Get CTA Liase with neurology Pt cannot drive

Question 60

A patiet reports diplopia walking down stairs. On examination they are holding their head tilted and struggled to look down when the eye is adducted. What nerve palsy do they have?

Answer 60

Cranial nerve IV (trochlear) ## Footnote Superior oblique moves eye down when adducted Emergent: giant cell arteritis Urgent: thyroid eye disease, myasthenia gravis, trauma, congenital Liase with neurology Illegal to drive

Question 61

Investigations for central retinal artery occlusion

Answer 61

- CT +/-aniogram head and neck - ESR , CRP - coags ## Footnote Examination findings: - poor visual acuity - marked RAPD - fundus: cherry red spot, pale retina, venule narrowing - painful temporal artery if due to GCA Situation may be improved if treatment started in 4 hours CT head non-con for rule out bleed if onset within 4.5 hours as may treat with thrombolysis coags for baseline beofore thrombolysis Angiogram not essential , can see carotid disease

Question 62

Differential sudden painless vision loss

Answer 62

- central retinal artery occlusion - central retinal vein occlusion - giant cell arteritis - amaurosis fugax - vitreous haemorrhage - retinal detachment - macular degeneration with bleed - optic neuritis (multiple sclerosis) ## Footnote optic neuritis may also be painful

Question 63

A patient reports a curtaining loss of vision but their visual acuity is 6/6. What condition is this and why is having 6/6 vision a greater emerency than impaired vision?

Answer 63

Retinal tear or detachment 6/6 vision means 'macula on' detachement and macula may be saved with early surgery. Fast patient | safe to dilate eyes, may see detached retinla ## Footnote precursor of retineal detachment is posterior vitreous detachment. Vitreous liquifies (age 50 - 60 most common) retracts and pulls on retinal causing flahsers and floats. Retinal has not torn or detached but is at risk. Should see opthalmologist within 24 hours. Retina can detach over 6 weeks

Question 64

A patient presens with diplopia and drooping of their eyelid worse towards the end of the day. What condition might they have?

Answer 64

Myasthenia gravis ## Footnote may have dysphagia, limb weakness, difficulty breathing Fatigable - particually of the eyelids causing various ptosis Ask pt to blink for 1 minute. Ptosis will get worse. 2 minuts later significant improvement. Ix: Ant-Ach (AChR) antibody, Anti-MuSK antibodies, TFTs Refer neurology

Question 65

Vision threatening complicatoins of thyroid eye disease?

Answer 65

- corneal ulcer (unable to close eyes) - compressive optic neuropathy ## Footnote Key eye examination: visual acuity, protptosis, incomplete eyelid closure/corneal ulcer, stabismus, optic nerve function, RAPD, EOM plasy Ix: TFTs, CT orbit if proptosis or red eye, FBC, LFTs, EUC, BSL in preparation fo corticosteroid treatment DDx: orbital cellulitis, trauma, orbital tumour

Question 66

Who do you refer a pt with episode of amauroxis fugax to?

Answer 66

General physician ## Footnote In addition basic bloods in ED need: Lipids, fasting glucose thrombophilia screen Echocardiogram Carotid doppler Differentials: Giant cell arteritis, vasculitis, transient visual obscuration, transient blurring of vision dry eye or vitreous floaters