Ophthalmology for AMC MCQ

A 74 year old man has two years of gradually worsening, painless blurring of vision in both eyes, with glare from oncoming headlights making night driving difficult and colours looking faded. His visual acuity is reduced, the red reflex is dim, and slit-lamp examination shows lens opacities. The rest of the eye, including the macula, looks normal. What is the most likely diagnosis?

1. Refractive error Blurry vision that gets sharp again with glasses. Here, the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye points elsewhere.
2. Retinoblastoma A white pupil in a child, from a rare eye cancer that must be ruled out. That does not match the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye.
3. Congenital cataract A white pupil or missing red reflex in a child. It does not fit the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye.
4. Diabetic retinopathy Vision loss with changes at the back of the eye in someone with diabetes. But the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye does not point to it.
5. Cataracts correct Correct. Slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye. This is a cataract from age.

The point: A cataract is a cloudy lens inside the eye. It is the most common cause of blindness that can be fixed. It usually comes on slowly with age. Vision gets blurry over time, and it does not hurt. Bright lights can look glary, with rings around them (haloes), and this makes night driving hard. Colours look faded, and vision gets dim. Sometimes glasses need to change as the lens changes. On exam, vision is reduced, and the red glow you normally see in the pupil (the red reflex) is dim or missing. A slit lamp (a special eye microscope) shows the cloudy lens. Things that raise the risk besides age are diabetes, steroid use, smoking, lots of sun, and past eye injury or surgery. In babies, a cataract from birth (congenital cataract) must be found early. It can stop the eye from learning to see properly, and it shows up as a white pupil or a missing red reflex. Diagnosis is made by looking at the eye. There is no drug that fixes a cataract. The treatment is surgery, done as a day case, called phacoemulsification (breaking up the old lens and taking it out), with a new lens put in its place. Surgery is offered once the cataract is affecting daily life or vision enough, or straight away in a baby. The operation works very well. The main serious risk to warn people about is endophthalmitis, a rare infection inside the eye after surgery that can threaten sight. It causes a painful red eye and vision that gets worse.

Source: Therapeutic Guidelines (Australia) — Eye: cataract Therapeutic Guidelines (Australia) · tier 3, national formulary

A 74 year old man has two years of gradually worsening, painless blurring of vision in both eyes, with glare from oncoming headlights making night driving difficult and colours looking faded. His visual acuity is reduced, the red reflex is dim, and slit-lamp examination shows lens opacities. The rest of the eye, including the macula, looks normal. What is the most appropriate next step in management?

1. Counsel about endophthalmitis warning signs Telling the patient the warning signs of infection after surgery: a painful red eye with vision getting worse. Here, the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye points elsewhere.
2. Cataract surgery with an intraocular lens correct Correct. A cataract is fixed by surgery, taking out the old lens and putting in a new one.
3. Urgent referral for a child with a cataract Sending a child with a cataract to a specialist fast. This protects how the eye learns to see. But the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye does not point to it.
4. Ophthalmology referral Sending the patient to an eye specialist for a full check and surgery. That does not match the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye.
5. Address modifiable risk factors Stopping smoking and controlling blood sugar. It does not fit the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye.

The point: A cataract is a cloudy lens inside the eye. It is the most common cause of blindness that can be fixed. It usually comes on slowly with age. Vision gets blurry over time, and it does not hurt. Bright lights can look glary, with rings around them (haloes), and this makes night driving hard. Colours look faded, and vision gets dim. Sometimes glasses need to change as the lens changes. On exam, vision is reduced, and the red glow you normally see in the pupil (the red reflex) is dim or missing. A slit lamp (a special eye microscope) shows the cloudy lens. Things that raise the risk besides age are diabetes, steroid use, smoking, lots of sun, and past eye injury or surgery. In babies, a cataract from birth (congenital cataract) must be found early. It can stop the eye from learning to see properly, and it shows up as a white pupil or a missing red reflex. Diagnosis is made by looking at the eye. There is no drug that fixes a cataract. The treatment is surgery, done as a day case, called phacoemulsification (breaking up the old lens and taking it out), with a new lens put in its place. Surgery is offered once the cataract is affecting daily life or vision enough, or straight away in a baby. The operation works very well. The main serious risk to warn people about is endophthalmitis, a rare infection inside the eye after surgery that can threaten sight. It causes a painful red eye and vision that gets worse.

Source: Therapeutic Guidelines (Australia) — Eye: cataract Therapeutic Guidelines (Australia) · tier 3, national formulary

A 74 year old man has two years of gradually worsening, painless blurring of vision in both eyes, with glare from oncoming headlights making night driving difficult and colours looking faded. His visual acuity is reduced, the red reflex is dim, and slit-lamp examination shows lens opacities. The rest of the eye, including the macula, looks normal. What is the most appropriate definitive management?

1. Manage coexisting eye disease Treating other eye disease too, such as glaucoma or retinopathy. But the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye does not point to it.
2. Address modifiable risk factors Stopping smoking and controlling blood sugar. That does not match the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye.
3. Offer surgery when function or vision is affected enough correct Correct. Surgery is offered because his night driving and daily life are affected.
4. Counsel about endophthalmitis warning signs Telling the patient the warning signs of infection after surgery: a painful red eye with vision getting worse. Here, the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye points elsewhere.
5. Update spectacles as an interim measure New glasses while waiting, for a mild cataract. It does not fit the picture of slow, painless blurry vision with glare, a cloudy lens on the slit lamp, and a normal back of the eye.

The point: A cataract is a cloudy lens inside the eye. It is the most common cause of blindness that can be fixed. It usually comes on slowly with age. Vision gets blurry over time, and it does not hurt. Bright lights can look glary, with rings around them (haloes), and this makes night driving hard. Colours look faded, and vision gets dim. Sometimes glasses need to change as the lens changes. On exam, vision is reduced, and the red glow you normally see in the pupil (the red reflex) is dim or missing. A slit lamp (a special eye microscope) shows the cloudy lens. Things that raise the risk besides age are diabetes, steroid use, smoking, lots of sun, and past eye injury or surgery. In babies, a cataract from birth (congenital cataract) must be found early. It can stop the eye from learning to see properly, and it shows up as a white pupil or a missing red reflex. Diagnosis is made by looking at the eye. There is no drug that fixes a cataract. The treatment is surgery, done as a day case, called phacoemulsification (breaking up the old lens and taking it out), with a new lens put in its place. Surgery is offered once the cataract is affecting daily life or vision enough, or straight away in a baby. The operation works very well. The main serious risk to warn people about is endophthalmitis, a rare infection inside the eye after surgery that can threaten sight. It causes a painful red eye and vision that gets worse.

Source: Therapeutic Guidelines (Australia) — Eye: cataract Therapeutic Guidelines (Australia) · tier 3, national formulary