School of Medicine

Teaching in the Department of Ophthalmology - MBChB Year V


Paediatric Ophtalmology

1. This child's mother thinks her eyes are crossed. What is your diagnosis?
Pseudoesotropia, cosmetically the result of prominent epicanthal folds / wide nasal bridge.

What screening test is illustrated?
Symmetrical central corneal reflexes, therefore no gross manifest tropia.

What diagnostic test will confirm your diagnosis.
Cover test. Lack of eye movement on cover/uncover or alternate covering demonstrates no phoria or tropia.

2. This 4 year old child presents with a manifest squint and the involved eye has unsteady fixation.

Which is the squinting eye?
Left eye (esotropia).

3. What test is illustrated?
Cover test – here cover / uncover. The cover / uncover test demonstrates the gross tropia, and an alternating cover test will demonstrate any latent (hidden) phoria.

What is the diagnosis?
Comitant alternating esotropia.

Is amblyopia likely to be present?
No because of alternating fixation.

What is the management?
Full history and examination to rule out other eye pathology. Refraction to address any hypermetropia (which can cause an esoptropia), glasses if required, and finally surgery to address any residual esotropia.

4. Mother is concerned about the acute onset of redness and swelling around her baby's left eye. What questions might you ask the mother?
Did you observe any tearing or discharge? Are there any changes when the baby cries?

What is the diagnosis and management?
Dacryocystitis, as a result of Congenital Nasolacrimal Duct Obstruction. Observation, massage, probing if older than 12 months, as over 90% resolve by the age of 1.

5. What two signs are present?
Pale red reflex on right, and right exotropia.

What is the differential diagnosis?
Retinoblastoma, cataract, persistent hyperplastic primary vitreous, retinopathy of prematurity, Coats' disease, uveitis, familial exudative vitreoretinopathy, retinal detachment, myelinated nerve fibres, other rare causes.

What is the correct medical term for the appearance of the right pupil?

6. What clinical test is demonstrated here?
Red reflex.

How do you undertake this test?
Use an ophthalmoscope to assess the eye from approximately a 1/3rd of a metre away so that the light is falling on both eyes at the same time. Viewing through the ophthalmoscope, dial in 'plus' lenses until the iris and then the red reflex is seen clearly (about +3). As some of the light entering the eye is reflected back by the retina, an even red glow is usually obtained. Any opacities within the normally transparent structures of the eye will cause dark obscuration of the red reflex. Cataract is the most common cause of obscuration of part or all of the red reflex.

What is the abnormality and diagnosis?
Opacity at the level of the lens on the right - nuclear cataract.

7. What condition does this child have?
Left ptosis.

What are the indications for surgical treatment?
The indications are: (1) Risk of amblyopia - operate ASAP and treat the amblyopia. (2) Cosmetic, may be postponed, usually until just before school age.

Can you see any sign that particularly concerns you in the management of this child ?
This child probably already has a degree of left amblyopia, because the visual axis is obstructed.

8. This is the picture of the left optic disc and macula in a 4 year old child that was born prematurely and required supplemental oxygen. The vision in this eye is 3/60. On which side of the disc is the fovea in this picture (Left eye!)?
On the right hand side of the disc.

Describe the abnormality which explains the poor vision.
Dragging of the macula in this case of chronic Retinopathy of Prematurity. Caught early, treatment with retinal laser can be very effective.

Eyelids & Orbital Disease

1. This is the upper lid of a patient complaining of persistent mild redness and irritation of the eyelids. State the physical signs you can observe.
Crusting of the lashes, dilated vessels.

This is a very common problem. What is the name of the disease? What treatment would you recommend?
Blepharitis. Treat with long term (for life!) daily lid hygiene (hot compresss and lid massage and then cleaning the lid margins with warm very dilute solution of baby shampoo and water). Short term antibiotic ointment (fucithalmic) may help reduce staphylococcal load, remembering this is a hypersensitivity and not an infection. In more severe cases low dose systemic antibiotic (doxycycline 50mg od for 3/12) will reduce inflammation and promote healthier meibomian gland oil production. There is no substitute for lid cleaning.

