% 4th Year MBBS Made By MEES Students of Various Medical Colleges of Med-ComAcknowledgement Alhamdulillah ved col earned its reputation as the only medical organization which is always willing to help other students, making everything easier for them as much as possible. We do believe\that goodness and badne: ae disappear completely; rather it’s the dominance of one d or bad. And we are determined to make this era as good as doing good to others, willingly and selflessly. Treating human beings properly is a great ré¥ponsibility for a doctor. We do recommend you to study from recommended syllabUS books and use these only for quick revision just before exams, as a patient may present with a disease that is not written in past papers. We owe special thanks to Nooriya Goher, Naila Shoukat, Bushra Shahid, Iqra Noor, Aeman Ali and Zoya Manzoor and Central Park students for spending their precious time in solving past papers. May they get return from God for this selfless effort. CEO Med-Com,.& Manager Papers Solving Project Muhammad Kamran Mehwar Allama Iqbal Medical College, Lahore Atto//www.facebook.com/Doc.M.Kamran chitto:// www facebook.com/MedCom.2011 All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationTable of Conten om Sections” # __ Page No Vision, Physiology, anatomy , errors, Pupil 4 a 4 Orbit , lid , lacrimal appat ep be 6 Conjunctiva , corr R redieye 35 Lens , vitreous ,uveal tract, glaucoma, optic *% 56 cataract, neurology All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSolved Past Papers of Eye By MedCom 4 Online Version Section 1 eat 2003" Q1.Write short note on Myopia? ‘Ans: "A form of refractive error in a: rays of light entering the eye are focused in front of retina wit eae at rest is called myopia or short-sightedness." ad ; az Etiology: # ba 1. Axial: due to increased an jor diameter of the globe. 2. Curvature: due to increase of cornea or lens 3, Index: due to increase refractive index of lens — 4, Forward displacement of the lens. Types: 1. congenital 2. simple 3. pathological(degenerative) s/s: Indistinct distant vision is the most common symptom. A scan US shows : increases in axial length. Treatment: ( Non-surgical) “L.Use concave lenses 2.contact lens (Surgical) 1 Flattening of central part of cornea a. Radial keratotomy b. Photorefractive keratectomy ¢. Laser epithelial keratomileusis 2. Clear lens extraction 3. Phakic posterior chamber implant. Annual 2004 Ql: Write a note on Astigmatism? Ans: "It is that condition of refraction in which a point of light cannot be made to produe\a punctate image upon the retina by any spher ayer lens (astigmatism = a p Etiology: 1. There is unequal curvature “eR ent eres 2. There is decentering of the rool in subluxation of lens. Types: 1. Regular : present when the. corrected by lenses. . Simple: simple myopic a il, Compound: compound ili, Mixed: one focus lies in 2. Irregular: when the corneal surface is irregular. It cannot Symptoms: 1. Diminished visual acuity is the most troublesome clinical sy 2. Eye strain and headache after short-time of near work is usually present. 3. The letters in the book appear to be “running together”. Treatment: 1. If there are no symptom, no treatment is required in low degree of astigmatism. )." adequately corrected by lenses All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Nor-Govermental Orgrization2. When there are symptoms, suitable cylindrical lenses are prescribed for constant use. (Surgical) 1.limbal relaxing incision 2.extra sutures 3.photorefracti keratectomy Q1: A 20 yrs old boy presented with son 6/8 improves to 6/6 with conca a. diagnosis? % b. where image form before and after correcting lens? rr ¢. other modalities to cor 3 Ans: . 4 - —_ jon. On examination his visual acquity is a. Myopia b. see jogi diagram topic myopi c. Treatment: Non-surgical : 1. contact lens 2.hygiene of eyes Surgical: a. Flattening of central part of cornea Radial keratotomy Photorefractive keratectomy ili, Laser Epithelial Keratomileusis (LASEK) b. Clear lens extraction c. Phakic posterior chamber implant (implantable contact leris) (Books jogi + jatoi) SOLVED BY RIYA. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSection 2 Q1: Write a note on ptosi e Ans: Abnormal drooping of the upPer eyelid below its normal position, Classification: L Con e a congenital toss al synkinetic ptosis . imosis syndrome Ne Acquire © Neurogenic ‘© Myogenic ‘© Aponeurotic ‘© Mechanical Etiology: 1. Congenital: |. Maldevelopment of musele or tendon I Nerve supply of levetor muscle 2. Neurogenic: © Nerve lesion © Third.nerve palsy © Horner's syndrome 3. Myogenic: * Defect of muscle ‘© Mysthenia gravis Ocular myopathy 4. Aponeurotic: © Senile | ‘isinsertion jostoperative © Defect of sere agrenoss 5. Mechanical: Weight on upper evel ees = Large chalazion Clinical features: > etic disfigurement > Amblyopia > Squint > Abnormal head posture Treatmer depends upon the > Etiology of ptosis > Degree of ptosis All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization> Function of levator muscle ‘© Medical: indicated in myogenic and some cases of neurogenic ptosis according to underline cause. ‘© Surgical: indicated in congenital and all other types of ptosis when medical therapy fails to improve condition, > Fasnella servat operation: indicated in mil ith good levator function 8-10mm or more. Involves excision of porti fee conjunctiva and muller’s muscle. > Levetor resection: acon e ite ptosis 3-4mm with fair levator function 5-7mm. Involves excision of portion of levator muscle aponeurosis. Amount of levator resection depends upon the degree of ptosis. > Brow-suspension proce levator function 4mm o tunica obtained from fa > Aponeurotic strengthing: aponeurosis. > Ptosis crunches: spectacle props are used where surgeRjis not indicated. ing procedure: indicat evere ptosis 4mm or more with poor ives the attachment of eyelid with frontalis muscle by fascia rnon-absorbable suture material. aponeurotic disinsertion. Involves the advancement of (page#39jatoi) 2003 Q1: what is blephritis? Discuss its clinical features? Give its treatment? Ans: It is a subacute or chronic inflammation of eyelid margin. Types and clinical features: 1. Antrior blephritis * Infective or ulcerative: > Infection of lash follicle along with glands of zies and moll Irritation itchingylacrima Gluing of eyes, photophobia Eyelisred and swollen Yellowdried crusts of pus Removal of crusts leave bleeding ulcer * | Nominfective or squamous: > Deposition of whitish material at id margins > Irritation > Watering 5 ttsonye Gy be appearance of eyelashes llow, greasy fine flakes on the lids * Posterior blepharitis or meibomianitis: > Burning sensation in the eye: ite foamy secretion onthe canthus es of meibomian glands capped with oil globules | shinning lines though the tarsal conjunctiva Vvvvy Treatment: 1) General: * Improvement of general health and perspal hygiene © Dandraf of scalp is treated 2) Local * Eyelid hygiene;removal of crusts by scrubbing the margins twice a day with 25% baby shampoo lotion ‘* Epilation of diseased eyelashes All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization‘* Antibiotic ointment; ciprofloxacin or bacitracin rubbed onto lid marginsnwith cotton or clean finger Topical steroids; four times daily to control inflammation Artificial tears; used if there is tearfilm instability © Systemic antibiotics; incase of p a blepharitis co (e' Annual 2004, 1; Describe clinical features and management of chronic dacryocystitis? An: ical features: e =) u © Common than acute vai F z * Presents with constant watering from eyes © Regurgitation may be positve with reflex of watery,fqucoid,mucoprulent discharge from puncti ‘© Mucocele formation © Chronic unilateral conjuctivitis Treatment: Dacryocystorhinostomy (DCR) operation; A passage is created b/w the lacrimal sac and nasal cavity through bony ostium, which drain tears from canaliculi into the lateral wall of nose. Types of DCR: * External DCR; performed through skin approach, preffered procedure, success rate 90%. * Endolaser OCR; performed through nasal approach;opening in the lateral wall of nose is made by laser through nasal cavity,success rate is less,no skin scar, (page#511 Jatoi) 2: Describe clinical features investigation & management of dysthyroid eye disease? Ans: Clinical features: Symptom: © Systemic; >, Tachycardia > Fine tremor of out stretched fingers 1 Weight loss com © Ocular symptoms re qed” » Photophobia ~ Retrobubor comfort x i > Proptosis ® , = > Red eye Signs: ° Eyelid: > Dalrymple’s signs;retraction of upper eyelid. It pr@duce characteristics staring and frightened appearance,most common sign of grave8disease, present unilateral or bilateral in 90% of patients in their clinical course. > Von-graefe’s sign;lid lag. When globe moves downward the upper eyelid lags behind. > Stellwag’s sign; infrequent blinking. > Mobius sign; weakness of convergence. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization© Exopthalmos: Commonly bilateral develops gradually or suddenly after lid retraction, severe proptosis causes exposure keratitis leading to corneal ulcer. © Soft tissue signs: > Eyelids become puffy and full Conjunctiva shows deep injects a nena) Superior limbic kerato; ee Keratoconjunctiviti Optic nerve sci occurs in 5% of patients,causes deterioration of vision papilloedema,papilitis,optic neuropathy Poa ‘the compression of optic nerve. VVVY * Restrictive mayopathy; ialy intense Moma later by fibrosis. > Diplopia Investigation: © Hyperthyroidism Serum TSH leval Serum 13 and T4 leval © Ocular musle enlargement Ultrasonography © CT scan orbit © MRI ‘Treatment: » Control of hyperthyroi 3 © Iodine and antithyroid drugs © Radioactive iodine © Thyroidectomy > Control ocular discomfort and dryness: * Artificial features = Lul ints abbed time > Orbital discompression: systemic corticosteriods; to reduce oedema and inflammation * Oral prednisolone + IV Methylprednisolone; for ot ne . Surge ecompreclb ontraindicated. . Surge ecompreclb ee > Surgery: © Tarsorraphy;for ex, © Squint surgery;to ratitis r pia e Bre. iad (page#233 jatoi) Q1: Short note on dry eye? Ans: Definiti Clinical condition where aqueous tear production is insufficient to maintain normal tear film. Etiology: > Pure keratoconjunctivitis sicca: lacrimal gland is involved alone. © Congenital alacrima All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSolved Past Papers of Eye By MedCom 49 _(Online Version * Denervation hyposecretion * Idiopathic hyposecretion Primary sjogren syndrome: associated with dry mouth. > Secondary sjogren syndrome: associated with systemic diseases. © Trauma;chemical,thermal,raiation Infectiontrachoma “com # Inflammation;sarc d- + Hypersensitivit johnson syndrome Autoimmune;rheumatoid arthritis and SLE Clinical feaures: * Irritation, burning and for = Stringy mucus discharge "Transient blurring of visior = Pain;worse with blinking due to presence of corneal epithilial filaments Examination: Reduced volume of tears in the marginal tear strip * Thining of precorneal tear film "Presence of mucus strand and debris in conjunctiva * Punctate epithilial erosion "Corneal filaments nosi Depends upon © Clinical signs © Decreased marginal tear film * Increased mucus products * Corneal filaments * Special tests; > Tear film break up time;is reduced less than 10 seconds Rose-behgal staining;shows dead and devitalised epithilial cells, mucus and corneal filaments >. Schimmer test;detect the mild cases Tip of whatman filament paper is placed in conjunctiva and its wetting is noted after 5 mins, In dry eye its is 6mi oneeey Treatment: ef + Tear substitute; artificial teal Stay for mile to moderate cases.they are made up of > Cellulose derivatives €.g isoptoplain > Polyvinyl alcohol e.g liquifi > Petroleum mineral oil e.g lacrilube eye gel © ~Mucolytic agents; 5% acet drops for ae ‘threads and decreasing tear viscosity. © Topical retinoids; help inr Reduction of tear drainage; rr ng the cellular de Sams ‘occlusion of puncti. Surgery; transplantation of parotid duct into the conjunctiva (page# 47 Jatoi) Annual 2006 Qi: Give management of ptosis? Ans: All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationTreatment: depends upon * Etiology of ptosis © Degree of ptosis Function of levator > Medical: Cc om © Indicated in © Also in net ases é > Surgical: Fasanella ser —— © mild ptosis 2mm ‘* good levator function 810mm Involves excision of a portion of tarsal, conjunttiva and Muller's muscle. IL Levator resection: Indicated in * Moderate ptosis 3-4mm © Fair levator function 5-7mm Involves excision of portion of levator muscle aponetirosis. ML. Brow-suspension operation: Indicated in severe ptosis 4mm or more © poor levator function 4mm or less Involves the attachment of eyelid with frontalis muscle by fascia tunica obtained from fascia lat or some other non absorbable suture material. IV. Aponeurotic strengthening: Indicated in ‘© Aponeurotic disinsertion Involves the advancement of aponeurosis.. Ptosis crunches: 7 oe COM vce rns e (Page#411 jatoi) 2 Gi iples of management of |.0 foreign body? q Management: LE L r 1. History: to determine the 2. Examination: © Visual acuity * Possible site for entry and exit © Damage to anterior segment Fundus examination 3. Localization: Direct visualization by Magnifying loupe © Slit lamp examination All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011. Med-com Non-Govermental Orgnization© Goniolens * Direct ophthalmoscope © Indirect ophthalmoscope Indirect visualization by © Xray orbit X-ray with limbal ri com Ultrasor owen creel 4. A is removed through Ippo ich ed by magnet and pars plana vitrectomy. Treatment: © F.Bin the anterior segr © F.Bin the posterior segr (page#237jatoi) Q3: List four causes of proptosis: Ans: Causes: ‘© Developmental anomalies * Infection: a) Thyroid ophthalmopathy b) Idiopathic inflammatory orbital disease * Neoplasm: ‘© Congenital tumor;dermoid cyst,retinoblastoma ‘© Vascular tumors; lymphangioma,capillary haemangioma,cavernous heamangioma, ‘© Neural;optic nerve glioma and meningioma ‘* Mesenchymal;rhabdomyosarcoma * Lymphatic;lymphoma © Systemic diseases: a) Leukemia & endocrine disturbances (page#229 jatoi,441 jogi) Q4: A3 year old'child has presented with history of squint. On corneal reflection test (Hirschberg test) Corneal reflection is in the centre of right eye pupil Corneal reflection is on the temporal side li isin let eye. What is the diagnosis? What ipl er of such patient? Ans: Left eye esotropia or converge! Treatmer * Full correction of r Eye become © Amblyopia thera when amblyopi the vision in the affected eye is improved by occlusion of normal eye. So chil fated eye and vigion is improved to normal or nearly normal,depending upon the age of child. * Bifocal glasses; Convex glasses for near correct deviation, whenit I®due to abnormal ratio of accommodative convergence to accommodation. © Surgery; error; ep gl tin is due toref s.. error. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationRecession: to weaken the strong muscle that causes the deviation of eye. The musle is detached from its normal site and is re-attached posteriorly near the equator hence turning force is reduced. Recesection: to strengthen the weak muscle. The muscle is cut short near insertion and reattached at the same site,this shortining aw increases the turning force of an ayeball. © Orthoptic exercise: to # noid far single vision. (page#258 jatoi,#386 jogi) Supply 2005 common surgical procedure to correct moderate ptosis? 1: Define and classify ptosis. Ans: Classification: ‘© Simple congenital ptosis * Congenital synkinetic ptosis © Blephrophimosis syndrome IV. Acquired * Neurogenic © Myogenic © Aponeurot * Mechanical Surgical procedures: Levator resection; indicated in moderate ptosis 3-4mim,with fair function of levator 5-7 mm. Involves the excision of portion of levator muscle apOneuirosis,amount of levator resection depends upon the degree of ptosis. (Page#41 jatoi) Q2: What are the causes of trichiasis? Ans: Causes: ® Blepharitis > Eyelid margir aie goo™ > Chemical burns me > Entropion t 3: Describe treatment of chal Ans: Treatment: > General; small soft chalazi be helped by conservative © Expression Hot fomentation * Topical steriod, antibiotic combination drops © Anti-inflammatory drops > Medical; large chalazion required following treatment: * Corticosteriod injection; good altrmate to surgery,triamcinolone acetonide 0.1-0.2 mls injected into the lesion through conjunctiva,success rate following 1 injection is 80%. In All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrizationunresponsive cases second dose may be repeated after two weeks,useful in multiple chalazion. © Systemic antibiotics; may be required for chalazion associated with acne rosacea or blepharitis ‘© Surgery; most common method of treatment. Conjunctiva and lid are anaesthesiz, {rOctine.lid is everted, lesion is fixed by clazion clamp to achieve the hea Seta incision is made and contents are curetted with chalazion scoo| en ‘auterized with carbolic acid to avoid recurrence,bleeding stops and no dressing is required usually. (page#29 jatoi) (Qa: How Ans: > Investigation and examinati History: © Age of onset Hitory of acute illness head injury or mental shocl Type of squint © Deviation of eye; uniocular or alternate Presence of Diplopia © Family history Inspection: ‘© Any deviation in the eye is noted ‘© Direction of deviation is noted Corneal opacity is noted ‘© Pupillary reactions are noted > Assessment you evaluate the 1. Visual acuity assessment. 2. Determination of presence of deviation by coveruncover test. 3. Measurement of deviation by corneal reflection test,prism cover test and synoptophore. 4. Performance af extraocular movements to find out any limitation of movement. 5. Performante of cycloplegic refraction with cyclopentolate 1% or atropine 1%. 6. Fundus examination to exclude retinal pathology. 