Eyes and vision for MRCGP AKT

A 67-year-old woman has a severe pain around her right eye and a right-sided headache that began this evening. She has vomited twice. Her vision in the right eye is blurred and she sees coloured rings around lights. She is long-sighted. She started oxybutynin for her bladder last week. The right eye is red and the cornea looks cloudy, like frosted glass. The pupil is mid-sized, oval and does not react to light. The eye feels hard compared with the left. Which is the most likely diagnosis?

1. Migraine with aura Wrong. Migraine can cause headache and vomiting, but it does not make the eye red, the cornea cloudy or the eye hard.
2. Anterior uveitis Wrong. In uveitis the pupil is usually small and irregular and the eye feels soft or normal. Her pupil is mid-sized and fixed, and the eye is hard.
3. Acute angle-closure glaucoma correct Correct. Sudden eye pain, headache, vomiting, blurred vision, halos, a cloudy cornea, a fixed mid-dilated pupil and a hard eye are classic. Long-sightedness and an anticholinergic drug such as oxybutynin raise the risk.
4. Giant cell arteritis Wrong. This causes headache and sometimes vision loss, but the eye is not red, painful and hard. There is no scalp tenderness or jaw pain.
5. Acute bacterial conjunctivitis Wrong. Conjunctivitis gives a gritty, sticky eye with a clear cornea and normal vision. It does not cause vomiting or a fixed pupil.

The point: In acute angle-closure glaucoma the drainage angle of the eye closes and the eye pressure shoots up. It is more likely in older, long-sighted people and can be set off by dim light or drugs with anticholinergic effects. Look for a red eye, a hazy cornea, a fixed mid-sized oval pupil and a hard globe. It is an emergency: send the person to the hospital eye service at once to protect sight.

Source: NICE CKS: Glaucoma NICE · tier 1, national regulator or guidance

A 31-year-old man has had two days of a painful, red left eye. Bright light hurts it and it waters. He has had stiffness in his lower back each morning for two years. Vision in the left eye is a little blurred. There is no discharge. The redness is deepest in a ring around the edge of the clear cornea. The left pupil is smaller than the right and slightly uneven. The cornea is clear and the eye does not feel hard. Which is the most likely diagnosis?

1. Viral conjunctivitis Wrong. This gives a gritty, watery eye with redness spread over the white of the eye and normal vision. It does not cause marked light sensitivity or a small pupil.
2. Episcleritis Wrong. Episcleritis gives a patch of redness with little pain. It does not cause light sensitivity, blurred vision or a small pupil.
3. Subconjunctival haemorrhage Wrong. This is a painless, flat, bright red patch with normal vision. It does not cause pain or light sensitivity.
4. Anterior uveitis correct Correct. A painful red eye with light sensitivity, blurred vision, a ring of redness around the cornea and a small irregular pupil is classic. Back stiffness points to an HLA-B27 related condition such as axial spondyloarthritis.
5. Acute angle-closure glaucoma Wrong. In angle closure the pupil is mid-sized and fixed, the cornea is cloudy and the eye is hard. His pupil is small and his cornea is clear.

The point: Anterior uveitis is inflammation of the iris and ciliary body. It causes pain, light sensitivity, watering, blurred vision and ciliary flush (redness that is deepest around the cornea), with a small or irregular pupil. Ask about back pain, bowel symptoms, psoriasis and joint problems, because it can come with HLA-B27 conditions. Arrange same-day assessment by ophthalmology, who use a slit lamp and prescribe steroid and dilating drops.

Source: RCGP curriculum topic guide: Eyes and vision Royal College of General Practitioners · tier 0, exam blueprint / regulator

A 54-year-old woman with rheumatoid arthritis has had three days of a painful red left eye. The pain is deep and boring, spreads to her brow and jaw, and wakes her at night. The eye is tender when touched through the lid. Paracetamol has not helped. The whole outer white of the eye looks deep purple-red in daylight. There is no discharge. Her vision is 6/9 and the pupil reacts normally. According to current good practice, which is the most appropriate next step?

1. Same-day referral to ophthalmology correct Correct. This is scleritis, which is linked to rheumatoid arthritis. Pain that wakes her, tenderness of the globe and a deep violet colour separate it from episcleritis. It needs urgent assessment and usually systemic treatment.
2. Oral naproxen and review in two weeks Wrong. An anti-inflammatory tablet may be used for episcleritis. Scleritis needs specialist assessment and often stronger systemic treatment, and a two-week delay is unsafe.
3. Prednisolone eye drops started by the GP Wrong. Eye drops do not treat deep scleral inflammation well. Steroid drops should not be started in primary care without an eye examination.
4. Chloramphenicol 0.5% eye drops Wrong. There is no discharge and no sign of bacterial infection. Antibiotic drops would not help this inflammation.
5. Lubricating eye drops and review in one week Wrong. This suits mild episcleritis. Severe boring pain that wakes her, with a deep purple-red eye, suggests scleritis, which can threaten sight.

The point: Episcleritis is common, mild and self-limiting: sectoral redness, little pain and normal vision. Scleritis is painful and can damage the eye. It gives severe boring pain that wakes the person, tenderness of the globe and a deep violet-red colour that does not fade with a drop of phenylephrine. It is often linked to rheumatoid arthritis, vasculitis such as granulomatosis with polyangiitis, or lupus. Refer for same-day ophthalmology assessment.

Source: RCGP curriculum topic guide: Eyes and vision Royal College of General Practitioners · tier 0, exam blueprint / regulator