Medical ophthalmology for MRCP Part 1

A 74-year-old woman has 18 months of gradually blurring vision with glare and haloes around headlights that make night driving difficult, and faded colours. Her eyes are white and painless. The red reflex is reduced, and slit-lamp examination shows lens opacities. What is the most likely diagnosis?

1. Corneal opacity Anterior opacity reducing vision. Gradual painless blurring with glare and a reduced red reflex and lens opacity redirects it.
2. Cataracts correct Correct. Gradual painless blurring with glare and a reduced red reflex and lens opacity is a cataract.
3. Open-angle glaucoma Peripheral field loss from optic nerve damage. Gradual painless blurring with glare and a reduced red reflex and lens opacity raises it.
4. Optic neuropathy Visual loss with an afferent pupillary defect. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it a consideration.
5. Diabetic retinopathy Retinal vascular changes reducing vision. Gradual painless blurring with glare and a reduced red reflex and lens opacity points elsewhere.

The point: A cataract is opacification of the normally clear crystalline lens of the eye, and it is the commonest cause of reversible visual impairment worldwide. The dominant risk factor is ageing, but cataracts also follow diabetes, long-term corticosteroids, previous ocular trauma or surgery, high myopia, smoking and, congenitally, intrauterine infection and metabolic disease. Patients report gradual, painless loss of vision, blurring, glare and haloes around lights (especially night driving), faded colour vision and, sometimes, a temporary improvement in near vision ("second sight") in nuclear cataract. The key clinical sign is loss of the red reflex, and the opacity is seen on slit-lamp examination; vision is otherwise painless with a normal eye, distinguishing it from causes such as acute glaucoma or optic neuropathy. The diagnosis is clinical, and the decision to treat is based on the effect on the person's daily life and vision rather than a fixed acuity threshold, taking account of other eye disease. The only effective treatment is surgical: phacoemulsification with removal of the cloudy lens and insertion of an artificial intraocular lens, usually done as a day case under local anaesthetic, with a high success rate. The most important postoperative complications are endophthalmitis (a rare but sight-threatening infection presenting with a painful red eye and reduced vision that needs urgent ophthalmology), and posterior capsule opacification, a common later cause of recurrent blurring treated easily with laser capsulotomy.

Source: NICE NG77 — cataracts in adults: management NICE · tier 1, national regulator or guidance

A 74-year-old woman has 18 months of gradually blurring vision with glare and haloes around headlights that make night driving difficult, and faded colours. Her eyes are white and painless. The red reflex is reduced, and slit-lamp examination shows lens opacities. What is the most appropriate investigation?

1. Assessment of the red reflex Lost or reduced in cataract. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it a bedside clue.
2. Visual acuity testing Documents the impairment. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it supportive.
3. Assessment of the impact on daily life Guides the decision to operate. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it decisive.
4. Blood glucose where diabetes is suspected A recognised risk factor. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it useful.
5. Slit-lamp examination of the lens correct Correct. Slit-lamp examination visualises the lens opacity.

The point: A cataract is opacification of the normally clear crystalline lens of the eye, and it is the commonest cause of reversible visual impairment worldwide. The dominant risk factor is ageing, but cataracts also follow diabetes, long-term corticosteroids, previous ocular trauma or surgery, high myopia, smoking and, congenitally, intrauterine infection and metabolic disease. Patients report gradual, painless loss of vision, blurring, glare and haloes around lights (especially night driving), faded colour vision and, sometimes, a temporary improvement in near vision ("second sight") in nuclear cataract. The key clinical sign is loss of the red reflex, and the opacity is seen on slit-lamp examination; vision is otherwise painless with a normal eye, distinguishing it from causes such as acute glaucoma or optic neuropathy. The diagnosis is clinical, and the decision to treat is based on the effect on the person's daily life and vision rather than a fixed acuity threshold, taking account of other eye disease. The only effective treatment is surgical: phacoemulsification with removal of the cloudy lens and insertion of an artificial intraocular lens, usually done as a day case under local anaesthetic, with a high success rate. The most important postoperative complications are endophthalmitis (a rare but sight-threatening infection presenting with a painful red eye and reduced vision that needs urgent ophthalmology), and posterior capsule opacification, a common later cause of recurrent blurring treated easily with laser capsulotomy.

Source: NICE NG77 — cataracts in adults: management NICE · tier 1, national regulator or guidance

A 74-year-old woman has 18 months of gradually blurring vision with glare and haloes around headlights that make night driving difficult, and faded colours. Her eyes are white and painless. The red reflex is reduced, and slit-lamp examination shows lens opacities. What is the most appropriate management?

1. Cataract surgery (phacoemulsification with an intraocular lens) correct Correct. Surgery to replace the cloudy lens is the only effective treatment.
2. Optimise other eye disease and risk factors Such as diabetes and steroids. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it thorough.
3. Laser capsulotomy for posterior capsule opacification For later recurrent blurring. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it a simple fix.
4. Base the decision to operate on the effect on daily life The decision to operate rests on the effect on daily life, not a fixed acuity threshold, and gradual painless blurring with glare and a reduced red reflex and lens opacity here points elsewhere.
5. Urgent ophthalmology for a painful red eye after surgery To exclude endophthalmitis. Gradual painless blurring with glare and a reduced red reflex and lens opacity makes it a safety step.

The point: A cataract is opacification of the normally clear crystalline lens of the eye, and it is the commonest cause of reversible visual impairment worldwide. The dominant risk factor is ageing, but cataracts also follow diabetes, long-term corticosteroids, previous ocular trauma or surgery, high myopia, smoking and, congenitally, intrauterine infection and metabolic disease. Patients report gradual, painless loss of vision, blurring, glare and haloes around lights (especially night driving), faded colour vision and, sometimes, a temporary improvement in near vision ("second sight") in nuclear cataract. The key clinical sign is loss of the red reflex, and the opacity is seen on slit-lamp examination; vision is otherwise painless with a normal eye, distinguishing it from causes such as acute glaucoma or optic neuropathy. The diagnosis is clinical, and the decision to treat is based on the effect on the person's daily life and vision rather than a fixed acuity threshold, taking account of other eye disease. The only effective treatment is surgical: phacoemulsification with removal of the cloudy lens and insertion of an artificial intraocular lens, usually done as a day case under local anaesthetic, with a high success rate. The most important postoperative complications are endophthalmitis (a rare but sight-threatening infection presenting with a painful red eye and reduced vision that needs urgent ophthalmology), and posterior capsule opacification, a common later cause of recurrent blurring treated easily with laser capsulotomy.

Source: NICE NG77 — cataracts in adults: management NICE · tier 1, national regulator or guidance