7. Determination of abnormal ratio b/w seo dh onvergence to accommodation. or e a (page#257 jatoi,#388 jogi) Annual 2007 qu: - a) What is chalazion? va I b) What is the treatme! oncition? yy a c) Name two differentis joints from stye? Ans: =a a) Chronic inflammatory lipogranuloma of meibomian glant Cause: By the obstruction of the orifice of the meibomian gland Byjinfection or due to unknown cause. Obstruction of orifice causes retention of secretions and induces chronic inflammatory reaction containing giant cells and epithelioid cells. b) See Q3 in supply 2006 All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationFeature Chalazion Stye Onset Chronic Acute Cause Obstuction of gland Staphylococcus _ aureus Signs of inflammation | No external signs ‘oedematous lid margin with pus € 5 ¢ > tS Gland waned Zies Type of inflammation _ | Grani tous, ‘Supportive ‘Symptoms ‘Acute pain and swelling Signs Localized, tender swelling near the lid margin Treatment jot fomentation itibiotics (page# 29,31 jatoi) aa a) What is orbital cellulitis? b) Name three clinical signs? ©) Howis it treated? Ans: a) Definition: Acute infection of orbital soft tissues posterior £0 the orbital septum. b) Signs: b) Proptosis ©) Periorbital and lid oedema 4d) Extraocular movements restricted e) Decreased vision f)Fundus examination; congestion of retinal vessals and dic oedema 8) Feverand cerebral signs c) Treatment: * General: '* © Hot compressors to relieve pain and te > Medical: mG! ‘©. Systemic ontbiont \e and vancgyen for four days. ‘© NSAID to control pain and inflammation > Surgical: Incision and drain ine | a7 L (page#232 jatoi,439 jogi) Q3: Write down the managemer Ans: > Investigation and examination: History: Age of onset Hitory of acute illness head injury or mental shock Type of squint Deviation of eye; uniocular or alternate Presence of Diplopia All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com 'Non-Govermantal Orgization© Family history Inspection: Any deviation in the eye is noted Direction of deviation is noted Corneal opacity is noted © Pupillary reactions are noted d com > Assessment: ual acuity assole * Determination of the presence of deviation by coveruncover test. in by corneal reflection test,prism cover test and synoptophore. lar movements to fi ny limitation of movement. refraction with cyclopentolate 1% or atropine 1%. \de retinal pathology. ratio b/w accofitmodation convergence to accommodation. » Treatment: © Full correction of refractive error: Eye become straight when deviation is due to refrattive error. © Amblyopia therapy: ‘When amblyopia is present ,the vision in the affected eye is improved by Occlusion of normal eye. So child uses deviated eye and vision is improved to flormial or nearly rnormal,depending upon the age of child. © Bifocal glasses: Convex glasses for near correct deviation, whenit is due to abnormal ratio of accommodative convergence to accommodation, Surgery: Recession: to weaken the strong muscle that causes the deviation of eye. The musle is detached from its normal site.and is re-attached posteriorly near the equator hence turning force is reduced. Recesection: to strengthen the weak muscle. The muscle is cut short near insertion and reattached at the same site, this shortining of muscle increases the turning force of an ayeball. > Orthoptic exercise: to achieve the binocular single vision. (page#258 jatoi,#388 jogi) Ql: A young girl is presented with Painful upper eyelid swelling with a pus points yellowish spot at the lid outer margin. a) What do you think is the diagnosis? b) Enlist few D/D? £ ba Ans: ‘ | a a) Hordeolum Externum or ~ b) * Hordeolum internum. ‘* Secondary infected chalazion (pagett 30 jatoi) 2: A 40 year old lady presents in the outdoor cl > What are the D/D? > What investigation wouild you like to do for this patient in order to confirm the diagnosis? ic with bilateral proptosis. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization> Orbital cellulitis > Thyroid ophthalmopathy > Tumor of eye > ocular and head injury b) a Lab investigations: mie » Blood CP and ESR » 73,74,TSH > ANCA; antineutrophilieytopla: » ACE;angiotensin con Imaging techniqu: » Xray » Ultrasoography > CTscan > MRI > Venography > Arteriography Histopathy studies: + Fine needle aspiration * Incisional biopsy * excisional biopsy (page#230 jatoi) 3: A child of 2 years is brought by the parents for inward deviation of right eye(convergent squint) How will you manage such patient? Ans: > Investigation and exar History: Age of onset Hitoty of acute illness head injury or mental shock ‘Type of squint Deviation of eye; rn edo™ Presence of Diplopia history me ed- Inspection: Any deviation in the eye is noted Direction of devi Corneal opaci ‘© Pupillary reaction > Assessment: © Visual acuity ass * Determination of the presence of deviation by 6Byeruncover test. * Measurement of deviation by corneal reflection t€t,prism cover test and synoptophore. Performance of extraocular movements to find out any limitation of movement. Performance of cycloplegic refraction with cyclopentolate 1% or atropine 1%. Fundus examination to exclude retinal pathology. Determination of abnormal ratio b/w accommodation convergence to accommodation. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSolved Past Papers of Eye By MedCom 18 Online Version >» Treatment: © Full correction of refractive error: Eye become straight when deviation is due to refractive error. © Amblyopia therapy: When amblyopia is present ,the vi normal eye. So child uses se normal,depending upo, © Bifocal glasses: wee Convex glasses for lear correct deviation, whenit is due to abnormal ratio of accommodative convergence to accommodation. n in the affected eye is improved by occlusion of is improved to normal or nearly Surgery: Recession: to weaken the strong muscle that Bre sovetion ot eye. The musle is detached from its normal site and is re-attached posteriorly near the equator hence turning force is reduced. Recesection: to strengthen the weak muscle qe muscle is cut short near insertion and reattached at the same site, this shortining of muscle increases the turning force of an ayeball. > Orthoptic exercise: to achieve the binocular single vision. (page#258 jatoi#388 jatoi) Annual 2008 Ql: A young labourer has came to an eye clinic with history of lime burn to the eye while white washing the roof of room followed by intense pain,redness and watering from eyes. a) What type of ocular burn do you suspect from this case? b) What emergency steps would you go for in order to manage the case? Ans: a) Chemical burn or alkali burn b) Emergency ste, ‘* Irrigate the eye immediately with plenty of water or normal saline. ‘© Removal oflime particleswith cotton swab or forceps. Double eversion of eyelid is necessary to remove the lime particulate matter from fornix. » | Removal of devatilized tissue. *» Neutralized the lime by weak acid suchas, eye to change the pH. © If there is corneal errs eee ulcer, Steroids drops are u: prevent symblepharon and chemosis of conjunctiva. * Antiboitic drops to pr nt x infection. * Conjunctivitis is treated byirrigation with bland lotion or normal saline. © Analgesics for reli 4 dl ‘ i (pagett 241 jatoi,363 jogi) inence of eye noticed recently by the relatives . There was iction or squint. Q2: A young lady presents with no history of diplopia or ocular ‘© What D/D you have in mind for this patient? Also give the appropriate diagnosis? * How will you investigate this patient? Ans: a) Graves ophthalmopathy D/D: > Thyrotropic exophthalmos » Goitre exophthalmos All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization» Exophthalmic ophthalmoplegia b) Investigations: History : * Mode of onset © Presence of duration com © Past history of thyroid, era © Family history Examination: t ¥ Visual accuity - © Pupillary reactions er ‘© Fundus examination F é Lab investigations:- wee To check Hyperthyroidist © Serum TSH leval © Serum T3 and T4 leval TSI detection in blood ‘* Routine blood examination To check Ocular musle enlargement © Ultrasonography © CT scan orbit © MRI (page#233 jatoi,442 jogi) ‘Annual 2009 Q4: what are the causes of entropion of lower eyelid in a man of 70 years? Ans: * Senile or involutional type: Most common type and affects only lower eyelid in elderly people. Caused by overriding of preseptal over the pretarsal part of orbicularis oculi muscle, as aresulr of the tarsus and lower lid'retractors. © Spastic or blepharospasm type: ‘Occurs due to spasm of the orbicularis ocala in patients with chronic irritating corneal condition, usually resolve s \ce the cause is eliminated. Also occur ane ‘ause called Essential Blepharospasm. : t » been hit with a ball on therighe face, He compl ‘ g i = (page# 36 jatoi) Q2: A young boy playing cricke crepetations around the orbit. a) What is the most likely b) What sign will you see o1 ¢) How will you manage thi 's of diplopia and Ans: a) Blowout fracture b) Tear drop opacity °) © Clear airway * Control bleeding All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization© Bed rest © Surgical retraction of fracture (paget239 jatoi) Q3: A1 year old girl presents with large convergent a a) What are the D/D? em whes case? b) How will you examin Ans: wi 5 ‘Amblyopia Refractive error Accommodtive squint Congenital squint > b) Investigation and examination: History: © Age of onset ‘© Hitory of acute illness head injury or mental shock Type of squint Deviation of eye; uniocular or alternate Presence of Diplopia © Family history Inspection: ‘Any deviation in the eye is noted © Direction of deviation is noted * Corneal opacity is noted © Pupillary reactions are noted: Assessment: Visual acuity assessment Determination of the presence of deviation by coveruncover test. Messurement of deviation by corneal reflection test,prism cover test and synoptophore. Performance of extraocular movements to find out any limitation of movement. Performance of cycloplegic refraction with cyclopentolate 1% or atropine 1%. Fundus examination to exclude reti rt Determination of al negre \ccommodation convergence to accommodation. @ (Page#257 jatoi,#388 jogi) Qu: mu u a) What is blepharitis? a cad b) Howis it treated? es c) What are the complicatiot Ans: a) It is a subacute or chronic inflammation of eyelid margin. b) Treatment: 1) General: * Improvement of general health and personal hygiene © Dandraf of scalp is treated 2) Local: All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationVi ‘* Eyelid hygiene;removal of crusts by scrubbing the margins twice a day with 25% baby shampoo lotion Epilation of diseased eyelashes Antibiotic ointment; ciprofloxacin or bacitracin rubbed onto lid marginsnwith cotton or clean finger Topical steroids; fo ties dy Seb inflammation Artificial tears; is tearfilm instability © Systemi fics; incase of posterior blepharitis c) Complications: t © Fyeli r > Trichiasi ion of eyelashes pp? > Mdarosis; lashes > Poliosis; | from the hair > Ptosis;drot er eyelid due t oedema > Recurrence; of stye and chalazion > Tylosis;thickening of the lid margin © Conjunctiva: > Bacterial Conjunctivitis > Mild papillary conjunctivitis © Cornea: > Punctate keratitis > Marginal kerti > Punctate epithiliopathy > Tear film instability in 30-50 % of cases (page#32 jatoi) 2: A 20 year old female has thyroid enlargment and complains of bilateral prominence of eyes. a) What is the diagnosis? b) What are likely the ocular signs? Ans: a) Graves ophthalmopathy b) frightened appearant 1on sign of graves disease,present unilateral or bilateral in 90% of patients in their clinical course. > Von-graefe’s sign: lid lag, When globe mo} © Stellwag’s sign; it © Mobius sign; weal © Exopthalmos: Commonly bilateral,develops gradually or suddenafter lid retraction, severe proptosis causes exposure keratitis leading to corneal ulcer © Eyelid: m ~ Dalymoessinsretraction of aeleydld It produce characteristies staring and ys ard the upper eyelid lags Behind. linking. (page#233 jatoi) Q3: What are the sign and symptoms of the paralytic squint? Ans: * Limitation of Ocular movements: in the direcction of action of paralysed muscle. © Diplopia All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization‘* False orientation; patient is unable to point out the object correctly on the side of paralysed muscle, Secondary deviation is greater than primary deviation. Abnormal head posture; compensatory mechanism to avoid diplopia. © Vertigo and nausea gcom (paget#261 jatoi, #391 jo, wes: ‘Annual 2010 Ql: a) What is ptosis? : b) Enumerate the causes 6f acquired ptosis? f is c) What is the treatment. snital ptosis? - ‘Ans: See Q1 in Annual 2003 a Q2: A4 weeks old baby is brought to you with watery eye Sprulunt discharge since birth: h) What is the diagnosis? i) At what age you surgically intervene? i) How will you treat? Ans: ©) Congenital nasolacrimal duct obstruction d) At to6 years of age e) Treatment: > General: * Massage of lacrimal sac; digital pressure is applied over the sac increases the hydrostatic pressure and rupture the membranous obstruction. Ten strokess 4 times a day. > Medical: * Antibiotics; topical and systemic antibi > Spotenous patency: ‘occur in 90% of eases in 6 months,in 95% cases in 9 months. > Surgical : ‘* Probing; done under general anaesthesia,a probe is passed through the puncti,canaliculi and ‘sac into NLD to overcome the obstruction. ‘Syringing; irrigation is done to confirt Intubation with silicon tube ae" fics are used to control secondary infection. 1g of NLD. Balloon dilatation Dacryocystothinostor he operation; when symptoms persist and probing and syringing attempts fails. - 5 ig (pagett49 Jatoi) 2: A five year old chi a) What is your diagnosis? & swollen eyelids. b) How Ans: a) Orbital cellulitis b) © General: "Hot compressors to relieve pain and prevent stasis. > Medical: ‘© Systemic antibiotics; ceftazidime and vancomycin for four days. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization‘© NSAID to control pain and inflammation > Surgical: Incision and drainage. (pagett232 jatoi) wm a3: ed _ a) What is accomodative squint? b) How would you managea two voor child with accomodative esotropia? Ans: a) Type of squint in which cr accommodative effort is ass es is caused by farsightedness. n children who are farsighted reflex crossing of eye hence called accommodative squint b) Fulltime use of appropriate farsighted glass © Bifocal glass * Occlusion of normal eye © Surgery © Orthoptic exercise (pageti258 jatoi,387 jogi) Supply 2010 Q1: A4 year old girl developed inward turning of her right eye soon after she started going to school: a) What is the diagn b) What investigations are necessary? ©) What are the serious complications that can happen? Ans: a) _Entropion (congenital type) b) Physical examination of eyes & eyelid to confirm the diagnosis ° ations: Trichiasis Instablity of precorneal tear film Punctate epithelial defects Corneal ulceration Secondary eye infect i Development of excessive eyelid skin to limit the field of vision Ia (page#36 jatoi) come abrasion g-oo™ y e Qu: a) What is the most likely di b) What are two pi ©) What are the condi Ans: a) Entropion b) © Discontinue the application of bendage. © Non-surgical; n that can cause such condition? All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 24 Online Version > taping the eyelid to the cheek > eyelid everting sutures > denervation of muscle by alcohol injection or botulinum toxin injection into the muscle © Surgical; > In mild cases tarsal hinge Pp aco is cut horizantly and everting sutures are applie« > Insevere cas o., of the contracted conjunctival tissue by mucus membrane gral Resection of skin,tarsus and muscle, V = © Spastic type; most a effects the lower eyelid. It is due to spasm of orbicularis oculi muscles may oc ate ht bendage after operation or follow the chronic irritative corneal condition. Cicatricial entropion; involves upper eyelid,commi conjunctiva which pulls the eyelid margin towards thi > Trachoma stage 4 Stevens johnsons syndrome Ocular cicatricial pemphigoid Chemical injuries Trauma;lacerating injuries ° pe. It is caused by scarring of palpebral lobe. It occurr in following condition; ° vVvVY (page#36 jatoi) Q2: A 20 year old male presents with self healing penetrating injury to the right cornea and the lens. His V.A is 6/60 in that eye. Examination shows collection of whitish material in the inferior angle of eye, B scan shows no vitritis. a. What will be the changes in the lens due to this type of injury? b. What is the material in the angle of eye? ¢. What will be the management if posterior capsule is intact? Ans: a. Disruption or dislocation of the lens. b. Collection of lens protiens in the inferior angle of eye. « Control and prevent the infection with suit: gom. antibiotics. To correct the vision !OL implan a Followup antibiotics to prevent AUR To correct the vision by IOL implantation in case of disruption. f S (paget367 jogi) Q3: A 20 year old male presents ul progressive proptoss of right eye since 2 days. He has got fever and history of chronic sinu afferent papillary defect on the s a) What is the most likely diagnosis? | b) What is the most important complication? c) What investigation will you perform? d) What is the treatment? Ans: a) Orbital cellulitis b) All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization> Panophthalmitis > Orbital abscess > Blindness > Meni, 4’ com > Blood CP and ESR med > Blood culture > Ultrasonography » X-ray PNS > CT scan orbit, sit rain, * 4d) Treatment: © General: + Hot compressors to relieve pain and prevent Stasis. >» Medical: © Systemic antibiotics; ceftazidime and vancom¥tin for four days. © NSAID to control pain and inflammation > Surgical: Incision and drainage. {page231 jatoi,439 jogi) 4: A 60 year old diabetic male presents with sudden onst of double vision of the right eye which is worsen on right gaze.Examination shows he has inward deviation of the right eye on distance fixation. a) What is the type of squint in this case? b) What is the cause of this condition? ©) What test can be perform to diagnose this condition? d) What is the treatment of mild diplopia? Ans: a) Paralytic squint b) Afferent pathway is intact but efferent pathway is defective. The lesion is situated at the leval of lower neuron affecting the nuclei,nerves and muscle. Co) Cover uncover test ocular meverent _com Diplopia charting me? Worth’s four dot test Hess screen » Synoptophore e ia a) . = Correction of refractive e' ed or optical ground glass,prisms. Patching of deviated eye. —_ (page#261 jatoi,391 jogi) Supply 2011 Q1: A 30 year old patient involved in a chemical burn of face presents with eversion of right eyelid margin. The patient complains of epiphora and and cosmetic deformity of face. a) What is the most likely diagnosis? b) What is the most important complication of this disease? ©) What is the treatment option for mild and severe disease? All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationOnline Version d) Name another cause of disease? Ans: a) Ectropion b) © Exposure keratitis : Mild cases; ac ° m Wasi n: involves the v shaped incision to the skin and sutured in y shaped pattern. conjunctivoplasty: involves excision of diamond shaped piece of iva jelesdbenctn| ag is z & a Severe cases; © Modifis 82 rocedure: involves full thickness base up on. he lateral third of eyelid combined with fangular excision of the Skin from lateral canthus to elevate the eyelid. d) Chronic conjunctivitis, (page#39 jatoi) Q2: A 30 year old female presents with painless axial proptosis of the right side. Her visual acuity is 6/6 unaided both sides. There is upper lid retraction and lid lag on down gaze.She is not complaining of sudden onset diplopia. a) What is the most likely diagnosis? b) What are the findings on CT scan of the orbit? ©) What is the cause of diplopia? d) How will you manage acute stage of this Ans: a) Endocrine exophthalmos b) Presence of orbital apex lesion. ¢) Swelling and scarring of eye muscles causes the abnormal alignment and motion of eyes. a) isease? > Control of hyperthyroidism: © Iodine and antithyroid drugs © Radioactive iodine (©) Thyroidectomy > Control ocular discomfort and dryness: "Artificial features a- : Lubricants at bed times, € > Orbital decompressio ‘Systemic corticosteriods; to reduce oedema and inflammation * Oral prednisolon: © IV Methylprednis © Orbital radiothera| © Surgical decompre: > Surgery: © Tarsorraphy;for exposure keratitis © Squint surgery;to treat diplopia and cosmetic disfiglrement. com riodsare contraindicated. bove measures fails. (page#233 jatoi,441 jogi) 3: The parents of four year old child have noticed inward deviation of of the right eye. The deviation is present in all direction of the gaze and worse on near fixation. a) What is the most likely diagnosis? All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrizationb) What findings are likely to be seen on retinoscopy? ¢) What are the three steps in the treatment of this case? Ans: a) Accommodative esotropia b) Hypoplasia of macula ww ret CO. » ane Treatment: © Full correction of refractive - Eye become st © Amblyopia therapy: When amblyopi normal eye. So chi normal,dependin © Bifocal glasses: Convex glasses for near correct deviation, whenit due to abnormal ratio of, accommodative convergence to accommodation. © Surgery: Recession: to weaken the strong muscle that causes the deviation of eye. THe musle is detached from its normal site and is re-attached posteriorly near the equator hence turning force is reduced. Recesection: to strengthen the weak muscle. The muscle is.cut short near insertion and reattached at the same site, this shortining of muscle increases the turning force of an ayeball. > Orthoptic exercise: to achieve the binocular single vision. ‘Annual 2012 for: deviations due to ref \ctive error. 