Cases of the opthalmology
Case 1
A 55 year-old man presents to his GP with a 5 day history of
sudden onset of floaters in the left eye . These were accompanied
by small flashes of light .He has treated hypertension but no
other medical problems.
The GP examines the eye and finds a normal visual acuity .
Dilated fundoscopy reveals no abnormality.
Questions
What should the GP advise ?
What is the diagnosis?
What are the associated risks?
Answers
As the symptoms are acute, the GP should arrange for an
urgent ophthalmic assessment
The man has a posterior vitreous detachment
The flashing lights are caused by traction of the vitreous gel
on the retina .A tear may occur in the retina that in turn
may lead to a retinal detachment .Laser applied around the
tear while it is flat can prevent retinal detachment
Case 2
A 75 year-old woman attends the main casualty department with
nausea and vomiting .She says that her right eye is painful and red .
Vision is reduced .She wears glasses for near and distance vision .
She is generally fit .There is no family history of medical problems.
On examination the casualty officer finds the vision to be
reduced to counting fingers, the eye to be red ,the cornea appears
cloudy and the pupil oval and dilated on the affected side .No
view of the fundus is obtained.
Questions
What is the diagnosis?
How might it be confirmed ?
What is the treatment?
Answers
The lady has acute angle closure glaucoma
Tonometry would reveal a high intraocular pressure .
Gonioscopy would confirm the presence of a closed angle
and a narrow angle in the fellow eye
The pressure must be lowered with intravenous
acetazolamide and
topical hypotensive drops including
pilocarpine .A peripheral iridotomy is then performed ,
usually with a YAG laser in both eyes ,to prevent further
attacks.
Case 3
A28 year-old man presents to his optician with a painful ,red right
eye .The vision has become increasingly blurred over the last 2
days .He is a soft contact lens wearer.
The optician notes that the vision is reduced to 60 /6 in the
right eye ,the conjunctiva is inflamed and there is a central opacity
on the cornea .A small hypopyo is present
Questions
What is the likely diagnosis?
What should the optician do?
Answers
It is likely that the man has an infective corneal ulcer
he requires immediate referral to an ophthalmic casualty
unit .The ulcer will be scraped for culture and the contact
lens and any containers cultured .Intensive broad spectrum
antibiotics are administered as an inpatient pending the
result of the microbiological investigation
Case 4
A mother attends her GP’s surgery with her baby ,now 8 months
old
. He has had a persistently watery eye since birth .
Intermittently there is a yellow discharge surrounding the eye .
The white of the eye has never been red .The baby is otherwise
healthy.
Examination reveals a white ,quiet ,normal eye .
slight pressure
over the lacrimal sac produces a yellowish discharge from the
normal puncta.
Questions
What is the diagnosis?
What advice would you give the mother?
Answers
It is likely that the child has an imperforate naso-lacrimal
duct .
The mother should be reassured that this often resolves
spontaneously .The lids should be kept clean and the skin
above the lacrimal sac can be gently massaged . Antibiotics
are generally not effective
. If the symptoms persist after
the child’s first birthday the child can be referred to an
ophthalmologist for syringing and probing of the
naso-lacrimal duct
Case 5
A 35 year-old man presents to his GP with erythematous, swollen
right upper and lower eyelids ,worsening over the previous 2
days .He is unable to open them
. He feels unwell and has a
temperature.
Examination reveals marked lid swelling ,and on manual opening
of the lids a proptosis with chemotic injected conjunctiva. Eye
movements are limited in all directions .Visual acuity and colour
vision are normal ,and there is no relative afferent pupillary
defect . The optic disc and retina also appear normal.
Questions
What is the diagnosis?
What is the management?
Answers
The man has orbital celluliti
Blood cultures and a high nasal swab should be performed
together with an orbital CT scan to confirm the diagnosis
and delineate any abscess .
He requires admission to hospital for intravenous
antibiotics and close monitoring of his vision ,
colour vision
and pupillary reflexes as he is at risk of severe optic nerve
damage.The ENT surgeons should be informed as they may
be required to drain an abscess .The normal acuity and
colour vision suggest that the optic nerve is not
compromised at present but should these change for the
worse urgent surgical drainage is required.
case 6
While working in the laboratory a colleague inadvertently sprays
his eyes with an alkali solution.
Questions
What is the immediate treatment ?
What should you do next?
Answers
The eyes must be washed out with copious quantities
(litters (
of water immediately .Alkalis are very toxic to the
eye .Failure to treat immediately
may result in permanent
severe ocular damage
The patient should then be taken to an eye emergency
clinic.
Case 7
A 27 year-old man presents with a 2 day history of a painful red
right eye. the vision is slightly blurred and he dislikes bright lights .
He is
otherwise fit and well, but complains of some backache .He
wears no glasses.
Questions
What is the likely diagnosis?
What would you expect to find on examination of the
eye?
What treatment would you give?
What is the eye condition likely to be associated with?
Answers
The patient has iritis
Examination would reveal a reduction in visual acuity ,
redness of the eye that is worse at the limbus ,cells in the
anterior chamber and possibly on the cornea (keratic
precipitate or a collection at the bottom of the anterior
chamber (hypopyon) . The iris may be stuck to the lens
posterior synechiae .There may be inflammation of the
vitreous and retina .
The patient is treated with steroid eye drops to reduce the
inflammation and dilating drops to prevent the formation
of posterior synechiae
The history of backache suggests that the patient may have
ankylosing spondylitis.
Case 8
30 year-old man develops an acute red eye associated with a
watery discharge .Vision is unaffected but the eye irritates .He is
otherwise fit and well.
Questions
What is the diagnosis?
What confirmatory signs would you look for on examination?
What precautions would you take following your examination?
Answers
The patient has viral conjunctivitis
Examination for a preauricular lymph node and conjunctival
follicles on the lower tarsus would confirm the diagnosis
This form of conjunctivitis is highly contagious it is important to
ensure that hands and equipment are thoroughly cleaned
following the examination and that the importance of good
hygiene is emphasized to the patient.