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 Clouding at the front of the eye reducing vision. It does not fit gradual painless blurring with glare, a reduced red reflex and a cloudy lens.
2. Cataracts correct Correct. Gradual painless blurring with glare, a reduced red reflex and a cloudy lens is a cataract.
3. Open-angle glaucoma Loss of side vision from damage to the optic nerve. Here, gradual painless blurring with glare, a reduced red reflex and a cloudy lens points elsewhere.
4. Optic neuropathy Vision loss with an abnormal pupil light response on one side. That does not match gradual painless blurring with glare, a reduced red reflex and a cloudy lens.
5. Diabetic retinopathy Changes to the blood vessels at the back of the eye, reducing vision. But gradual painless blurring with glare, a reduced red reflex and a cloudy lens does not point to it.

The point: A cataract is clouding of the lens inside the eye, which is normally clear, and it is the commonest cause of sight loss that can be reversed worldwide. The main risk factor is getting older, but cataracts also follow diabetes, long-term steroid use, a previous eye injury or operation, high short-sightedness (myopia), smoking, and, in babies, an infection in the womb or an inherited metabolic disease. Patients describe gradual, painless loss of vision, blurring, glare and haloes around lights, especially when driving at night, faded colours and, sometimes, a temporary improvement in near vision ("second sight") in the type called a nuclear cataract. The key clinical sign is loss of the red reflex (the red glow normally seen when a light is shone into the eye), and the cloudy lens is seen on slit-lamp examination (a special microscope used to look closely at the eye). Vision loss is otherwise painless with a normal-looking eye, which tells it apart from causes such as sudden glaucoma or optic nerve disease. The diagnosis is made clinically, and the decision to operate is based on how much it affects the person's daily life and vision, not a fixed cut-off on a vision chart, while also taking account of any other eye disease. The only effective treatment is surgery: phacoemulsification (breaking up and removing the cloudy lens using ultrasound) followed by inserting an artificial lens, usually done as a day case under local anaesthetic, with a high success rate. The most important complications after surgery are endophthalmitis (a rare but sight-threatening infection inside the eye, showing as a painful red eye and reduced vision, and needing urgent ophthalmology review), and posterior capsule opacification, a common later cause of blurring coming back, which is easily treated with a quick laser procedure (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. Laser capsulotomy for posterior capsule opacification A simple fix for blurring that returns later. Here, gradual painless blurring with glare, a reduced red reflex and a cloudy lens points elsewhere.
2. Update glasses after surgery Once the eye has settled down. But gradual painless blurring with glare, a reduced red reflex and a cloudy lens does not point to it.
3. Optimise other eye disease and risk factors Such as diabetes and steroid use. It does not fit gradual painless blurring with glare, a reduced red reflex and a cloudy lens.
4. Cataract surgery (phacoemulsification with an intraocular lens) correct Correct. Surgery to replace the cloudy lens is the only effective treatment.
5. Urgent ophthalmology for a painful red eye after surgery Rules out endophthalmitis. That does not match gradual painless blurring with glare, a reduced red reflex and a cloudy lens.

The point: A cataract is clouding of the lens inside the eye, which is normally clear, and it is the commonest cause of sight loss that can be reversed worldwide. The main risk factor is getting older, but cataracts also follow diabetes, long-term steroid use, a previous eye injury or operation, high short-sightedness (myopia), smoking, and, in babies, an infection in the womb or an inherited metabolic disease. Patients describe gradual, painless loss of vision, blurring, glare and haloes around lights, especially when driving at night, faded colours and, sometimes, a temporary improvement in near vision ("second sight") in the type called a nuclear cataract. The key clinical sign is loss of the red reflex (the red glow normally seen when a light is shone into the eye), and the cloudy lens is seen on slit-lamp examination (a special microscope used to look closely at the eye). Vision loss is otherwise painless with a normal-looking eye, which tells it apart from causes such as sudden glaucoma or optic nerve disease. The diagnosis is made clinically, and the decision to operate is based on how much it affects the person's daily life and vision, not a fixed cut-off on a vision chart, while also taking account of any other eye disease. The only effective treatment is surgery: phacoemulsification (breaking up and removing the cloudy lens using ultrasound) followed by inserting an artificial lens, usually done as a day case under local anaesthetic, with a high success rate. The most important complications after surgery are endophthalmitis (a rare but sight-threatening infection inside the eye, showing as a painful red eye and reduced vision, and needing urgent ophthalmology review), and posterior capsule opacification, a common later cause of blurring coming back, which is easily treated with a quick laser procedure (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 definitive treatment?

1. Base the decision to operate on the effect on daily life correct Correct. The decision to operate rests on how much it affects daily life, not a fixed cut-off on a vision chart.
2. Optimise other eye disease and risk factors Such as diabetes and steroid use. Here, gradual painless blurring with glare, a reduced red reflex and a cloudy lens points elsewhere.
3. Urgent ophthalmology for a painful red eye after surgery Rules out endophthalmitis. But gradual painless blurring with glare, a reduced red reflex and a cloudy lens does not point to it.
4. Update glasses after surgery Once the eye has settled down. That does not match gradual painless blurring with glare, a reduced red reflex and a cloudy lens.
5. Laser capsulotomy for posterior capsule opacification A simple fix for blurring that returns later. It does not fit gradual painless blurring with glare, a reduced red reflex and a cloudy lens.

The point: A cataract is clouding of the lens inside the eye, which is normally clear, and it is the commonest cause of sight loss that can be reversed worldwide. The main risk factor is getting older, but cataracts also follow diabetes, long-term steroid use, a previous eye injury or operation, high short-sightedness (myopia), smoking, and, in babies, an infection in the womb or an inherited metabolic disease. Patients describe gradual, painless loss of vision, blurring, glare and haloes around lights, especially when driving at night, faded colours and, sometimes, a temporary improvement in near vision ("second sight") in the type called a nuclear cataract. The key clinical sign is loss of the red reflex (the red glow normally seen when a light is shone into the eye), and the cloudy lens is seen on slit-lamp examination (a special microscope used to look closely at the eye). Vision loss is otherwise painless with a normal-looking eye, which tells it apart from causes such as sudden glaucoma or optic nerve disease. The diagnosis is made clinically, and the decision to operate is based on how much it affects the person's daily life and vision, not a fixed cut-off on a vision chart, while also taking account of any other eye disease. The only effective treatment is surgery: phacoemulsification (breaking up and removing the cloudy lens using ultrasound) followed by inserting an artificial lens, usually done as a day case under local anaesthetic, with a high success rate. The most important complications after surgery are endophthalmitis (a rare but sight-threatening infection inside the eye, showing as a painful red eye and reduced vision, and needing urgent ophthalmology review), and posterior capsule opacification, a common later cause of blurring coming back, which is easily treated with a quick laser procedure (capsulotomy).

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