3 = the vision in the affected eye is improved by occlusion of ated eye and yision is improved to normal or nearly jon the age of child. Qi: a. What is ptosis? b. Enumerate the causes of acquired ptosis? ¢. What is the treatment of congenital ptosis? Ans: see Ql in’Annual 2003 Q2: A 30 year old female presents with painl a. What is the most likely the o b. What investigations are ne ¢. What are the serious complications that can happen? » Ans: a re a. Endocrine exophthalmos ie b. Investigations: History : © Mode of onset Presence of duration © Past history of thyroid function © Family history Examination: © Visual accuity © Pupillary reactions All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization* Fundus examination Lab investigations: To check Hyperthyroidism Serum TSH leval © Serum T3 and T4 leval * TSI detection in blood com © Routine bloo To check Ocular musle ent © Ultrasonography © CT scan orbit a a Ls ©. Complications: wt © Exposure keratiti * Corneal ulceration © Tear film instablity * Optic nerve compression (paget233 jatoi,442 jogi) Annual 2013, Q1: An 85 years old patient reports with gradual onset of bilateral drooping of upper eyelids. On examination there was high upper lid crease in both the eyes with intact levator function. The gentleman was healthy otherwise. a. What is your diagnosis? b. Name three surgical procedure to correct this condition. ©. What is the marginal reflex distance? Ans: Ptosis. See Q1 in Annual 2003 Q2: Give an account of the following: a. Blowout fracture b. Cavernous haemangioma Ans: a. Fractute of walls or floor of the orbit it is a closed globe injury, most commonly involves the floor and medial wall of the orbit. a-c oO Causes: © Direct orbital blunt injury me © Sports injury © Facial trauma >) al features: ie Ls Diplopia in upgaze when Wiaaalidry ithe nocge ee Resticted vertical movement of eyé EE Subconjunctival harmorrh: Swollen lid Loss of sensation over upper cheek Periorbital ecchymosis Diagnosis: Tear drop sign in x-ray Treatment: © Most blowout fracture heal spotanously without treatment. ee ee een All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization© Corticosteriod therapy to reduce swelling. Surgery is indicated when fracture is greater than 50%. b. Cavernous haemengioma: Type of blood vessals malformations in the brain, where collection of dilated blood vessals is present in cavernous sinus. Cause: wm It can arise anywhere in the body qe Seren cin. Sign & symptoms: © Siezures * Strokes * Double vision © Memory loss ' = Headache Balancing problems Treatment: © Benign tumors do not require the treatment. + Applying pressure to the tumor minimize the tumor. © Steroids are taken orally or injected into the tumor directly. Q3: A six month old baby presented with alternating esotropia. On examination there was no significant refractive error,media is clear and extra ocular movements were normal with normal looking fundus forced duction test was negative. a) What is the D/D and final diagnosis? b) What is your management plan for the diagnosis you have made? ©) Wht is the appropriate time for management? Ans: a) —_Non-paralytic squint D/D: infantile esotropia b) Treatment: a. Full correction of refractive error: Eye become straight when deviation is due to refractive error. b._‘Amblyopia therapy: When amblyopia is present ,the “o ted eye is improved by occlusion of vi normal eye. So child uses devi ision is improved to normal or nearly normal depending ug Wes Of child. c. Bifocal glasses: Convex glasses for near c accommodative d. Surgery: Recession: to we: detached from its force is reduced. Recesection: to strengthen the weak muscle. Th reattached at the same site,this shortining of mus ayeball. > Orthoptic exercise: to achieve the binocular single vision. ©) Atage of 3-5 years. rect deviation, whenit is due to abnormal ratio of to accommodation. ' ng muscle that causes the deviation of eye. The musle is re nd is re-attached posteriorly near the equator hence turning uscle is cut short near insertion and increases the turning force of an (page#258 jatoi,#388 jatoi) All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization‘Supply 2013 Q4: An ill looking poorly nourished young girl presents with painful progressive proptosis of left eyesince four days. She had sinusitis a week ago and noe she has this proptosis and is febrile. Her V.A on this side is reduced to 6/18 and she has afferent pupliiary defect. a. What is the most likely the diagnosis? b. What is the most important comotearon? oy YW ¢. What is the treatment? a- a me a. Orbital cellulitis é b. Orbital abscess f is Meningitis . - Brain abscess. Corneal ulceration © Even death ©. Treatment: © General: * Hot compressors to relieve pain and prevent stasis. > Medical: © Systemic antibiotics; ceftazidime and vancomycin for four days. © NSAID to control pain and inflammation > Surgical: Incision and drainage. (page#232 jatoi,439 jogi) Q2: A3 year old boy is brought to eye OPD, Mother says that the child turns his eyes inward especially when looking near objects. a) How will you investigate this case? b) What is likely refractive error the child has? c) What is the treatment? Ans: a) > Investigation and examination: ihe goo™ ‘Age of onset e Hitory of acute illness,head injury or mental shock Type of squint Deviation of eye; Presence of Diplo} © Family history Inspection ‘* Any deviation in the eye is noted © Direction of deviation is noted © Corneal opacity is noted Pupillary reactions are noted > Assessment: cular or alternate i pe ual acuity assessment * Determination of the presence of deviation by coveruncover test. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 34 Online Version Measurement of deviation by corneal reflection test, prism cover test and synoptophore. Performance of extraocular movements to find out any limitation of movement. Performance of cycloplegic refraction with cyclopentolate 1% or atropine 1%. ‘* Fundus examination to exclude retinal pathology. * Determination of abnormal ratio b/w sccopggatin convergence to accommodation. b) _Hypermaetropia or farsightedness. a co ©) Treatment: ‘© Full correction of ret TOF; Eye become straight when deviation is due to refractive error. © Amblyopia therapy I s when amblyopia is present ,the vision in the affected eye is improved by occlusion of normal eye. So cl viated eye and vision is improved to normal or nearly normal,depending upon thelage of child. * Bifocal glasses; Convex glasses for near correct deviation, wiignit is due to abnormal ratio of accommodative convergence to accommodatio} © Surgery; Recession: to weaken the strong muscle that causes the deviation of eye. The musle is detached from its normal site and is re-attached posteriorly near the equator heneé turning force is reduced. Recesection: to strengthen the weak muscle. The muscle is cut short near insertion and reattached at the same site,this shortining of muscle increases the turning force of an ayeball. > Orthoptic exercise: to achieve the binocular single vision. (page#258 jatoi,#388 jatoi) Annual 2014 Qi: Ina match a cricketer is hit by a ball on his right eye w! 1g bouncer,he now complains of double vision on upward gaze. a. What is the diagnosis? b. What investigation will confirm your diagnosis? Ans: a. Blowout orbital fracture b. le batting and m (#363 jogi) ¢ © Tear drop sign in x-ray face wi © CTscan shows the soft Ke aieanboe holveent Su 14 P Id by her friend that she has right upper eyelid small r part of the lid away from the lid margin. It is felt brtter than \cy. Now that she is aware and concious of it. She wants Q1: A 20 years old university st swelling.The swelling is located seen and is non tender and firm proper management for the pro! a. What is the diagnosis? b. What is the trearment of choice at this stage of the ail ¢. What refractive error it can cause if left untreated? nt give steps? Ans: a) Chalazion b) Astigmatism caused by the large chalazion of upper eyelid pressing the cornea. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization°) Treatment: > General: small soft chalazion may undergo self resolution and disappear spontaneously but it can be helped by conservative treatment: ‘© Expression het see qm . ic combination drops . or drops > Medical: large chalazion ee following treatment: i * Corticosteriod injection; good altmnate to surgery,triameinolone acetonide 0.1-0.2 ml is injected into thé lesion through conjunctiva,sui following 1 injection is 80%. In unresponsive ca: dose may be eA a: two weeks, useful in multiple chalazion. Systemic antibiot blepharitis. Surgery; most common method of treatment. Conjunctiva and lid are anaesthesized with procain@slid is everted, lesion is fixed by/elazion clamp to achieve the haemostasis,small vetical incision is made and contents‘are curetted with chalazion scoop cavity is cauterized with carbolic acid to avoid recurrenceybleeding stops and no dressing is required usually. zion associated with acne rosacea or (page#29 jatoi) Q2: Give an account of the following: a. Blowout fracture b. Management of blowout fracture ©. What happens if condition is left untreated?’ Ans: a. Fracture of walls or floor of the orbitit is a closed globe injury, most commonly involves the floor and medial wall of the orbit. Causes: © Direct orbital blunt injury © Sports injury © (Facial trauma Clinical features: m © Diplopia in upgaze when there is it pleats? orbit © Resticted vertical movers © Subconjunctival harmorrhags ' * Swollen lid * Loss of sensation over upper che S = ls © Periorbital ecchymosis ‘ z Diagnosis: Tear drop sign in x-ray Treatment: © Most blowout fracture heal spotanously without treatment. © Cotticosteriod therapy to reduce swelling. © Surgery is indicated when fracture is greater than 50%. Complications if untreated: * Rebleeding or secondary haemorrhage * Glaucoma Al Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationCorneal staining Diplopia Orbital cellulitis, Restrictive ocular movements Enophthalmos - ac om (#239 jatoi,365 jogi) Q3: a) What is the difference b/w comitant and incomitant squint? b) What is meant by recession and esection of extraocular muscles? ©) Ifa patient has right esotropia, which extraocular muscle you resect and which one will you > recess? Ans: _ a Difference Concomitant Incomitant Etiology Efferent pathway is Efferent pathway is defective intact,afferent pathway and centres are defective Type of onset Gradual or congenital Sudden ‘Age of onset During childhood ‘At any age Sign & symptoms ‘Symptomsless only cosmetic {| Limitation of disfigurement movement © Diplopia © Abnormal head poture © False orientation Difference in deviations Primary deviation is equal to__| Secondary deviatation is the secondary deviation greater than the primary deviation Investigations Hirschberg’ test,cover Cover test, diplopia chart,hess test,synoptophore screen,worth's four dot test, Synoptophore Treatment ‘© Optical correction of ‘© Optical ground glass or refracti m occluder hc Fos eye © Operative measures nie optic exercise © Operative measures 5 ») I. £2 id Resection | Recession To strengthen the weak mi To weaken the strong muscle that ‘Themuscle is cut short neat causes the and reattached at the same site,this shortining of muscle increases the turning force of an ayeball. reduced. °) Medial rectus muscle recession Alll Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationLateral rectus muscle rese. (page#263,258 jatoi #390,398 jogi ) Q: A middle aged lady having Diabetes suddenly developed horizontal diplopia in left gaze. Examination showed inward deviation of left eye. a) What is the probable diagnosis? mw -Co b) Which type of squint is present? A: ©) How will you confirm san ‘clinically? ana, d) What should be the gement? Ans: - a a) Left eye esotropia = Le b) Paralytic squint 9 Se ) co Cover uncover te: <= © Ocular movemen © Diplopia charting © Worth’s four dot test co Hess screen ©. Synoptophore d) Treatme Diplopia is treated by prism,smoked or tinted ground glass. Occlusion of deviated eye. (page#261 jatoi,#392 jogi) SOLVED BY NAILA SHOUKAT All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSolved Past Papers of Eye By MedCom 35 Online Version Section 3 QL: Define trachoma, give its clinical icon “ions and measures of prevention? Ans: Trachoma is a contagious - ion of the eye, causing inflamed granulation on the inner surface of the lid . Clinical Features: 1. Mild irritation and foreign b nis often present. 2. Frequent blinking may be pre Ae 3. Mild itching is a common com 4. In chronic stage, cornea is involved causing pain, lacrimatidp and photophobia Signs: The primary infection is epithelial and involves the @pithelium of both the conjunctiva and the cornea. 1. Conjunctival 1. Congestion—There is red, velvety, jelly-like thickening of the palpebral conjunctiva. 2. Papillae—They may be present in the palpebral conjunctiva. 3. Follicles—Follicles are seen in the upper and lower fornix, palpebral conjunctiva, plica, bulbar conjunctiva (pathognomonic). They measure 1-5 mm in size. 4. Typical star-shaped scarring is seen at the centre of the follicles in late stages. 5. Arlt’s line—A line of palpebral conjunctival scarring is seen 2 mm from'the upper lid margin. 2. Corneal: 1. Superficial keratitis may be present in theupper part. 2. Herbert's pits—There is follicle-likes infiltration near the limbus in the upper part. This later results in depression caused by (Cicatrization of limbal follicles. Pannus—There is lymphoid infiltration with vascularization seen in the upper part of cornea Complications: The only complication of trachoma is corneal ulcer. All the rest are sequelae of trachoma. 1 Trichiasis—Misdirected éyelashes occur due to conjunctival scarring. 2. Entropion—In rollirig of the lid margin results from scarring. 3. Corneal ulcer Itis often due to dry eye and misdirected eyelashes. 4. Corneal opacity—It results from corneal ulceration. Arlt’syline and star-shaped scarring Trichiasis and corneal ulcer | Subclinical stage ll Stage of typical Eau lesions Ill Stage of scarring IV Stage of sequelae and complications 5. Xerosis—Scarring of conunctiva AS in destruction of goblet cells which secrete mucus. 6, Ptosis—It occurs due to large follicles formation. Itis rare nowadays. 7. Blindness— Perforation of corneal ulcefis a common cause of blindness Measures of prevention : Personal hygiene and en A good water supply impr habbits. Blanket antibiotic treatmer given in enderfilt. area. WHO has recommended the following regime to be carried out in endemic areas to minimige the severity of disease. The regime is to apply 1% tetracycline eye ointment twicw daily for 5 days per month. this is done for 6 months regularly. Implementation of the SAFE strategy (recommended by WHO ) Surgery to correct the advanced, blinding stage of the disease (trichi Antibiotics to treat active infection, Facial cleanliness and, sanitation is improved. is), All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationOnline Version Environmental improvements in the areas of water and sanitation to reduce disease transmission, (pg#86 jogi) ‘Supply 2003 Q1: Give sign & treatment of vernal kertaoconjuntivitis . (supply 2003) Ans: signs & Symptoms: wi 1. Itching is the most common.co i ° 2. Thick, white, ropy mac is characteristic, 3, Burning and foreign body sensation may be present, 4, Photophobia is present in cases of corneal involvement. 5. Lacrimation or watering is a associated feature. Fd Types Two typical form: Both forms may occu together as mixed type. 1. Palpebral Form Exogenous al i. There is conjunctival hy ii. On everting the upper lid, palpebral conjunctiva\ghows multiple polygonal-shaped raised areas like cobblestones, due to diffuse papillary hypertrophy ii, The colour is milky white due to thickened epithelium @f.the conjunctiva. iv. The nodules are hard and consist of dense fibrous tissue (hypertrophied papillae), Palpebral form Bulbar form v. Eosinophils are present in great number. 2. Bulbar Form i. Multiple nodules or gelatinous thickening appears all around or inithe upper part of the limbus. It is diagnostic of spring catarrh ji. Discrete chalky white superficial spots (Horner-Tranta’s dots: composed of eosinophils may be seen at the limbus. Treatment: use of eyedrops, antivirals, rest, wearing dark glasses (pa # 89-91 jogi) Q2: write short note on Ophthalmia neonatorum? Ans: It is preventable disease o¢curing in newborn babies Pathogenesis : Inflammation of conjunctiva causing erythema, blood vessel dilation, tearing, and drainage. This reaction tends\to be more serious due to the following: reduced tear secretion, decreased immune function, decreased lysozyme activity and relative absence iyignohold tissue of the conjunctiva. Neonate tears alsollack immunoglobulin IgA. Go Etiology: Virulent gonococcus nego wd fesponsible for 50% blindness in children but due to r effective methods of prophylaxi eatment, it is jfare nowadays. Chlamydia oculogenitalis, Streptococcus pneumoniae or other organism cause mild infection. Symptoms: , 1. Any discharge from a baby’s t week of Ii fe i alarming as tears are secreted only 3-4 weeks after birth, 2. The conjunctiva is bright red ar at the lid borders, lashes and cantI 4. Sticking together of the lids is a common feature. Signs: 1. Lids are swollen and tense due to dense infiltration of the bulbaPconjunctiva. 