2. This patient has been punched and has a "black eye". What is a "black eye"?
Periorbital haematoma.

What immediate examination would you undertake to assess whether there is other damage to the eye or orbit?
Full examination of eye - vision, anterior segment, pupil responses, dilated fundal exam. Need to rule out globe rupture. Assess eye movements. Palpation of orbital rim (fracture?), Test sensation of infraorbital nerve – upper teeth / gum numbness most reliable sign of damage to the nerve. CT scan of orbits if blowout fracture suspected (motility limited or gross enophthalmos). In young patients, if unwell and vomiting may have a “greenstick” trapdoor blowout fracture and muscle entrapment. These can be ischaemic (hence the vomiting) and need urgent surgery. Adult bone is not as flexible, and the fractured segment does not flex back and trap structures, and surgery is often not required, or performed later if chronic motility problems or enophthalmos.

3. What clinical signs are present in this patient?
Upper and lower lid retraction. Dilated conjunctival vessels R>L. Red lid margins. Rash/redness of cheeks and forehead (probable rosacea).

What symptoms will the patient be complaining of?
Prominent eyes/cosmesis. Decreased vision one/both eyes. Double vision. Foreign body sensation, pain, photophobia. Systemic symptoms of thyroid disease.

What is the most likely diagnosis?
Thyroid orbitopathy.

4. Describe the lesion.
Raised lump in lateral third of lower eyelid, extending to lash margin, red/brown in colour with dilated vessels, "rolled" edges and central crusting.

What is the main aetiological factor?
Chronic sun (UV) exposure.

What is the most likely diagnosis, and the treatment?
Basal cell carcinoma. Perform complete full thickness excision – up to 1/3 of the eyelid can be removed and still allow direct closure.

5. This painless lump has developed slowly. It is common and non-malignant. What is the diagnosis?
Meibomian cyst / Chalazion.

How do they arise?
Granulomatous reaction to retained meibomian secretions.

What is the treatment?
Initial hot bathing and massage to encourage drainage from involved duct. Oral antibiotics 10/7 if infection present. If not resolving after 6 months, then incision and curettage (lid everted, internal approach).

6. What symptoms might this man be complaining of?
Watering eyes, sore/irritated burny eyes/lids, cosmetic appearance.

What condition does he have?
Bilateral ectropion.

What is the management?
If patient not bothered then nil. If problems of exposure then ocular lubricants (artificial tears) or surgical correction (usually by lid shortening procedure). If problems with watering then surgical correction (usually by lid shortening procedure). Both ectropion and entropion are most commonly due to eyelid laxity.

7. What clinical signs can you observe?
Lower lid rolled in. Lashes rubbing on cornea.

What symptoms will the patient experience?
Foreign-body sensation, irritation, soreness, watering.

What is the management?
For entropian, taping of the lower lid to the cheek (lateral tension) in order to pull lashes away from cornea can help for a few days. Quick everting sutures can be placed while awaiting definitive surgical correction, often with a lid-tightening procedure.

How would you examine the patient's cornea?
Slit lamp examination (or ophthalmoscope and blue filter if no slit lamp available) with fluorescein to stain corneal drying/trauma. Spotty or confluent fluorescein inferior staining will give an indication of the severity of corneal irritation. Long term can lead to corneal scarring.

8. This man ran into a tree branch, and sustained an eyelid laceration. His eye is OK. Describe the image.
Medial left lower eyelid laceration with ectropion secondary to laxity. Mild bruising of the upper lid and inferior subconjunctival haemorrhage.

What lid structure is likely to be involved which would complicate the repair?
The lacrimal canaliculus, which travels within the medial canthal tendon. Probing through the punctum would demonstrate whether it is severed or not.

Anterior Eye Disease

1. What symptoms might this patient complain of?
Gradually decreasing hazy / foggy vision. Glare (particularly driving at night).

What test could you undertake in the absence of the slit lamp?
Assess the red reflex with an ophthalmoscope (best when dilated with tropicamide 1%).

What is the abnormality and where is it located?
Cataract - posterior subcapsular lens opacity. The slit-lamp here is focussed on the posterior lens surface.

2. This patient is suffering from increased myopia and astigmatism. What is the diagnosis?
Keratoconus – evident by the conical shape of the cornea.