2. Conjunctiva is markedly congested and chemosed. Lids are separated by lid retractors to see the cornea. Pseudomembrane may be present. 3. Later the conjunctiva becomes puckered and velvety with free discharge of pus, serum and blood. Complications: the . ith pouring out of thick yellow pus. 3. Thick pus accumulates All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 7 Online Version These are common in untreated cases. 1. Corneal ulcer and opacity. 2, Perforated corneal ulcer with prolapse of iis. 3, Adherent leucoma and panophthalmitis. 4, Metastatic stomatitis and arthritis involving knee, wrist and ankle joints occur rarely. 5. In case of corneal opacity, there may be nysogpus eee fixation occurs during the first 3-4 weeks of life. Treatment: e It is same as for adults. Topical therapy is supplemented by parenteral penicillin or newer cephalosporin (cefotaxime: for 3:5 days. ” Frequent washing of the cor (pg #77 jogi) QL: Discuss the pathogenesis an complication. Ans: Pathogenesis: Herpes human virus 3 causes chickenpox as primary infection in non immune host. After the primary infection, the virus remains latent in the sensory ganglion of dorsal nerve roots and trigeminal ganglion of the patient the rest of the life. if the immunity is impaired, the infection reoccur locally, the virus replicate and migrate down, along the sensory nerve of the skin, or'skin and eye cau lesion of herpes zoster (shingle) or Herpes zoster ophthalmicus respectively: linical Featur (©. SKIN LESION: pain , rash, edema, post herpetic néuralgic © OCULAR LESION: acute epithelial keratitis déVelop within 2 day © Microdendritic ulcer develops within to 6’day © Filamentary keratitis occasionally develop ° ° Nummular kerati 10 days Disciform keratitis develop within 3 weeks NEUROLOGICAL COMPLICATION: cranial nerve palsies affects the 3" nerve most commonly. Optic neuritis may occur in about 1:400 cases ‘Treatment: > Systemi¢ therapy Acyclovir, analgesics, antibiotics, systemic. set: > Topical therapy Antiviral, steroids, “wr aces antiglaucoma. ° Q1: Describe the pathogenesis, tures & treatment of ophthal Ans: 4 a Pathogenesis : Inflammation of conjunc reaction tends to be more seri due to the following function, decreased lysozyme activity and relative absence of tears also lack immunoglobulin IgA. Etiology: Virulent gonococcus infection used to be responsible for 50% blindness in children but due to effective methods of prophylaxis and treatment, it is rare nowadays. Chlamydia oculogenitalis, Streptococcus pneumoniae or other organism cause mild infection. Symptoms: phoid tissue of the conjunctiva, Neonate All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationVi 1. Any discharge from a baby’s eye during the 1st week of life is alarming as tears are secreted only 3-4 weeks after birth. 2. The conjunctiva is bright red and swollen with pouring out of thick yellow pus. 3. Thick pus accumulates at the lid borders, lashes and canthi. 4. Sticking together of the lids is a common feature. Signs: Cr gm 1. Lids are swollen and tense due to ‘the bulbar conjunctiva. 2. Conjunctiva is markedly congested and chemosed. Lids ae: y lid retractors to see the cornea, Pseudomembrane may be present. 2, Later the conjunctiva becomes puckered and velvety with fe discharge of pus, serum and blood. Complications: is These are common in untreat: , = 1. Corneal ulcer and opacity. 2. Perforated corneal ulcer with 3. Adherent leucoma and panop! 4, Metastatic stomatitis and arthritis involving knee, wrist and@pkle joints occur rarely. 5. In case of corneal opacity, there may be nystagmus as maculaifixation occurs during the first 3-4 weeks of life. Treatment: i, It is same as for adults. Topical therapy is supplemented by parenteral\ penicillin or newer cephalosporin (cefotaxime: for 3-5 days. ji, Frequent washing of the conjuntiva with warm saline. ( pg # 77 jogi ) Annual 2005 Q1: What is the cause of red eye? Discuss the treatment of corneal ulcer? Ans: conjunctivitis, Keratitis Acute congestive glaucoma Acute iridocyclitis Episcleritis Sdleritis Subconjunctival haemorrhage Foreign body in the cornea or conjut Ney om me - conta gfeerof acing ° ° ° ° ° ° & ° © Tocontrol the infection © Torelieve the pain Cycloplegic, anal © To prevent the perforation Viral: > Topical antiviral > Debridement removal of virus laden epithelium > Topical antibiotic for control secondary infection > Cycloplegic 1% atropine drop for relief of pain Al Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 9 Online Version Q2: Describe etiology, symptoms, signs and treatment of trachoma ? (Annual 2005: Ans: Etiology: Trachoma is caused by a. Chlamydia trachomatis, a bedsonian organism (serotype A, B, Ba, C). b._ it belongs to psittacosis lymphogranulomas group. c. it lies b/w bacteria n virus. d. they multiple by binary fission. they stay Com Which makes them relative immune from effects of drugs. a: it is seen in the conjuntvel bigs he epi bodies. Symptoms: 1. Mild irritation and foreign by 2. Frequent blinking may be pré 3. Mild itching is a common cor 4. In chronic stage, cornea is inve Signs: The primary infection is: cornea. 1, Conjunctival 1. Congestion—There is red, velvety, jelly-like thickening of the palpebral conjunctiva, 2. Papillae—They may be present in the palpebral conjunctiva. 3. Follicles—Follicles are seen in the upper and lower fornix, palpebral conjunctiva, plica, bulbar conjunctiva (pathognomonic). They measure 1-5 mm in size. 4. Typical star-shaped scarring is seen at the centre of the follicles in late’stages. 5. Arlt’s line—A line of palpebral conjunctival scarring is seen 2 mm from the upper lid margin, 2. Corneal 1. Superficial keratitis may be present in the upper part. 2. Herbert's pits—There is follicle-like infiltration near the limbus in the upper part. This later results in depression caused by cicatrization of limbal follicles. Pannus—There is lymphoid infiltration with vascularization seen in the upper part of cornea. Complications: The only complication of trachoma is corneal ulcer. All the rest are sequelae of trachoma. 1. Trichiasis—Misdirected eyelashes occur due to conjunctival scarring. 2. Entropion—In rolling of the lid margin results from scarring. 3. Corneal ulcer—Itis often due to dry eye and misdirected eyelashes. 4. Corneal opatity=It results from corneal ulceration. Arit’s line and star-shaped scarring Trichiasis and corneal"ulcer. Subclinical stage Il Stage of typical trachomatous lesions Ill Stage of scarring IV Stage of sequelae and complications 5. Xerosis—Scarring of conjunctiva ar ion of goblet cells which secrete mucus. 6. Ptosis—It occurs due to large vate mation. It is rare nowadays. 7. Blindness—Perforation of corneal ulcer is a common cause of blindness. Ps 4 ki lial cells as the Halberstaedter-prowazek inclusion a ion is oftenpresent. ' é ig pain, lacrimation and photophobia. ithelial and involves tl pithelium of both the conjunctiva and the 1. Sulphacetamide 20-30% eyed tilled four times dally for 6 weeks. 2. Topical treatment with 1% erythromycin, 1% tetracycline o rifampicin ointment is far more effective. It is applied twice daily for 3- 6 weeks. B. Systemic treatment: 1. Systemic administration of tetracycline, erythromycin, rifampicin and sulphonamides is effective. Tetracycline or erythromycine 250 mg four time daily may be given for 3-4 weeks 2. Initially oral doxycycline 100 me is given twice daily for 3-4 weeks 3, Nowadays treatment with a single dose of azithromycin 2 mg/kg body weight has been recommended. C. Combined topical and systemic treatment: It is preferred when the ocular infection is severe. Tetracycline or erythromycin ointment is applied 4 times a day for 6 weeks. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 40 Online Version Surgical Treatment: Excision of fornix. Tarsectomy Treatment of various sequlae such as trichiasis, entropion, dry eye should be done. Q1: Enumerate four complication Name drugs used in treats Ans: Complications: The only compl 1. Trichiasis—Misdirected eyel 2. Entropion—In rolling of the li 3, Corneal ulcer—It is often due id misdirectecyeyelashes. 4. Corneal opacity—It results from corneal ulceration. Arlt line and star-shaped scarring Trichiasis and corneal ulcer | Subclinical stage II Stage of typical trachomatouss lesions Ill Stage of scarring IV Stage of sequelae and complications 5. Xerosis—Scarring of conjunctiva results in destruction of goblet cells which secrete mucus. 6. Ptosis—It occurs due to large follicles formation. Itis rare nowadays. 7. Blindness—Perforation of corneal ulcer is a cornmon cause of blindness. Treatment: A. Topical treatment 1. Sulphacetamide 20-30% eyedrops are instilled four times daily for 6 weeks. 2. Topical treatment with 1% erythromycin, 1% tetracycline or rifampicin ointment is far more effective. It is applied twice daily for 3- 6 weeks. B, Systemic treatment: 1. Systemic administration of tetracycline),erythromycin, rifampicin and sulphonamides is effective. Tetracycline or erythromycine 250 _mg.fourtime daily may be given for 3-4 weeks 2. Initially oral doxycycline 100 mes iven'twice daily for 3-4 weeks 3. Nowadays treatment with a single dose of azithromycin 2 mg/kg body weight has been recommended. C. Combined topical and systemic treatment: It is preferred when the ocular infection is severe. Tetracycline or erythromycin ointment is applied 4 times a day for 6 weeks. Surgical Treatment: i. Excision of fornix. Tarsectomy °o ww Toe ant pion, dry eye should be done. (pg #81 jogi) ‘due to conjunctival irring. sults from scarring. Q2: Give clinical features of scleritis. ys * necrotizing scleritis » © diffuse sclerit * Nodular scleritis Symptoms: wee A localized redness is seen in the deep scleral tissue in nodule scleritis discomfort and mild to moderate pain Signs: Diffuse scleritis: multiple hard, whitish nodules about the size oPpin head and they disappear without disintegrating. Nodular scleritis: one or more nodules present which are less circumscribed than episcleritis , swelling is dark red or bluish at first then become purple. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationVi there are large areas of avascular sclera leading to necrosis, sclera may appear as a sequestrum or dead tissue, exposure of uveal pigment through markedly thin sclera, anterior uvitis is ususally present. Q3: What are the complications of the ae corneal Ans: |. Prolapsed of iris ac ll. Subluxation and anteri@h Aside n of lens I Endophthalmitis IV. Panophthalmitis V. Intraocular haemort Vi. Retinal detachment VIL. Anterior synechiae Vill. Corneal fistula ist four common and important causes of painful red eye? Ans: © conjunctivitis © Keratitis © Acute congestive glaucoma © Acute iridocyclitis © Episcleritis © Scleritis © Subconjunctival haemorrhage Foreign body in the cornea or conjunctiva Annual 2007 Q1: A6 year old boy present with pain, redness, purulent discharge and a whitish lesion on the cornea with a history of corneal trauma. A) What is diagnosis? B) How would you treat the patient? Ans: A) bacterial corneal ulcer ° B) Treatment: © To control the infection Topical antibiotic aguenstnte in, om Antibiotic onmetlh ‘as pol fax, tobramycin Sub-conjunctival injection © Torelieve the pain j Cycloplegic, analgesics, antiglaucoma drug. © Toprevent the perfor Q2: A 10 year old boy presents wi What is the diagnosis ? Name two drugs used in its treatment ? What are complications of severe disease ? Ans: spring catarrhal ( vernal conjunctivitis) Treatment: Treatment It is purely symptomatic. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 42 Online Version 1. Topical corticosteroids—Frequent application of steroid drops (0.1% dexamethasone or betamethasone: and ointment is very effective. A maintenance dose 3-4 times daily is given during the season. 2, Acetyleysteine 10-20% drops controls excess mucus formation. It may be useful in the treatment of early plaque formation, 3. Disodium cromoglycate 2% drops is applied four times daily, ‘4.Lodoxamide 0.1% drops is a new preparation th aye BUberior to cromoglycate. 5. Cryotherapy of the nodule. d- 6. Tinted glasses provide consideraBlé edmtort and relief. 7. Non-steroidal anti-inflammatory drugs (NSAIDs), eg. flurbiprofen, indomethacin, diclofenac 0.1%, ketorolac tromethamine can be used safely for a longer period. They act by inhibiting arachidonic acid i 8. Supratarsal injection of st is very effective in patients with severe disease not responding to conventional topical steroid therapy. = e 9. Recently topical cyclosporin Surgical management—It is useful for severe vernal kerati + Debridement of large mucous plaques may speed up rep. + Lamellar keratectomy of densely adherent plaques may als > Complications are mainly due to corneal involvement. Seri ultimate prognosis is good. keratopathy Buckley has classified the corneal involvement into 5 clinical stages: i. Superficial punctate keratitis—These are tiny microerosions in upper cornea. Epithelial macroerosion and ulceration occurs due to epithelial loss. Plaque—There is bare area caused by macroerosion of epithelium which becomes coated with mucus. iv. Ring scar is formed as a result of subepithelial corneal scarring. v. Pseudogeron toxon—It resembles arcus senilis with appearance of ‘cupid’s bow’ found to be useful in steroid resistant cases. athy. f persistent epithelial defects beneficial com tions are never seen and the (pg # 90 jogi ) ‘Annual 2008 Q1: A young man sustained injury to the right cornea with finger nail followed by intense pain, irritation, and visual deterioration in the eye. Patient did some self medication without consulting and presented with severe pain, intense redness and significant visual deterioration. Examination revealed ircumcorneal congestion, mild corneal edema and hypopyon along with pupil in the eye. ‘A) What is hypopyon B) Name the bacteria capable of producing hypop) 11) C) Describe the mechanism of hypopyonii 3 epithelium without perforation. in Ans: A) it is cornea ulcer, with ome’ ff (RYpopyon) in the anterior chamber due to association iridocyclitis, B) Gram positive and Gram negative bacteria eo o0o00 & g 8 Moraxella C) Mechanism: in the case of corneal ulcer there is always associat iridocyclitis due to liberation of toxins by bacteria which diffuse into anterior chamber via the endothelium. This resutt in dilation of blood vessels and outpouring of leukocytes which become enmeshed in the fibrin network .such hypopyon are fluid and change their position with position of head .these gravitate to bottom of anterior chamber. It All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 43 Online Version may fall half of the anterior chamber thus obscuring. The hypopyon is sterile and is usually gets absorbed when hypopyon corneal ulcer is adequately treated with routine treatment for corneal ulcer. the optical functions of comea with reference to its refractive power and refractive 8B) Enlist the reason for corneal wansgarerargy wm A) Functions of Cornea: e It act as major refractive mediur It protects the intraocular eontent B) 1. Regular arrangement of corneal lamellae 2. avascular nature of cornea 3, Relative state of dehydration > It acts as power refractive lens for focusing the rays on retina. > Refractive power of anterior conyex surface has +48 dioptres > Refractive power of posterior concave surface has -5 dioptres > So, average power of comea i 43 dioptresy Q3: a young boy of 13 years old was noted for excessive rubbing of both eyes associated with redness and thick discharge collected at the inner corners of eye. he started these symptoms some years ago which were more marked during summer season. Diagnosed as a case of atopy and vernal catarrh or seasonal allergic conjuntivitis he was managed accordingly aa: what type of hypersensitivity reaction is involved in this type? b: what would happen if the patient is moved to cooler enviroment? c: how an acute attack of allergic conjunctivitis is treated ? Ans: IgE mediated hypersensitivity or type | in cold enviroment it will regress or subsides! > See Q1in Annual 2014 Qu: Describe the clinical features of trachoma? what are the complications and treatment of thi Ans: Symptoms: 1Mild irritation and foreign body sensation is oftenypresent. 2.Frequent blinking may be sei Co isease ? 3. Mild itching is a common ge 4. In chronic stage, cornea cd causing pain, lacrimation and photophobia Signs: The primary infection is epithelial and involves the epithelium of both the conjunctiva and the cornea - 1. Conjunctival j Q p 1. Congestion—There is r jelly-like thickening of the palpebral conjunctiva. 2. Papillae—They may be present in the palpebral conjunctiva. 3, Follicles—Follicles are seen in the upper and loWer fornix, palpebral conjunctiva, plica, bulbar conjunctiva (pathognomonic). They measure 1-5 mm inlsize 4, Typical star-shaped scarring is seen at the centre of line of palpebral conjunctival scarring is seen 2 mm from th 2. Corneal: 1. Superficial kerat follicles in late stages. 5. Arlt’s line—A ipper lid margin. may be present in the upper part. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 44 Online Version 2. Herbert's pits—There is follicle-like infiltration near the limbus in the upper part. This later results in depression caused by cicatrization of limbal follicles. Pannus—There is lymphoid infiltration with vascularization seen in the upper part of cornea. Complications: The only complication of trachoma is corneal ulcer. All the rest are sequelae of trachoma. 1 Trichiasis—Misdirected eyelashes occur sae scarring. 2. Entropion—In rolling of the lid mata r ring. 3. Corneal ulcer—tt is often d estes isdirected eyelashes. 4, Corneal opacity—It resul ‘neal ulceration, Art's line and star-shaped scarring Trichiasis and corneal ulcer 1 rei al stage Il Stage of typical trachomatous lesions Ill Stage of scarring IV Stage of sequelae and complications 5. Xerosis—Scarring of eonjunctiva results in destruction of goblet cells which secrete mucus. 6. Ptosis—It occurs due to large follicles formations It is rare nowadays. 7. Blindness—Perforation of corneal ulcer is a common cause of blindness. ‘Treatmen - A. Topical treatment 1. Sulphacetamide 20-30% eyedrops are instilled four times daily for 6 weeks. 2. Topical treatment with 1% erythromycin, 1% tetracycline or rifampicin ointment is far MOge effective. It is applied twice daily for 3- 6 weeks. B. Systemic treatment: 1. Systemic administration of tetracycline, erythromycin, rifampicin and sulphonamides is effective. Tetracycline or erythromycine 250 mg four time daily may be given for 3-41weeks 2. Initially oral doxycycline 100 mg is given twice daily for 3-4 weeks 3. Nowadays treatment with a single dose of azithromycin 2 mg/kg body weight has been recommended. C. Combined topical and systemic treatment: It is preferred when the ocular infection is severe. Tetracycline or erythromycin ointment is applied 4 times alday for 6 weeks. Surgical Treatment: i. Excision of fornix. Tarsectomy Treatment of various sequiae such as'trichiasis, entropion, dry eye should be done. ( pg #81 jogi) ‘Annual 2009 Ql: A young body who has recently recovered from flu complains of painful left red eye. He has branching type Of lesion on the cornea with fluorescence a A), Whats the diagnosis? B) What is etiology? ano™ ) How will you treat this conan? ih jugs are contraindicated in this condition? s es Ans: A) acute epithelial keratitis simplex virus B) Caused by herpes simplex virus type 1 and type 2 C) Treatment: , > Topical antiviral nee * > Debridems of virus laden epithelium > Topical antibiotic for control secondary infection > Cycloplegic 1% atropine drop for reli steroids are contraindicated, 2: A 9 year old boy presents with burning, itching and thick roapy discharge. the symptoms get aggravated in summer season and respond well to topical medications. a) what is probable diagnosis? b) what is the etiology of the disease? ©) what are treatment options? All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 45 Online Version Ans: a) Spring catarrh (vernal conjuntivitis } b) It is caused by exogenous allergen. It occurs due to hypersensitivity reaction to exogenous allergen such as pollens and dust. It is mediated by IgE as shown by the accompanying eosinophilia. c) see Q1 in Annual 2014 oo" Q1: A motorcycle has been hit in l&ff eVe-by’an insect while driving, Now he complains of redness, pain, photophobia, blurring of vision in his eye. he has mucopurulent discharge. how will you examine this case ? how will you establish diagnosis’? 4 Ans: History: Patients may cot upon waking, blurry vision, light * Allergic conjunctivitis is al s secondary t presents with bilateral symptoms. Infections cause organisms: are transmissible by eye-hand contact. eye (unilateral: , with the second eye becoming involve Physical examination: The patient should be examined in a well-lit room. Before performing the ocular examination, the physician should search for regional lymphadenopathy and should examine the face and eyelids carefully. B: Acute mucopurulent conjunctivitis or bacterial conjunctivitis is diagnosis bz itis contagious and spread by flies, fingers and fomites. ‘ nvironmental allergens and, therefore, usually y viruses and bacteria (including Chlamydial , these infections initially present in one -w days later. (pg # 74 jogi ) Annual 2010 Q1: A young man presents with itchy, swollen, red-eyes with clear watery discharge following exposure to dust. What is the most likely diagnosis ? What drugs can be used to trest ? What complications can develop in cornea ? What is the natural course of disease if left untreated ? Ans: Acute catarrh conjunctivitis. Drugs used to tréattthis condition are following 1. Topical'corticosteroids—Frequent application 7 aaa (0.1% dexamethasone or betamethasone: and ointment is very effective. A maintenance laily is given during the season. 2. Acetylcysteine 10-20% drops a \ fucl Ont It may be useful in the treatment of early plaque formation. 3. Disodium cromoglycate 2% drops is applied four times daily 4.Lodoxamide 0.1% drops is a newpreparation that may be superior to cromoglycate. 5. Cryotherapy of the nodule. 6. Tinted glasses provide consider rt and relief. drugs (NSAIDs), e.g. flurbiprofen, indomethacin, diclofenac 0.1%, safely for a longer perl. They act by inhibiting arachidonic acid. 8. Supratarsal is very effective in patiefits with severe disease not responding to conventional topical steroid therapy. 9. Recently topical cyclosporine 1% has been found to be useful in 10. Surgical management—tt is useful for severe vernal keratopathy. ‘+ Debridement of large mucous plaques may speed up repair of persistent epithelial defects. + Lamellar keratectomy of densely adherent plaques may also be beneficial. Complications of this condition: roid resistant cases. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 46 Online Version Complications are mainly due to corneal involvement. Serious complications: are never seen and the ultimate prognosis is good. Keratopathy Buckley has classified the corneal involvement into 5 clinical stages: i. Superficial punctate keratitis—These are tiny microerosions in upper cornea. ji.Epithelial macroerosion and ulceration occurs due to epithelial loss. ili, Plaque—There is bare area caused by macroert ej Fium which becomes coated with mucus. iv. Ring scar is formed asa result of sube ela scarring. v. Pseudogeron toxon—It resembl lis with appearance of ‘éupid’s bow’. Natural course of disease : It may persist for several year common. In majority of cases, Seasonal recurrences with exacerbations and remissions are se eventually subsides around puberty. - ( pg # 89-91 jogi ) Q1: A20 yr old boy developed brother had same condition 3-4 days ago which he incurred redness, and wateringhin both eyes one after the other. his younger ‘hool. (supply 2010 ) a) what is your diagnosis ? b) what is the treatment of this condition? ¢) how can you prevent this condition from spreading ? Ans: a) viral conjunctivitis. b) Prevention: i. Don't touch or rub the infected eye(s) Wash your hands often with soap and warm water. Wash any discharge from your eyes several times a day Using’a fresh cotton swab or paper towel. Afterwards, discard the cotton swab or paper towel and wash your hands with soap and warm water. Wash your bed linens, pillowcases, anid towels in hot water and detergent. v. Never wear another person's contact lenses. vi. Wear eyeglasses instead of Contact lenses. Throw away disposable lenses or be sure to clean extended-wear lenses and allleyewear cases. vii. Avoid sharing common articles such as unwashed towels and glasses. Wash your hands after applying the eye drops or ointment to your eye or your child's eye. ix. Do not.use eye drops that were used for an infected eye in a non-infected eye. x. Ifychildhas viral pinkeye, keep your child home err 101 or day care until he or she is no longer contagious. It's usually safe to return ig) 6) Siero: have been resolved; however, it's important to continue practi giené just to be sure. xi, Avoid contact with others a your hands frequently. €) Treatment: Use of eve drops, ar i rest, wearing dark glasses. — Annual2011 Qi: A 15 year old boy presents :n onset of bilateral pink eye with fever and phrayngitis. On examination his visual acuity is re aré follicles present in the inferior fornix in association ‘co eal with diffuse conjuntival congesti examinationishows punctate keratitis bilaterally. (annual 2011: what is most likely diagnosis ? what organism cause this disease ? why should the child advise to stay at home ? what is the most appropriate treatment ? Ans: Follicular Conjuntivitis —Pharyngoconjunctival fever is one of its subtypes , caused by adenovirus. Viral diseases are contagious to avoid spread patient must be isolated for some days. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 47 Online Version Treatment: 1 Astringent eyedrops are applied frequently. 2. Improve general health and nutrition of the patient. 3. Treat associated adenoids, tonsils and upper respiratory tract infection promptly and adequately. (pg#81_jogi) 1: A.30 year old man present with metallic foreign body in his cornea during work. The foreign body is removed with a needle and no medication is prescribed by mistake. The patient present with reduce visual acuity and whiting around the foreign body bed. ‘A) What is most likely di ris? B) How will you perform investigation? C) What is most appropri i D) What is most serious complication? = Ans: A) non healing corneal ult B) Active ulceration area stain with fluorescein dye © Routine Investigation : Blood cp, ESR, blood sugar and urine © Microbiological investigation: Gram’s and Geimsa staining for identifice 10% potassium hydroxide for identifi Culture and sensitivity nof infecting agent, ion of fungal hyphae C) Treatment: Y Conjunctival flap Y Tarsorrhaphy Y Therapeutic keratoplasty D) Corneal perforation is most serious complication. Q2: A 15 year old boy presents with sudden onset of bilateral pink eye with fever and phrayngitis. examination his visual acuity is 6/6 and there are follicles present in the inferior fornix in association with diffuse conjuntivalcongestion. Corneal examination shows punctate keratitis bilaterally. (annual 2011: what is most likely diagnosis ? what organism cause this disease ? m why should the child advise to stay at home ?, CG Oo what is the most appropriate treats a- Ans: Follicular Conjuntivitis nar eS ijunctival fever is one of its subtypes , caused by adenovirus. Viral diseases are contagious to avoid spread patient must be isolated for some days. Treatment: 5 ind upper respiratory tract infection promptly and adequately. (pg#81_jogi) 3. Treat associated adenoids, tor a 1. Astringent eyedrops are applied frequently. ge’ 2. Improve general health and nutrition/of the patient. ni Supply 2011 Q1: A.40 year old female is using steroid for rheumatic arthritis and she present with pain, photophobia and redness of right eye. The vision is reducing to 6/24 and there is linear ulcer with branching pattern in the inferior cornea. A) What is most likely diagnosis? B) Which stain would be used to help the diagnosis? All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization€)_ Which other corneal signs will be present? D) What is most appropriate treatment? Ans: A) acute viral keratitis or dendritic ulcer Itis caused by herpes simplex virus; both type 1 and type 2 B) Fluorescein stain bed of ulcer Rose bangal stain margin of ulcer laden with ZC om C) Corneal signs: © Ciliary congestion © Corneal sensitivity is m: Me. diminish é © Satin show dendritic or geographical shaped corneal ulcer © Foreign body sensat be © Reduction in vision , = D) Treatment: ment mechanical remoWal viral laden epithelium Topical antibiotic Cycloplegic. e000 Q2: A) What are etiological causes of corneal abscess? B) What laboratory tests are necessary? Ans: A) 1. Neisseria gonorrhea 2. Neisseria meningitis 3) Cornybacterium diphtheria 8B) Slit lamp examination Biopsy Blood test: indicated to check for inflammatory disorder. 3: A) Classify keratitis? B) Describe the treatment of each type of keratitis? Ans: A) _ bacterial corneal ulcer Y To control the infection by topical antibiotics such as gentamycin antibiotic ointment, subconjuctival injection, systemic antibiotics. ¥ Prevention of perforation m Y relief of pain by atropine ,afalgésles, and antiglaucoma drug B) Treatments: me Fungal keratitis je Y To} ingal such as fluconazole ,natamycin ¥ systemic ant ree 7 ie sub nazole v ther trating keroplasty Acanthamoeba keratitis: Y Debriment to remove effectedjepithelium Y Topical amoebicides e.g. aminoglycoside , propamidine isethionate, polyhexamethylene, Y" therapeutic keratoplasty Viral keratitis 1. Herpes simplex keratitis All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization2. Acute epithelial kerati 3. Stromal necrotic keratitis Y Topical antiviral ¥ Debridement Y Topical antibioti Cycloplegi om Disciform keratitis: ea: -C antiviral i Topical prophylactic ¥ pical weak steroids cloplegic al oid ic iAOsuRgressive Topical cycloplegic Surgical: conjunctival resection v Keratoplasty Moorens ulcer: Medical Interstitial keratitis: ¥ Systemic penicillin injection Y Acyclovir ¥ Topical corticosteroids Y Cycloplegics Filamentary keratitis: Mechanical removal of filaments Hypertonic 5 % saline Mucolytic agent Bandage contact lenses Q4: A new born child who is 48 hduf$ old is brought to accident emergency with bilateral sever purulent discharge. on opening the eye with retractor ulceration of cornea is seen in the right eye. a) what is most probable diagnosis ? bb) which organism is most likely the cause of this con: ) what investigation would you perform ? d) what is most appropriate treatment ? Ans: Ophtalmia neonatorum. ano™ Etiology: Virulent gonococcus inf Tesponsible for $0% blindness in children but due to effective methods of er lg ent it is fare nowadays. Chlamydia oculogenitalis, Streptococcus pneumonize or other organism cause mild infection. Treatment: It is same as for adi ical therapyis supplemented by parenteral pencil or newer cephalosporin (cefotaxime: for Pn Investigations: ¥ Laboratory studies for suspected i. Conjunctival scraping w/ Culture on chocolate agar for N gonorrhoeae. (Thayer: Culture on blood agar for other strains of bacteria . Culture for HSV if vesicles present or is supicious of viral maternal exposure v. Direct antibody testing or PCR may also be indicated. jon? tin media may also be used) ology including evidence of perinatal All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 50 Online Version Note: Conjunctival specimens for chlamydia testing must include conjunctival epithelial cells because C. trachomatis is an obligate intracellular organism and exudates are not adequate for testing. vii. Cultures may need to be repeated if symptoms worsen or recur following treatment. QA: A) classify keratitis? e @ B) Describe the treatment of each type of keratitis? Ans: Already answered check Q3 in x” 2011) (pg # 77 joy Q2: A 20 yr old boy developed brother had same condition 3. a) what is your diagnosis ? b) what is the treatment of this lition? ©) how can you prevent this condition from spreading ? Ans: a) viral conjunctivitis. b) Prevention: Don't touch or rub the infected eye(s).. Wash your hands often with soap and warm water. Wash any discharge from your eyes several times a day using a fresh’cotton swab or paper towel. Afterwards, discard the cotton swab or paper towel and wash your hands with soap and warm water. Wash your bed linens, pillowcases, and towels in hot water and detergent. v. Never wear another person's contact lenses. vi. Wear eyeglasses instead of contact lenses» Throw’ away disposable lenses or be sure to clean extended-wear lenses and all eyewear, cases. i. Avoid sharing common articles such as unwashed towels and glasses. Wash your hands after applying thé eye drops or ointment to your eye or your child's eye. ix. Do not use eye drops that were used for an infected eye in a non-infected eye. x. If child has viral pinkeye, keep your child home from school or day care until he or she is no longer contagious. t's usually safe to return to school when symptoms have been resolved; however, it's important to continue practicing good hygiene just to be sure. ess, and watering in both eyes one after the other. his younger ‘ago which he incurred at school. xi. “Avoid contact with others and wash your hands frequently. c) Treatment: Use of eye drops, antivirals, rego lasses. wi Annual 2013 Ql: A 35 year old laborer who recently had typhoid fever of 2 weeks starts complaining of pain, watering, redness, photophobia shows a branching type of area a. What is the diagnosis? Al b. What are different morp! Ans: a) Dendritic ulcer D/D: > Herpes zoster keratitis > Acanthamoeba keratitis > Healing corneal ulcer > Toxic drug induced keratopathy b) Morphological forms: All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 51 Online Version Acute Form: Dendritic ulcer, geographical ulcer. Chronic form: punctuate, filamentry, blotchy Q2: During month of summer, principal of school reported that half of his secondary class has red, painful and watery eyes associated with the itching. he wants to have your expert opinion about. how will you manage this situa d: how can you prevent this situa Ans. a: vernal conjuntivitis (spring cattaggh). it's a\fecuurent,blateral/Seasonal conjunctvits occuring with the onset of hot weather. at b: Clinical ings: ’ | a 1. Itching is most common complai : 2. Thick, white, ropy mucous discharge is characteristis 3. Burning and foreign body sensation may be present. 4. Photophobia is present in case of corneal involvement. 5. Lacrimation or watering is associated feature. it has 2 typical forms. Both are clinically significant and may occur together as mixed type. Palpaberal form i.there is conjunctival hyperaemia and chemosis. ii. On everting upper eye lid palpebral conjuctiva shows multiple polygonal-shapped raised areas like cobbelstines, due to diffuse papillary hypertrophy. iii, Colour is milky white due to thickened epithelium of conjuntiva. iv. the nodules are hard and consist of dense fibrous tissue ( hypertrophied papillae). Bulbar Form: i. Multiple nodules or gelatinous thickening appears all around or in the upper part of the limbus. It is diagnostic of spring catarrh. ji, Discrete chalky white superficial Spots (Horner-Tranta’s dots: composed of eosinophils may be seen at the limbus. c: Treatment: Treatment it is purely symptomatic. 1, Topical, \corticosteroids—Frequent application of steroid drops (0.1% dexamethasone or betamethasone: and ointment is very effective. A maintenance dose 3-4 times daily is given during the season. 2)Acetylcysteine 10-20% drops control OM matin It may be useful in the treatment of early plaque formation. a 3, Disodium cromoglycate 2 s applied four times daily 4.Lodoxamide 0.1% drops is a new preparation that may be superior to cromoglycate. hat is diagnosis ? : what clinical findings will help yo is acing eee ie 5. Cryotherapy of the nodi » | 6. Tinted glasses provide considerable comfort and reliefus 7. Non-steroidal anti-in drugs (NSAIDs), e.g. flurbiprofen, indomethacin, diclofenac 0.1%, ketorolac tromethamine can\be used safely for a longer period. They act by inhibiting arachidonic acid. 8. Supratarsal injection of steroid is very effective in patients with severe disease not responding to conventional topical steroid therapy. 9. Recently topical cyclosporine 1% has been found to be useful in steroid resistant cases. 10. Surgical management—It is useful for severe vernal keratopathy. ‘+ Debridement of large mucous plaques may speed up repair of persistent epithelial defects. * Lamellar keratectomy of densely adherent plaques may also be beneficial. Prophylaxis n prevention: All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 52 Online Version 1, Beta-radiation is given in proliferative cases at monthly intervals during the months of February, March and April to prevent the onset of symptoms. This does not cure the disease. 2. Disodium cromoglycate 2% eyedrops are applied 3-4 times before the onset of the disease. 3. Desensitization has also been tried without much rewarding results, (pg # 89-91 Basic Ophthalmology Renu jogi) Ge: or QL: A 15 year old male present wdc iching and. burning of both eyes. The condition gets aggravated in summer. His eyes sI mer." redness, a gelatinous mass all around the cornea and flat topped nodules on the upper a onjunctiva. Visual acuity 6/6 of both eyes (supply 2013) a) what is the most likely dia | b) what are the likely complicat a c) what is the treatment ? Ans: Acute catarrh conjunctivitis Drugs used to treat this conditior following. 1. Topical corticosteroids—Frequent application of steroid dros (0.1% dexamethasone or betamethasone and ointment is very effective. A maintenance dose 3-4 times daily.is given during the season. 2. Acetyleysteine 10-20% drops controls excess mucus formation. It may be useful in the treatirient of early plaque formation. 