How is it demonstrated?
(1) On downgaze, the cornea pushes the eyelid out in a V pattern (Munson’s sign). (2) Abnormal non-uniform red reflex – like a “tear drop” in the centre – best viewed following dilation with tropicamide 1%). (3) Gold standard is computed Corneal Topography, which can detect very early (forme fruste) keratoconus, even before it is symptomatic.

What initial treatment would you refer this young man for?
Glasses for very early disease, then rigid contact lenses once glasses no longer correct the astigmatism satisfactorily. Surgery (corneal grafting) is reserved for very severe disease.

3. This man appears after work in the Casualty department stating his eye has been "sore and watering" for most of the day. What is the diagnosis?
Corneal foreign body.

What occupational hazards are likely to lead to this injury?
Grinding, welding, drilling, hammering, especially without adequate eyewear / protection.

What is the treatment?
Full history and examination to establish nature of incident (Any high velocity potential penetrating injury/ intraocular metallic foreign body should be excluded with plain xray) Foreign body removed with needle. Topical antibiotic.

4. What clinical signs are present?
“Wing” shaped extension of conjunctiva on to nasal side of cornea.

Which eye is this?

What is the diagnosis?

What are the indications for treatment?
(1) Approaching visual axis / affecting vision. (2) Inflammation / thickening of pterygium causing discomfort. Note: Recurrence of pterygium is difficult to manage, therefore primary excision is done only when necessary, excision for cosmesis is discouraged.

5. This man complains he awoke with a "red eye", no history of trauma. What is the diagnosis? Can you offer any treatment?
Subconjunctival haemorrhage. No treatment required - resolve spontaneously. What history might you elicit and what simple investigations could you undertake? Any history of raised blood pressure, coughing, vomiting. Check blood pressure. (Note: Subconjunctival haemorrhage in the setting of ocular trauma is a ruptured globe until proven otherwise.)

6. What is the infective agent?
Herpes simplex / HSV.

How would you describe this corneal lesion?
Dendritic epithelial defect of the epithelium (stained with rose bengal).

What is the treatment? Do you expect recurrences?
Acyclovir eye ointment 5x day for 10 days. Recurrences common.

What medication is contraindicated?
Topical steroid, as the infection will expand to a geographic ulcer if used.

7. This man has chronically irritated eyes and experiences photophobia. Rose bengal has been instilled into the conjunctival sac What has the stain demonstrated?
Devitalised epithelial cells in the conjunctiva and cornea in the area of the palpebral aperture indicating dry eyes.

What history, examination and investigations might you undertake?
Examine for signs of associated blepharitis, lid scarring, lid closure. History of nocturnal lagophthalmos (lids open whilst sleeping). History of systemic illnesses related to dry eyes (Collagen vascular diseases – Rheumatoid Arthritis, Sjogrens, SLE). Schirmers test (strips of filter paper in lower fornix to assess tear production).

What is the condition and how can it be relieved?
Dry eye, first line is artificial tear drops. Other avenues include optimising environment (avoiding dry places - dehumidifiers, air conditioning etc.), punctal plugging, treatment of concurrent blepharitis, dietary supplementation with flax oil and omega 3.

8. This child presents with an acute onset painful swollen left upper lid. What is the most probable diagnosis?
Preseptal cellulitis.

What else would you be thinking of?
Orbital cellulitis.

How can you tell the difference?
Careful history and examination - orbital cellulitis suggested by red eye, decreased vision, double vision, pain, fever, chemosis, proptosis, reduced ocular motility, and is usually secondary to concurrent sinusitis. A preseptal infection leaves the eye unaffected which is white and moves and sees normally if the lid is lifted. The lid MUST be lifted to differentiate, best accomplished with two cotton buds. Treat with systemic antibiotics and careful review.

Posterior Eye Disease

1. Compare and describe the appearance of these two optic nerve heads both of which illustrate pallor.
A) This colour photograph of the left eye demonstrates a large cap/disc ratio of more than 0.9, with nasal displacement of the vessels and visible lamina cribrosa. The most likely diagnosis is glaucoma. DD chiasmal tumors, syphilis, ischaemic optic neuropathy, retinal degenerative disease. B) This colour photograph of the left eye demonstrates pale disc with attenuated vessels typical of primary optic atrophy. The causes include compressive optic neuropathy, post optic neuritis, optic nerve tumours, congenital optic atrophy, hereditary optic neuropathies, toxic/metabolic optic neuropathies.