3. Disodium cromoglycate 2% drops is applied four times daily 4.Lodoxamide 0.1% drops is a new preparation that may be superior to cromoglycate. 5. Cryotherapy of the nodule. 6. Tinted glasses provide considerable comfort and relief. flammatory drugs (NSAIDs), e.g. flurbiprofen, indomethacin, diclofenac 0.1%, ketorolac tromethamine can be used safely for a longer period. They act by inhibiting arachidonic acid. 8. Supratarsal injection of steroid is very effective inpatients with severe disease not responding to conventional topical steroid therapy. 9. Recently topical cyclosporine 1% has been found to be useful in steroid resistant cases. 10. Surgical management—It is uséful forsevere vernal keratopathy. + Debridement of large mucous plaques may speed up repair of persistent epithelial defects, + Lamellar keratectomy of densely adherent plaques may also be beneficial. Complications of this condition: Complications ate mainly due to corneal involvement. Serious\ complications: are never seen and the ultimat: nosis is good. Keratopathy Buckley has classified the corneal involvement into § clinic ses i, Superficial punctate keratitis—T! an erosions in upper cornea. ii.Epithelial macroerosion and ulceration occurs due to epithel ERE iii, Plaque—There is bare area caused by macroerosion of epithelium which becomes coated with mucus. Ring scar is formed as a result of,subepithelial comeal scarring, v. Pseudogeron toxon—It resembles arcus senilis with appearancsor cupe's s bow’, 2014 Ql: A 19 year old boy presented with fluorescein. a) What is your diagnosis? b) What complication can occur if the above condition remains untreated? Ans: a) bacterial corneal ulcer b) Complication of Corneal Ulcer: 1. Toxic Iridocyclitis, occur usually with purulent corneal ulcer. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 53 Online Version 2. Descemetocele, it is an outward bulging of descemet’s membrane due to sloughing corneal stroma, 3. Secondary glaucoma, due to blockage chamber angle by fibrinous exudates 4, Perforation of corneal ulcer, is very dreadful complication of corneal ulcer, which produce \n threatening complication: 1. Prolapse of iris qm MI ‘Subluxati: G:! lislocation of lens mM. canes IV. Endophthalmitis Q2: A 15 years old girl comes to eye OPD complaining of intenge itiching and mild photophobia in both eyes. History reveals it is to be seasonal. On examination, her visual acuity in both eyes is6/6++ NS. Eyes show mild redness and cobble stone appearance on eversion of the upper eye lids. ( Annual 2014 ) What is your diagnosis? what are the different types of this conditions ? what is the treatment ? Ans: Spring Catarrh ( vernal Conjunctivitis ) Types: Two typical forms are seen. Both forms may occur togethers mixed type. 1. Palpebral Form Exogenous allergen i. There is conjunctival hyperaemia and chemosis. ii, On everting the upper lid, palpebral.conjunctiva shows multiple polygonal-shaped raised areas like cobblestones, due to diffuse papillary hypértrophy. ili, The colour is milky white due to thickened epithelium of the conjunctiva. iv. The nodules are hard and consist of dense fibrous tissue (hypertrophied papillae). Palpebral form Bulbar form v. Eosinophils at@ present in great number. Spring catarth 2. Bulbar Form i. Multiple nodules or gelatinous thickening re GOm or in the upper part of the limbus. It is diagnostic of spring catarrh. Y ii, Discrete chalky white supertcalf EN Faorner-rant's dots: composed of eosinophils may be seen at the limbus. y Treatment: > Treatment It is purely symptom: j = p 1. Topical corticosteroids—Freq tion of steroid drops (0.1% dexamethasone or betamethasone: and ointment is very effective. A maintenance dose 3-4 times daily is given during the season. 2. Acetylcysteine 10-20% drops c¢ Is excess mucus forr plaque formation. 3. Disodium cromoglycate 2% drops is applied four times daily 4,Lodoxamide 0.1% drops is a new preparation that may be superi 5. Cryotherapy of the nodule. 6. Tinted glasses provide considerable comfort and relief. 7. Non-steroidal anti-inflammatory drugs (NSAIDs), e.g. flurbiprofen, indomethacin, diclofenac 0.1%, ketorolac tromethamine can be used safely for a longer period. They act by inhibiting arachidonic acid. ion. It may be useful in the treatment of early to cromoglycate. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 54 Online Version 8. Supratarsal injection of steroid is very effective in patients with severe disease not responding to conventional topical steroid therapy. 9. Recently topical cyclosporine 1% has been found to be useful in steroid resistant cases. Surgical management—t is useful for severe vernal keratopathy. * Debridement of large mucous plaques may speed up repair of persistent epithelial defects. * Lamellar keratectomy of densely adherent eo mt. beneficial. ' ; Supply 2014 Ql: A 15 years old boy present in examination revealed diffues the both sides. hat is your diagnosis for th }: Enumerate four causative fa C: how will you manage this cas Ans: A: Allergic conjuntivitis or Giant papillary conjuntivitisyalso known as GPC, is a condition of the conjunctiva in which the structures known as papillae (glands: imtthe upper lid become very largesin severe cases, the enlargement of papillae is accompanied by itching and mucus discharge). B: Causative factors: It is acute or subscute non specific urticarial reaction to allergens. Bacterial proteins of endogenous nature, e.g staphylococcus in nose OF upper respiratory tract can cause this condition commonly. Exogenous protein as in hay fever, contact with animals( horse, cat : pollens or flowers. Chemicals, cosmetics, drugs, e.g atropine, hair dye, ‘etc. can cause severe conjunctivitis and dermatitis. iv. Anallergic reaction to the chemicals in contact lens solutions. Your eyes may react to chemicals at any time, even after you have used the same'products for months or years. v. A contact lens, old cornea scar,,a loose stitch after eye surgery, or other types of foreign bodies rubbing on the inside of thé upper eyelid. Treatme! i. removal of the allergens is absolutely necessary. if this cannot be done, desensitization may be done by long Course of injections. lose the Contacts: Discontinue wearing contact lenses, at least temporarily, as the best solution for GPC is to get rid of whatever is causing the irritation, |. Find a new cleaning solution: switch t rnin and cleaning contact lense solution. Astrigent lotions are applies Vasoconstrictor, e.g adren sagem ion (1 in 1000: reduces the congestion. vi. Antihistamine drugs (antistine privinel 1%: are affecting in controlling allergic reaction. Disodium cromoglycate2% i safe and can be used for vili,Corticosteroid drops are ix. In atropine irritation, the subconjuntival: may be sul (pg # 89-91 jogi ) 'D with complaints of mucoid discharge from the both eyes , chemosis, and Biant pappiliae on the palpebral conjuntiva on a All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSOLVED BY BUSHRA SHAHID miedo" He Lr All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSection 4 Q1: Enumerate the early and epost oe complications of CATARACT EXTRACTION. Ans: Early complication of cataract extraction: Acute infection(endophthalmitis) # Corneal oedema Wound leakage Iris prolapse Raised intraocular pr Choroidal detachment Iridocycli Hyphaema Malposition of IOL Late postoperative complication: Chronic endophthalmitis i Phacoantigenic uveitis Corneal decompensation Cystoid macular oedema Retinal detachment pacification of posterior capsule Epithelial and fibrous down growth (Page 119 jatoi) Q2: Describe signs, symptoms, causes and treatment of optic neuritis. Ans: Signs of optic neuritis: 1- Pupil ; direct light reflex is sluggish or absent. 2- Fundus examination a)». Early changes: i Optic disc is hyperaemic with bl etn? ii The swelling spread, fing'retina. i Retinal veins are and distorted. iv Exudates are present at the disc and retina. is v- Vitreous is cloudy withfine opacification. ul b) Late changes: i} Postneuritic a ii Disc margins a i Physiological ci iv. Perivascular sh ©) Visual field defects: i- Generalized depression of visual field is the mosttcommon i Central, centrocaecal or paracentral scotoma may be present. Symptoms of optic neuritis: a) Transient blurring of vision may be present initially b) Profound visual loss is the most important clinical feature. < up with organized fibrous tissue. ng is usually present. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization¢) Unilateral involvement d) There is sudden onset and rapid progress of disease process. e) Complete blindness set in rapidly in untreated cases. Causes of optic neuritis: 1+ Multiple sclerosis is the most common cause 2+ Central nervous system disease are: _com a) Neuromyelitis optica of deyic b) Acute disseminated endSphalomyelitis c) Herpes zoster + d) Epidemic encephalitis e) Poliomyelitis f) Leber's disease . , = 3+ Local causes: = a) Retinitis b) Uveitis c) Meningitis 4- Endogenous causes: a) Acute infection such as influenza, measela and mumps. b) Septic foci in teeth, tonsils, throat, etc. ©) Metabolic conditions such as in diabetes, anaemia, starvation. Treatment of optic neuritis: 1. Find and treat the underlying cause first. 2 Corticosteroids with certain restrictions and may help in early recovery (ONTT) 3- Vitamin B1, B6 and B12 injection. (Page no 346; JOGGI) Q1: Discuss differenti Congenital cataract Retinoblastoma Persistent hyperplastic primary vitreous Rretinal astrocytoma ve Toxocariasis vie Coat’s disease com (Page 276; jatoi) Q2: Describe the surgical proceaurlilh fee atment of GLAUCOMA. Ans: je a) iridectomy- creation of hy riphery of iris b) goniotomy- incision in thi ¢) trabeculotomy- trabecul d) trabeculectomy e) non-penetrating filtration subconjunctival space f) _cyclodialysis- direct communication is created between tig anterior chamber and subarachnoid space 8) cyclocryotherapy- lowering the IOP by coagul body h) artificial shunts- plastic devices which create communication between anterior chamber and subtenon space. aspect of trabecular II er goiecpe is broken up by passing atrabeculotome into Schlemm’ canal eation of commiitinication between anterior chamber and the ‘ion necrosis of secretory epithelial cells of the ciliary All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrizationi) laser therapy- argon and diode laser trabeculoplasty (chapter 10; jatoi page no 150) Q3: Write a note on Central Artery Occlusion Ans: it is an ocular emergency. Etiology: it is due to embolus or thrombosis along, artery, It is commonly occur in case of hypertension, arterseclerosis, eke rteritis or buerger’s disease. Common site of origin of embolus Carotid artery in the neck, aorta or endocardium of the heart. Fundus examination: retina become opaque and milky White especially near the disc and macula. Cherry red spots is seen on the\fovea centralis. ba Pupil: dilated and does not rea ’ * Treatment: vasodilators Massage the globe al iii Paracentesis Panretinal photocoagulation ith asetazolamide ions: Complete blindness ‘Thrombotic or neovascular glaucoma (Page 306; joggi) Annual 2004 diagnosis of SECONDARY GLAUCOMA. 41: Discuss differenti Ans: i- raised IOP; retinoblastoma, ii- corneal enlargement; megalocornea and high myopia corneal clouding; inflammatory corneal disease, keratomalacia (page 149 chapter 10 jatoi) Qa:Describe clinical features and management of DIABETIC RETINOPATHY? Ans: clinical features are given above Management: i \ Background diabetic retinopathy: control gf danggye low fat and anti-diabetic drugs and regular review after every 6 month Cc °o I- Maculopathy: focal phot y iv. Preproliferative retinopathy: frequent reviews after every 3 months. : panfetinal photocoagulation(PRP); it prevents further haemorrahge reoretinal surgery with photocoagulation v- Proliferative retinopat! neovascularization a vir Advance diabetic reti (Page no 318; joggi) Q4: Discuss pathogenesis, and clinical feature of diabetic retin Ans: Q1, Annual 2004 ‘Supply 2004 Q1: Discuss clinical features and treatment of ACUTE CLOSED ANGLE GLAUCOMA. An: All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSevere unilateral headache, nausea, vomiting and prostration ‘Sudden onset of unbearable pain in the eye Marked dimness of vision Redness, lacrimation and photophobia Cc om Oedema of the lid and afl Marked conjunctival and ciliary congestion Cornea is cloudy and insensi iv Anterior chamber i I v- Iris pattern is lost ant - vi Pupil is moderately vii- Glaucoma flackens ar r subcapsuler opacities seen in the lens in the pupillary area vili- Raised intraocular pressure ix Fellow eye has a shallow anterior chamber with a nartow angle ‘Treatment of primary angle closure glaucoma: A- Medical a) Local i Pilocarpine i Timolol maleate iii Betaxolol b) Systemic i Acetazolamide ii Sedative ©) Hyperosmotic agents i Oral- glycerol and isosorbide Intravenous- manitol and urea B- Surgical treatment: a) Peripheral buttonhole iridectomy b) Laser iridotomy c) Trabeculectomy (CHAPTER 12; PAGE NO 284 JOGGI) Ql: Discuss EARLY and LATE compl AE Ans: Early complications: be ii ili- iv. a Infection(endophthalmitis) Corneal oedema Wound leakage Malposition of IOL Cystic macular oedema less extent as compared to WECE Late complications: Chronic infection Secondary cataract Retinal detachment less extent as compared to ICCE 2: Discuss the clinical features and treatment of primary open angle glaucoma. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrizationical features of primary open angle glaucoma Symptom: Painless progressive visual loss Mild headache and eyeache may be present Defect in visual field Increasing difficulty in near —e Cc om Light sense Is defective Visual acuity decreases Me 5 Cornea is usually clear 5 - ile Anterior chamber depth and angle are normal Pupillary reactions remai al until the late stage When they become sluggish le glaucoma: Pilocarpine Beta- blockers Adrenergic drugs Carbonic anhydrase inhibitors Prostaglandins analogue b) Systemic i- Carbonic anhydrase inhibitors Hyperosmotic agents B- Surgical a) Trabeculectomy C- Argon and diode laser trabeculoplasty (ALT &AST) D- Recent advances a) Laser filtration b) Seton valve ©) Deep sclerectomy, d) Viscocanalostomy (Page 266; JOGGI) Q1: Enumerate the early and late me s of CATARACT EXTRACTION. Ans: Immediate complication ea" a) Prolapse of vitreous b) Rapture of capsule 3 cc) Expulsive haemorrhage - iP Late complications: a) Striate keratitis b) Iris prolapse es c) Hyphaema d) Delayed formation of anterior chamber e) Cystoid macular oedema f) Infection leading to iridocyclitis, endophthalmitis or panopthalmitis Delayed complications: a) Aphakic glaucoma b) Detachment of retina c) Epithelization of anterior chamber All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental Orgnization(Page 227 joggi) z 4 Annual 2006 Q1: Describe signs, symptoms, causes and treatment of optic neuritis. Ans: Signs of optic neuritis: Cc rs) wm Pupil ; direct light reflex is slu esd Fundus examination wi d) Early changes: ¢ vi- Optic disc is hyperaemic with blurred margin. vi- The swellin vili- Retinal veins i Exudates are Pea id x Vitreous is clot e) Late changes: v- _Postneuritic atrophy vi- Disc margins are blurred. Physiological cup gets filled up with organized fibrous tissue. vili- Perivascular sheathing is usually present. isual field defects: Generalized depression of visual field is the most common, iv Central, centrocaecal or paracentral scotoma may belpresent. f) Symptoms of optic neuritis: f) Transient blurring of vision may be present initially 8) Profound visual loss is the most important clinical feature. h) Unilateral involvement i) There is sudden onset and rapid progress of disease process. i) Complete blindness set in rapidly in untreated cases. Causes of optic neuritis: 5 6 Multiple sclerosis is the tmiost common cause Central nervous system disease are: g) Neuromyelitis optica of devic h) Acute disseminated encephalomyelitis ip Herpes zoster 1) » Epidemic encephalitis k) Poliomyelitis 1) Leber’s disease Local causes: d) Retinitis e) Uveitis f) Meningitis Endogenous causes: d) Acute infection such as influenza, measela and rilimps. e) Septic foci in teeth, tonsils, throat, etc. f) Metabolic conditions such as in diabetes, anaemia, st@tyation. Treatment of optic neuritis: 4- Find and treat the underlying cause first. 