2. Picture A shows the appearance of one optic disc, the contralateral eye is unaffected. Picture B shows one eye and the other optic disc has a similar appearance. Describe and compare the appearances of the two optic discs.
A) The disc is pale, swollen with flame shape haemorrhages; B) the disc is hyperemic, swollen with blurring of the margins and obscured blood vessels.

What visual symptoms would A experience in comparison with B?
A) Will have profound loss of vision down to counting fingers or hand movement; B) May not experience visual loss, or experience short periods of decreased vision (transient obscuration) often precipitated by head posture.

What systemic symptoms might A and B have?
A) May have headache, jaw claudication, scalp tenderness, polymyalgia rheumatica, anorexia, weight loss, fever (and be older than 70) B) May have headache, double vision, nausea and vomiting.

What investigations would you undertake for A and for B? A) ESR, CRP, Platelets, and temporal artery biopsy suspecting Giant Cell (Temporal) Arteritis. (Unilateral optic disc swelling is not papilloedema). B) neuro-imaging (CT, MRI), as bilateral optic disc swelling due to raised ICP is papilloedema.

3. What is the feature in this fundal photograph?
Embolus within branch retinal artery (from carotic artery or cardiac). The retinal veins are usually darker and fatter than the arteries.

What systemic and ocular symptoms might this patient have noticed?
Systemic - transient ischaemic attacks, may be hypertensive. Ocular - transient visual loss (amaurosis fugax) or sudden painless onset of visual field defect.

What investigations might be necessary?
Systemic investigations to find source of emboli: blood pressure, complete blood test including cholesterol and lipid profile, carotid duplex ultrasound, cardiac evaluation. Ocular: the diagnosis is clear.

4. The vision in this patient's right eye is reduced following a traumatic injury some time previously. Compare the appearance of the right and left optic disc and nerve fibre layers.
The right optic disc is atrophic, with increased cup/disc ratio, together with prominent atrophy of the nerve fibre layer.

Where is the likely site of injury?
The injury is more likely to involve the retrobulbar portion of the optic nerve, and be direct or indirect.

What other simple test could you undertake to demonstrate the site of the lesion?
Examine the pupils for right relative afferent pupillary defect (swinging flashlight test – R pupil dilates as light is shone from L to R, then constricts again as shone from R to L). Patient will notice light is a lot dimmer (or absent) of R side (a subjective RAPD).

5. This is a photograph of a common retinal problem, what is the underlying disease?
Diabetes (with non-proliferative diabetic retinopathy).

What is the white lesion called?
Cotton wool spots (fluffy), and hard exudates (well defined).

What are the red lesions called?
Dot and Flame haemorrhages.

6. This picture shows one type of retinal vascular occlusion. Describe the signs present in this picture.
Diffuse retinal haemorrhages in all quadrants of the retina, dilated, tortuous retinal veins, (not clearly shown but cotton wool spots and disc oedema may also be present).

What is the diagnosis?
Central retinal vein occlusion.

What will be the approximate level of vision?
Average to poor (variable from 6/12 to counting fingers).

7. This picture shows another type of retinal vascular occlusion. Describe the signs present in this picture.
Pale retina (ischaemic / oedema), narrowed retinal arterioles with segmentation of the blood column, cherry red spot at the macula (thinnest part of retina).

What is the diagnosis?
Central retinal artery occlusion.

What will be the approximate level of vision?
Very poor (counting fingers to light perception).

8. This is the appearance of the retina in a myopic person who had symptoms of photopsia (flashes) and floaters, then progressive visual loss (like a curtain obscuring vision) over he last 3 days. What is the diagnosis? 
Left retinal detachment.

What would this person’s approximate vision be? 
The macula is detached (centre of image) therefore vision likely to be poor – around the 6/36 or worse level.

What is the prognosis? 
With surgery, the vision potentially could be as good as 6/12.