5+ Corticosteroids with certain restrictions and may help in early recovery (ONTT) 6 Vitamin B1, B6 and B12 injection. (Page no 346; JOGGI) All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSupply 2006 Qi: a) Define CATARACT. b) Name different methods of CATARACT EXTRACTION. Ans: a) Cc ° we Catara A - Any opacity in lens or its capsule vibeth lopment or acquired is called cataract. b) Methods of cataract extraction: + Intracapsular cataract extraction(ICCE) a a) What are the three diagnostic features of OPEN ANGLE GLAUCOMA? b) Name at least two visual field defects. Ans: a) diagnostic features of open angle glaucoma: Raised intraocular pressure Cupping of the optic disc isual field defects b) visual field defects: i- central field defests a) Baring of blind spot b) Small scotomatous areas ©) Seidel’s sign ii-peripheral field defects a) Raenne’s step (Page 276; joggi) Q3: Discuss causes of optic neuritis. Ans: Causes of optic neuritis: 1 Multiple sclerosis is the most common cause 2+ Centralnervous system disease are: Mm) Neuromyelitis optica of devic 1) Acute disseminated encephalomyeliti 0) Herpes zoster mea p) Epidemic encephalitis q) Poliomyelitis 1) Leber’s disease 3- Local causes: 8) Retinitis h) Uveitis i) Meningitis 4- Endogenous causes: 8) Acute infection such as influenza, measela and mum} h) Septic foci in teeth, tonsils, throat, etc. i) Metabolic conditions such as in diabetes, anaemia, starvation. Q4: Describe the features of DIABETIC RETINOPATHY? Ans: All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationDiabetic Retinopathy i. Pathogenesis: essentaily it is microangiopathy affecting retinal precapillary anterioles, capillaries and venules. Microangiopathyresults in microvascular occlusion, microaneurysm, capillary leakage and haemorrahge. iii: Retinal ischemia and retinal oedema em iv. Retinal hypoxia in turn causes ovchat ird exudates, arteriovenous shunt and ca neovascularization we Clinical features: + Symptoms: - i- usually asymptomatic unless, volved or there is vitreous haemorrhage. gradual deterioration of vi é , ili- suden deterioration of vision Signs of diabetic retinopathy: i- Background diabetic Microaneurysm Round shape dot and blot deep haemorrhages Hard exudate all over the posterior pole i Preproliferative retinopathy: Multiple cooton wool or soft exudates Proliferative retinopathy Neovascularization Spontaneous vitreous haemorrahge Tractional retinal detachment iv. Diabetic maculopathy Involvement of fovea by oedema and/or,hard exudate Cystoid macular oedema is frequently seen VITRECTOMY :the term vitrectomy implies the cutting of formed vitreous gel which is responsible for producing various compl = A variety of vitrectomy units are available. all instruments perform vitreous cutting@and aspiration under microscopeic control with the help of fiberoptic illumination, e.g. vitreo suction cutter (VISC), vitreous cutter, vitreous stripper, etc. ¢) vitreous haemorrahge is most ae due to systemic disease like hypertension ,diabetes mellitus and blood dyscrasias like leukemia, sickle cell anaemia theyefore most of the time both eyes are involved therefore examination of fellow is important and findin} i- gray opacities in the vitreous Q3: Classify uveitis.discuss the role of cycloplegics in management of uveitis. Ans: Anatomical classification: depend on part of uveal tract involved > Anterior uveitis (iritis , iridocyclitis ) > Intermediate uveitis (cyclitis ) > Posterior uveitis (choroiditis) > Pan uveitis (iflamation of all parts) Clinical classification: depend on mode of onset. > Acute uveitis —-—less than 3 weeks » Chronic uveitis ----- more than 3 weeks Histological classification --depend on type of inflammatory reaction > Granulomatouse uveitis)---- Iymphocytes,epitheloid, gaint cells > Non granulomatouse uveitis —-- polymorhs The role of cycloplegics in uveitis is > Torcomfort and rest to the eye by relieving gene body and iris > Dilatation of the pupil to prevent posterior syne mation and break already form synechiae to avoid secondary glaucom; Ped > To reduce exudate formatior Cessine capillary petmeability. extraction and IOL implantation in left eye.postoperatively ind visual deterioration in that eye. examination revealed intensly chemosis and hypopion along with papillary tained and found to contain pseudomonas aeruginosa Q4: An old man was operated for, patient complain of pain ,redne: inflamed eye with swelling and membrane.anterior chamber as upon culture. a) Which antibiotic is most appropriate for this condition? b) Which route of antibiotic therapy will provide the best resul c) What is the natural course of illness if left untreated. Ans: a) Tobramycin ,third generation cephalosporins b) IV route ¢) If left untreated it will progress to Panopthalmitis , papillitis and phthisis bulbi Qu: a) What is endopthalmitis? All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 67 Online Version b) How it is different from panopthalmitis? ¢) How do you treat acute post operative endopthalmitis? Ans: a) Endopthalmitis is the inflammation of the internal structures of the eyei.e choroid retina and vitreouse b) Endopthalmitis is the inflammation of the internal structures while panothamitis is the inflammation of the whole eye ball including the tenon’s capsule. ual encopthainits result into panopthalmitis. Q - > Intravitreal antibiotics key gement... ( Ceftazidime, Vancomycin amikacin } > Anterior subtenon antibiotic injection for 5-7 days > Topical therapy (fortified gentamycin, steroids, cycloplegics atropine ) Systemic antibiotics~ d rol at Pars plana vitrectomy re ise to conservative treatment and visual acquity reaches to light perception. Q; List ocular manifestations of An: Xerosis Xeropthalmia Kretomalacia Night blindness Dermatosis Demylination of optic nerve Decrease resistance to infection VY VVVYY Annual 2009 Q1: A 70 year old man presents with sudden painless visual loss in the right eye. Fundus examination shows dilated veins & hemorrhages all over'the retina, (a)What is probable diagnosis? 1 (b)How will you investigate this case? 2 (c)What are the likely complications? 2 ‘Ans: a)Retinal vein occlusion (b) BP. CG Blood glucose level, ESR, CP, 1 Spiastad Ween electrophoresis Fluorescein ansioereay 1d capillary perfusion {¢) * Secondary neovascular glaucoma . © Large vitreous rhage & subhyaloid haemorrhage * Maculopathy ‘ iF * Complete blindn * cystoid macular edema —_ \ce: KANSKI Book Chapter;13 Page 551.552 Q2: A 60 years old man complains of gradual painless loss of vis cataract in his left eye 2 years ago. (a) What is the most likely diagnosis? 1 (b) What ocular examinations are required before surgery? 2 (c) What are your operation of choice? 2 Ans: in right eye. He has been operated for All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationOnline Version (a) Senile cataract (b) _ Measurement of IOP * —— Fundoscopic (c) Phacoemulsification c oO (Reterence ; KANSKI Book Chapter:9 Page:270 Q3: A 16 years old boy cooing ers which is progressive in nature. His father & uncle have difficulty at night vision. On examination fundus shows bone spicules (pigment bone corpuscles) with pale disc & narrow vessels. {a)What is diagnosis? 1 & Le (b)What is most likely heredit A 2 = (c)What advice you will give to Sod Ans: =i (a) Retina pigmentosa (b) It appears recessive trail and usually occur due to consanguinity of parents (c) Genetic counseling is advised. There should be no consanguin@ous marriage Reference:KANSKI Book Chapter:15 Page:651 ‘Supply 2009 Qi: a) What are the causes of visual loss in diabetic retinopathy ?_ (4) b) What are the treatment option ? (1) An a) Causes Of Visual Loss In Diabetic Retinopathy:~ 1-Macular edema 2-Ocular hypertension 3- Retinal Haemorrhage 4- Retinal ischemia 5-Glaucoma b) Treatment :- 1 control of diabetes 2- Grid laSer and focal coagulation 3-panretinal photocoagulation 4- pars plama vitrectomy a: a) what is marfan’s syndrome? (1) b) what are its ocular manifestations ? (4) sD | Ans: é 3 ope a) Marfan’s Syndrome: It is a genetic disorder of confiective tissue . b) Ocular manifestations: it inclu 1- angle anomaly which may result in glaucoma 2- Retinal detachment associated with lattice degenerat 3-Hypoplasia of the dilator pupillae 4- Peripheral iris transillumination defects 5- cornea plana 6- strabismus 7- Axial myopia All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationQ3: A mother brings a 6 months old child complaining of right white pupil since birth. a) What is the differential diagnosis? (4) b) How will you investigate this case ? (1) Ans: a) Differential Diagnosis: Cc O° sn L-eataract a 2- corneal opacity mie Glaucoma ¢ Hypopyon 3- congenital abnormal f I coloboma of ' , = myelinated ner r é myopia 4- Infection toxocara 5- Neoplasia retinoblastoma 6- Trauma foreign body retinal fibrosis, 7- vascular abnormalities 8 coats disease 9- Endopthalmitis b) Investigation: 1- observation 2- Intrauterine Infection : toxoplasmosis , rubella 3- Galactosemia : urine test for reducing substance , red blood cell transferase and galactokinase 4- Hyperelycaemia : blood sugar 5- Hypocalcemia : serum calcium and phosphate levels and x- ray skull 6- lowe’s syndrome ; urine chromatography for amino acids Qa: a) What are the causes of papilloedema? (4) b) What will be the fields changes in ravateaten com Ans: a) Causes of papilloedema: me 1- Idiopathic intracranial hypertension 2- Obstruction of the vent 3- Space occupying intra 4- Impairment of CSF ab: subarachnoid haemorrhas lesions ion , including ae arachnoid villi, which may be damaged by meningitis , | trauma. 6- Diffuse cerebral oedema from blunt head trauma 7- Severe systemic hypertension. 8-Hypersecretion of CSF by a choroid plexus tumor. b) 1. Enlargement of blind spot 2- Progressive contraction of visual fields 3- Complete blindness sets in eventually Al Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationAnnual 2010 Qi: a) What are clinical feature of central retinal artery occlusion in 65 years old male? b) What systemic investigations are required? Ans: a) co wm Symptom: a: 1. symptoms of GCA such SB heatac ,jaw claudication, scalp tenderness, limb girdle pain weight loss 2. Sudden, complete and permanent loss of vision 3. Sometimes central may persist due to presence of cilioretinal artery 4, Amaurosis fugax: m eated transient episodes of decreased vision or blindness thar ‘may occur before visual Signs: * Visual activity: profound loss of vision even upto no perception of light. Pupil: widely dilated and light reflex absent Fundus examination: In complete block Retinal arteries are extremely thin Veins are normal except at disc where they are contracted Retina become opaque and milky white due to cloudy swelling caused by edema Cherry red spot is seen in fovea centralis Optic disc is pale due to ischemia In partial or incomplete block Cattle track sign: the column of venous blood may break into red beads separated by clear interspaced which move to and fro by gentle pressure on eyes. * Obstruction of branch: sector onshaped retinal pallor b) . Blood pressure measurefefit . Auscultation of heart . Carotid Doppler ultrasonography |. 2-dimensional echocardiography . Fasting blood glucose test id profile cBC 8. ESR 9. C-reactive protein 10. Biopsy 11.ECG 12.pulse NOY awNE Q2: 4A young man presents with history of night blindness since birth. a) What is diagnosis? 1 b) What vitamin deficiency can cause the same? 1 c) What genetic transmission is possible? 1.5 d) What retinal signs are present? 1.5 Ans: a) Pigment retinal dystrophy (re b) Vitamin A ¢) It appears as recessive trait and usually occurs due to consanguinity of the parents. pigmentosa) All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationCo) 1. Fundus examination: * The retina is studded with jet black spots which resemble bone corpuscles with a spidery outline. It affects the equatorial region first. The retinal blood vessels become resi attenuated and thread like. * Optic disc- it shows features of ongscies: phy, pale, wax like, yellowish appearance. 2. Visual fields: ao > annular or ring sce ;nt which leads to tubular vision. > complete blindness in later stage. function, .ctro-oculogram (EOG) are markedly subnormal or completely 3. Dark adaption: increased due to rod 4, Electroretinogram (ERG) ant extinguished early in disease. 3: a) Name four common causes of cataract? 02 b) Name surgical methods used for its removal? 1.5 c) What are advantages of phaco-emulsification? 1.5 Ans: a) 1. Degeneration and opacification of lens fibers already formed 2. Formation of aberrant lens fiber 3. Fibrous metaplasia pf the lens fiber 4. Abnormal production of metabolisms; drugs or metals can bedeposited in storage diseases (Fabry), metabolic diseases (Wilson) and toxic reactions (Siderosis). b) 1. intracapsular cataract extraction (ICCE) 2. Extracapsular cataract extraction (ECCE) 3. Phaecoemulsification 4, Phacolysis ¢) Advantages: > Intraoperatively phacoemulsification allows excellent control of each phase of operation for cataract removal. Small incision, self-Sealing ‘no stitch’ or sutureless incision produced very secure and stable wound. Thus rapid wound healing and shorter convalescence. > Removal of nucleus through continuous circular capsulactomy (CCC) with closed chamber. So low tisks oft damaging epithelium and iris. > Small incisions are compatible with aReoeon matism early return of vision. Qa: a) What are the clinical features mw optic neuritis? 3.5 b) What is the treatment? 1.5 a 2 is Ans: i se a) Symptoms: 1. Sudden, profound loss of vision is the most'common. 2. Transient blurring of visi lay be present. 3. Usually unilateral involvement 4.Sudden onset and rapid progression of diseases. 5.Complete blindness sets in rapidly in untreated cases Signs: Visual field: central, paracentral, sectorial scotomas or ring shaped scotoma. Local pain on moving eyes. Tenderness over the attachment of superior rectus tendon. Early loss of color vision and contrast sensitivity. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom Online Version Marcus gun pupil: lack of sustained constriction of pupil to light in swinging. Flash light test: it indicates afferent papillary defect. It is a diagnostic sign. Fundus examination: neither patient nor ophthalmologist see anything Temporal pallor of disc if lesion is near laminan cribrosa, ste ge ons fn b) Treatment: a: indication: when visual sf) 3¢ first week of onset is worse than 6/12 ,treatment may speed up recovery by 2-3 2.Regimen: * a) intravenous Inisolone sodium succinate b)intramuscular beta-la - 3.Retrobulbar injection 4.Systemic corticosteroi 5.Vasodilator are effectiv 6.Vitamin B1, B6 and B12 are administered in high do: 2010 Qa: a) What is retinal detachment? 01 b) Discuss the types of retinal detachment? 01 ¢) how do you treat rehmatogenous retinal detachment? 03 Ans: a) A retinal detachment (RD) describes the separation of the nelrosensory retina (NSR) from the retinal pigment epithelium(RPE) b) Types: * Rhegmatogenous * Tractional * Exudative * Combined tractional rhegmatogenous ¢) Treatment Of Rhegmatogenous Retinal Detachment: The aim of retinal detachment therapy is to counter the factors and forces that cause retinal detachment and to,re-establish the physiological conditions that normally maintain contact between the neural retina and pigment epithelium. The main goal of sii e., to close each retinal break) is usually sufficient to reattach the retina. Long-term cl eaks may also require permanent reduction or elimination of vitreoretinal tracti cence 'y maneuvers designed to offset the harmful effects of fluid currents in the vitreous cov 2: 20 years old man presents wi a) What is the diagnosis? 01 b) what would be the sign in reti c) What photo recepters are effet Ans: a) Retinitis pigmentosa b) Signs in chronological order: * Subtle mid-peripheral RPE atrophy associated with mild arteriolar narrowing, and mid- peripheral intraretinal perivascular ‘bone-spicule’ pigmentary changes. * Gradual increase in density of the pigmentary changes with anterior and posterior spread © Tessellated fundus appearance, due to RPE atrophy and unmasking of large choroidal vessels. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 73 Online Version * Severe arteriolar narrowing and gliotic ‘waxy pallor’ of the optic discs * The macula may show atrophy, epiretinal membrane formation and CMO; the latter may respond to systemic acetazolamide. ©) Rods are affected Q3: A30 years old female presents with unligoroce yD and pain on eye movement. a diagnosis of optic neuritis is made a a) what are the signs to be expectea? od b) what is the treatment? 01 c) what is the prognosis? 01 5 Ans: | a) Signs: a “visual acuity is reduced 5 *color vision is impaired - *RAPD is present *tenderness Fundus examination: blurred disc margins b) Treatment: “treat the underlying cause *corticosteroid therapy “oral prednisolone alone is contraindicated ©) prognosis is poor because it can lead to multiple sclerosis Supply 2011 Q1: A 30 year old patient develops with flashes and floaters a few days following blunt trauma to his eye. He presents in the outpatient with a black curtain in front of his eye and his vision is reduced to 6/36 in that eye. a) What is the most appropriate diagnosis? () b) What technique will be used to examine this case? () c) What is treatment of this condition? (2) d) How long should you wait before doing surgery? () Ans: a) Retinal detachment b) Techniques * B scan(ultrasonography) com * Plane mirror examine da- * Dice and inet ona eopy ©) Treatment Treatment is surgical. Procedures mainlylsed are = * Photocoagulation * Cryosurgery * Scleral buckling ae * Pars Plana vitrectot d) We should go for surgery as soon as possible. 2: A two year is brought to the outpatient department with leucdcoria and esotropia in the right eye. The parents have noticed that the disease is progressing rapidly and they are very concerned as his elder brother died few years ago at the same age. a) What is the most likely diagnosis? () b) What investigation will you perform? (a) Al Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization¢) What is the management in early disease? (2) d) What is the most common inheritance pattern of this disease? (1) Ans: a) Retinoblastoma b) Investigations * Red reflex testing with a direct rg * Tonometry a- . Measurement of theBtriéal meter. * Bscan + Wide-field photography oe * CT scan i MRI * | ae Genetic studies c) Management The approach to management is collaborativelbetween the ophthalmologist, pediatric oncologist, ocular pathologist, geneticist, allied health professi@nals and parents. The procedures used are * Chemotherapy(l.v. carboplatin, etoposide and vinetistine are given in 3 to 6 cycles according to the grade of retinoblastoma) TIT (transpupillary thermotherapy) achieves focal consolidation following chemotherapy, or is sometimes used as an isolated treatment. * Cryotherapy * Brachytherapy * Enucleation d) Inheritance Pattern * Its inheritance is autosomal dominant. In heritable retinoblastoma one of the pair Of alleles of RBI is mutated in all the cells in the body. When a further mutagenic event (‘second hit’ according to the ‘two-hit’ hypothesis proposed by Knudson) affects the second allele, the cell may then undergo malignant transformation. Q3: A40 years old female has unilateral congenital cataract in the right eye. She undergoes intracapsular cataract extraction and anterior vitrectomy but an intraocular lens could not be implanted. a) How will you fehabilitate patient visually until second surgery? (1) b) What complications can develop in this patient? m (2) c) What will be the second procedure? d °o 2) Ans: e a) Rehabilitation M e Spectacles are useful for visual rehabilitation in patients with aphakia. b) Compl ns, » ul * Endophthalmitis # * Suprachoroidal hi ¢ - * Rupture of the posterior lens eapsule * Cystoid macular oedema * Corneal decompensation * Ptosis. * Retinal detachment. ©) Second procedure ECCE (extracapsular cataract extraction) Alll Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 75 Online Version Q4: A 20 years old female presents with sudden loss of vision in the right eye only. There is slight pain on extra-ocular movements and afferent papillary defect is present on that side. Rest of the eye examination is within normal limits. a) What is the most likely diagnosis? (1) b) Which other clinical test would you like to perform? (a) c) What investigations would you like to pertgenpal sts are normal? (a) d) What is the most common cause of this. spi i @ e) What is the most appropriate ‘eainan ) Ans: a) Retrobulbar neuritis (Demyelinating optic neuritis) _ b) cli ical test | ‘Swinging Flashlight test. - c) Investigations “D Perimetery = * Lumbar puncture shows oligoclonal bands oniprotein electrophoresis of cerebrospinal fluid in 90-95%. * MRI almost always shows characteristic white matter lesions d) Most common condition Multiple sclerosis. e) Treatment * Intravenous methylprednisolone sodium succinate 1g dally for 3 days. * Oral prednisolone (1 mg/kg daily) for 11 days subsequently tapered over 3 days. * Immunomodulatory treatment which includes interferon beta, teriflunomide and glatiramer reduces the risk of progression to clinical MS in some patients. Annual 2012 Qu: a) What is retinal detachment? [1] b. Discuss the type of retinal detachment ? [1] c. How do you treat Rehmatogenous retinal detachment ? [3] Ans: a) Condition in which there is separation of the two layers of retina. The retina proper and pigmentary epithelium by the subretinal fluid. b) Primary: due to break in the retina in the form of hole . Secondary detachment: secondary to the ocular diseases °), 1. To seal retinal break Photocoagulation Cryosurgery 2. To approximate the sclera, choroid and detached retina Scleral buckling Drainage of subretinal fluid Pars plana vitrectomy Pneumoretinopexy : *~ Q2: A 30 year old female presents with unilateral loss of vision and pain on eye movement. A diagnosis of optic neuritis is made. a.What are the sign to be expected ?[3] b. What is the treatment ? [1] c. What is the prognosis ? [1] Ans: a) Signs All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 76 Online Version Visual field : central , paracentral ,sectorial scotoma or ring shaped scotoma. Local pain on moving eye. Tenderness Early loss of color vision and contrast sensitivity Marcus gun pupil b) Retrobulbar injection of dexamethasone Vasodilator e) Itis poor. Annual 2013 QI: A sixty year old male with history ta mellitus and hypertention presents with sudden deterioration of left eye of with no pupillary abnormalitie: obscuring the retinal vasculatu a. What is most likely diagnosis b. How will you proceed to cor Ans: a. Central vein occlusion b. ition. On examination his left eye appeared normal to look at ja was clear and retina showed extensive hemorrhage all over lar anatomy. your diagnosis and howwill you manage this case? 04 Blood pressure ECG Blood CP and ESR Blood glucose level Lipids Plasma protein electrophoresis Auto antibodies: ANA ,Anti-DNA and ANCA, Fluorescein angiography Optical coherence tomography Fundus fluorescein angiography Management: Treatment of macular oedema © Intravitreal anti-VEGF agents (e.g.ranibiumab 0.5mg) given monthly for 6 months Intravitreal dexamethasone implant Intravitreal triamcinolone (ee pioiaeplacn aco™ Investigational trash @ ae chorioretinal anastomosis, vitrectomy with radial optic neurotomy and locabrecombinant tissue plasminogen activator (rtPA) CRV infusion. Treatment of neovascularization: - Panretinal photocoagulation (PRP) Intravitreal anti-VEGF injections administered aelinctively every 6 weeks Q2: Give account of: a. Primary open angle gla b. Beta blocker as a treatment of choice for open angléiglaucoma 1.5 ¢.Retinoblastoma 1.5 Ans: a, Primary open angle glaucoma: Primary open-angle glaucoma (POAG) is a commonly bilateral disease of adult onset. It is characterized by: All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization* IOP >21 mmHg at some stage. * Glaucomatous optic nerve damage. * An open anterior chamber angle. * Characteristic visual field loss as damage progresses. * Absence of signs of secondary glaucoma or a non-glaucomatous cause for the optic neuropathy. Ww Risk Factors: ° Increase IOP med® Race ( more in blacks ) Family history % Diabetes mellitus lyopia : ¥ ” Clinical Feature: - a ‘Symptoms: 4 Sudden loss of visir —_ Night blindness Mid headache Signs: Raised intraocular pressure Optic disc changes Visual field defects Diurnal vai Treatment: Medical therapy Filtration surgery b. Beta Blockers: Recommended as first drug of choice. They decrease the production of aqueous humor. > Betaxolol (Betoptic) 0.25%, Cardioselective > Timolol maleate (Timoptic) 0.25%, 0.5% noncardioselective > Levobunolol (Betagan) 0.25% fioncardioselective Dose twice daily c. Retinoblastoma: “tis a congenital malignant tumor of primitive retinal cells of sensory retina” Etiology: Itis a.childhood tumor presents within 3 years of age. Inheritance: The retinoblastoma predisposing gene onychi SoG axe Clinical Feature: M ea Symptoms: Leukocoria Strabismus Defective vision Secondary Glaucoma Pseudo hypopyon Proptosis Signs: Fundus Examination: Exophytic type; pale pink or white mass with newly formed vessels on its surface Endophytic type; gives appearance of exudative retinal detachment with subretinal, bulated white mass mul Calcium deposition on surface of tumor appears pearly white ‘Treatment: All Rights Reserved. Join Us @: http://\www.facebook.com/MedCom.2011 Med-com Non-Govermental OrgnizationSolved Past Papers of Eye By MedCom 78 Online Version ‘Tumor destructive therapy Enucleation Q3: A seventy years old male presented with gradual progressive painless visual deteriorati both the eyes. On examination there was no aa congestion and there is diminished red glow in both the eyes with distant direct opthalm a, What is most likely diagnosis? ee b. Name the surgical procedures a available now a days. 03 «. Give an account of the compliéation it can cause ifleft untreated. 01 Ans: - a. Senile cataract b. Surgical Procedures: Intracapsular cataract extraction (ICCE) Extracapsular cataract extraction (ECCE) Phacoemulsufication Phacoincision Anterior capsulotomy Hydroprocedures Nuclear emulsification Aspiration of residual cortex Intraocular lens implantation Phacolysis c. Complications: Phacolytic glaucoma Phacomorphic glaucoma Phacoantigenic uveitis Pupillary block glaucoma Dislocation of lens ( ants or post.) lable to handle this condition with reference to new technology 2013 Q1: A.80 years old male has been complaining of headache suddenly complains of loss of vision in right ayes at both temples. eye. He'is'tender in both temples and one can feel roy a) What investigations will you do in this cal “Ct b) What is the likely diagnosis? Ni ea o1 ¢) What will fundus look like? ox d) What is the treatment? on y Ans: , | a) j gt * erythrocyte sedimentationifate (ESR) is very high © platelet count is elevat © Creactive protein is ral © Temporal artery biopsy is performed © fundoscopy b) Artretic anterior ischemic optic neuropathy caused by giant cell afteritis, €) Optic disc will be strikingly pale (chalky white) and edematous. d) Treatment: ‘* intravenous methylprednisolone © oral prednisolone All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 79 Online Version ‘© antiplatelet therapy ‘*immunosuppressives are given Q2: A 35 years old lady presents with severe headache, vomiting and blurring of vision since 15 days, CT scan shows space occupying lesion, visual acuity is 6/6 partial.in eyes. ir westeatin a) What are the most important oculai b) What will be fundus findings? c) What ocular complications can Sebi freated? “a Ans: a) Ocular investigations: 7 ‘© Fundoscopy | * Ocular computerized y ‘© Fluorescein angiogra ’ © Xray orbit MRI b) Fundus Findin; © Discis hyperemic, elevated with blurred margins * Blood vessels are tortuous and engorged ‘* Splinter and flame shaped hemorrhages ‘* Exudates and cotton wool spots are present © Macular star is present © Cupis obliterated ©) Untreated papilloedema leads to optic atrophy which causes reduced visual acuity. Q3: A 20 years old male c/o night blindness since birth, his visual acuity has been gradually reducing especially in the dark, his visual acuity at presentis 6/12 both eyes and he wears -2.5 diopter glasses both eyes. His maternal uncles have the same problem but his female siblings are all right. a) What will be the visual field changes? 02 b) What will be the fundus findings? 02 c) What is the advice? o1 Ans: a) Annular or ring Scotoma is present which leads to tunnel vision b) —_Theretina is studded with jet black spots which resemble bone corpuscles with a spidery outline. It affects the equatorial region first. The retinal blood, 0 eins and arteries become extremely thread like. The retinal veins, never ar rahe Peat of pigment for part of their course. ©) Genetic counseling is ace ahereditary disorder so there should be no consanguinous marriages. right eye, he refuses operation. 4: An 80 years old male has hypétmature cataract in a) What are the likely complications which can occur? 03 b) What are the signs of hypermature cataract? 02 Ans: a a) © Phacolytic glaucoma occurs because in hypermature cataract proteins leak through the intact capsule into the aqueous. The macrophages phagacytose these lens proteins and the trabecular meshwork is then blocked by these macrophages and protein causing glaucoma © Phacoantegenic uveitis * Dislocation of lens All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 80 Online Version b) Examination reveals an active and free pupil with cells in the anterior chamber and keratic deposits on the back of the cornea. Annual 2014 Q1: A 39 year old factory worker complains of difficulty in seeing tt reveals that he has night blindness since childh Fenster, his visual acuity is 6/18 in both eyes. Visual fields are tubular. Fundus sl disc, attenuated vessels and bone corpuscle type of pigment dispersion in the mid indus. a) What is your diagnosis? (3) b) What is your advice to him? (2) BS passing by his sides. History 5 Ans: at a) Retinitis Pigmentosa a b) Prognosis of this diseas ae with severe visual loss by the 4 decade of life and regular follow up of the patient is advised to detect other vision-threatening complications(e.g. open angle glaucoma, myopia, keratoconus, vitreous changes, optic dis@ldrusen, posterior subcapsular cataract) Q2: A'56 year old woman comes with the history of gradu: nin bothyeyes. On examination, her visual acuity is 6/60 in both eyes; retina shows anterio-venous nipping, macular star, flame shape hemorrhages and optic disc swelling. a) What is your diagnosis? (2) b) How will you classify retinopathy? Describe the signs. (3) Ans: a) Diabetic Retinopathy. b) Classification: > Background diabetic retinopathy (BDR) is characterized by microaneurysms, dot and blot haemorrhages and exudates. These are generally the earliest signs of DR, and persist as more advanced lesions appear. > Diabetic maculopathy strictly reférsto the presence of any retinopathy at the macula, but is commonly reserved for significant changes, particularly vision-threatening oedema and ischaemia. > Preproliferative diabetic retinopathy (PPDR) manifests __with cotton wool spots, venous changes, intraretinal microvascular anomalies (IRMA) and often deep retinal haemorrhages. PPDR indicates progressive retinal ischaemia, with a heightened risk of progression to retinal neovascularization. >» PDR is characterized by negocio =D ‘one disc diameter of the disc (NVD) and/or new vessels else\ in the fundus. > Advanced diabetic eye di characterized by tractional retinal detachment, significant persistent vitreous haemorrhage and neovascular glaucoma, Signs: , * Microaneurysms. nee * * exudates. : * Retinal Hemorrhages. ae Diabetic Macular Eder Focal Maculopathy. Diffuse Maculopathy. Ischemic Maculopathy. Cotton Wool Spots. Intraretinal Microvascular Abnormalities. Retinal Arteriolar Dilation. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 84 Online Version Q3: A 30 year old gardener presents in eye OPD with the history of painless gradually decreasing vision in his left eye. He had penetrating thorn injury 3 months back while working in rose bushes. On examination, visual acuity in his right eye is 6/6and in left eye is 6/24. On slit lamp examination, a small opacity in the cornea and briskly reacting pupil with white pupillary reflex are present. a) What is your diagnosis? (2) b) What important complications can occur with oo (3) Ans: a) Traumatic Cataract M ed b) Complic: Corneal and Scleral: ifthe cng is large, adhesion of iri or its prolapse can occur. Occasionally, in a corneal wound caused bY a dirty implement, pyogenic organisms are carried into the eye, multi there and cause rapid ‘1 ntire cornea, Usually, panophthalmitis sets in. ifit finds access to anterior chamber, pyoge! leads to‘ purulent iridocyclitis with hypopyon, endophthalmitis and usu _ halmitis. Lens: Traumatic cu josterior synechia can Q4: A 42 year old woman complains of right painful red eye wil examination, eye is red and painful with oedematous cornea. Visual acuity is 6/60. The eye is stony hard on digital tonometry with narrow anterior chamber and dilated sluggishly reacting pupil. a) What is your diagnosis? (2) b) What further clinical tests are required to confirm the diagnosis? (2) c) What is the surgical treatment? (1) Ans: a) Glaucoma. ical tests: Diagnosis of glaucoma is made after looking for a combination of clinical signs- characteristic changes in the optic nerve heads, abnormalities in the visual field and a rise in intraocular pressure. To check the intraocular pressure, tonometry is done(most commonly Goldmann tonometry). Gonioscopy is done to evaluate the anterior chamber angle Optic nerve head changes are seen by evaluating optic disc size, cup-disc ratio and neuroretinal rim ¢) Surgical treatment: * Glaucoma -filtering operations are employed to control the intraocular pressure by establishment of filteringbleb. © _TepBechldtomy involves the creation ofa lameliarsclgagtfen. 2014 Ql: A60 year old male presents wih, painless loss of vision in his right eye. His visual acuity is PL (Perception of light) in right eye and 6/9 in left eye. ou fundoscopy, a cherry red spot is seen on the retina. (5) a) Give the differential diagnos a red spot on Pe macula, (2) b) How will you manage this pa Ans: a) S Central retinal artery oh oe Tay-Sachs disease Niemaan-Pick disease Sandhoff disease Generalized gangliosidosis Sialidosis types 1 and 2 b) Treatment of major retinal artery occlusion is aimed at restoring the retinal circulation as quickly as possible by increasing retinal perfusion and dislodging emboli. Although retinal tissue cannot survive All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 82 Online Version ischemia for more than a few hours, complete occlusion is rare. It is therefore reasonable to treat all cases even within 48 hours. * The patient should lie flat as this helps to maintain the circulation and is also a convenient position for administrating therapy. Firm ocular massage should be applied intermittently for at least 15 minutes. It is hoped that this manoeuvre will lower intraocular ak 4 1d flow and dislodge emboli. Intravenous acetazolamide 5 ribs 0 lower the intraocular pressure further. * Ifthe above measures are sce an anterior chamber paracentesis should be performed. Unfortunately, the results of i ment are usualy very dseppci diameters are 13mm. so a) What is the diagnosis? (1) b) How will you investigate thi ¢) How will you treat him? (2) Ans: a) Infantile glaucoma (Primary congenital glaucoma) b) Q2: A mother brings her 1 year we with a eyes and white corneas. On examination, corneal is Measurement of Intraocular pressure Optic disc measurement (optic disc cupping) * Measurement of corneal diameter (>13mm confirm enlargement) * Gonioscopy ©) The management of PCG is always surgical and presents a difficult long-term problem. Because of its relative rarity it should be managed by an ophthalmologist who is familiar with the surgical techniques that may be required to control the IOP. The initial evaluation should be performed under general anesthesia using intravenous ketamine because other agenit8 may falsely lower IOP. * THE IOP is measured with either the Perkins.or Schiotz tonometer. * The Corneal diameter are measured in vertical and horizontal meridians with the same calipers that are used during strabismus surgery. 1A normal infants most of the increase in horizontal corneal diameter occurs within the first year of life. A corneal diameter greater than 12mm prior to the age of one year or 13mm at’any.age should be viewed with suspicion. Diameters of 14mm are typical of advanced bupthalmos. SURGERY: Goniotomy, Trabeculotomy, Trabeculectomy. Follow-Ups It is extremely important to detect and treat refractive errors and amblyopia. The IOP and corneal diameters should also be measured an intervals. Q3: A50 year old female presents ula? pain, decreased vision, photophobia, watering and redness of eye. On examination, “red pressure(IOP) is 45mmbg in right eye. (5) a) What is your diagnosis? (1) y b) How will you investigate and manage'this patient? (4) | Ans: a) Acute primary angle clost ma 7 ‘ x Investigation: y * Slitlamp biomoscroscapy| ciliary flush, 1OP is epithelial vesicles, the anterior chamber is shal * Gonioscopy shows complete peripheral iridocornt * Opthalmoscopy, when possible, shows optic disc o Management: Initial medical therapy: jerely elevated, corneal edema with with peripheral iridocorneal contact) contact - Shaffer grade 0 ma and hyperemia. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental OrgrizationSolved Past Papers of Eye By MedCom 83 Online Version * Intravenous acetazolamide 500mg is given initially followed by oral acetazolamide 250mg four times daily after the acute attack has been broken. There is no point in giving intramuscularly. * Hyperosmotic agents are used if the IOP is extremely high and if acetazolamide is ineffective. * Topical therapy: Plocapne ange > PERIPHERAL HEYA SS BOP Q4: A 60 year old diabetic male presents with gradual loss of vision in both eyes. His visual acuity is 6/36 in both eyes. On examination, cataractis seen in both of his eyes. How will you manage this patient? (5) Ans: When managing the catafact of a patient with diabetes, you should remember that cataract surgery may make diabetic retinopathy worse. Eyes with mildto moderate non-proliferative diabetic retinopathy at the time of surgery are considered lessat risk. Those with severe non-proliferative and proliferative diabetic retinopathy have a higher risk of proggessive disease. Clinically significant macular oedema (CSMO) present at the time of surgery is likely to prOgress and eyes with previously treated CMO are at increased risk of recurrence. The risk of progression is inGyeased if the operation is complicated by excessive manipulation, vitreous loss, or severe post-operative inflammation, * Ideally, when the cataract does not preclude laser treatment, you should achieve'and maintain effective control of retinopathy and maculopathy for at least three months before surgery. * The severity of the cataract sometimes prevents adequate examination or treatment of the retina in patients with diagnosed or suspected severe non-proliferative and proliferative diabetic retinopathy. In this case, you should deliver pan-retinal photocoagulation either during the procedure or in the early post-operative period. When performing intraoperative pan-retinal photocoagulation with an indirect ophthalmoscope, you should fill the anterior chamber with viscoelastic and place a corneal suture. Complete the pan-retinal photocoagulation before inserting the intraocular lens. This will provide'a stable anterior chamber and optimal view, particularly if you anticipate indentation of the periphery: * “ indiabetes patients, itis very important to minimise post-operative inflammation. You should use post-operative topical non-steroidal anti-inflammatory drugs in addition to routine topical steroid preparations, particularly in those with pre-existing macular oedema. * — Insummary, diabetes patients with mild to moderate diabetic retinopathy and no maculopathy have a good prognosis following cataract surgery. You should treat more advanced Tetinopathy or maculopathy at least three months prior'to surgery if possible. Whereas laser is the most recognised form of treatment, phi maka play an important role in the management of these a isaléo impdrtant to monitor high-risk patients in the post- operative period. THE END. All Rights Reserved. Join Us @: http://www.facebook.com/MedCom.2011 Med-com Non-Gevermental Orgrization