Melissa is a 7-year-old girl who is brought to her pediatrician by her mother for evaluation of a 2-day history of fever (temperature, 101 ° F), sore throat, and redness and tearing in both eyes. She denies any cough, nasal congestion, or any pain or photophobia in her eyes. Melissa has been taking swimming lessons 2 days a week for the past month. Findings on physical examination include copious watery discharge and scanty exudate in both eyes, prominent follicles present on both her conjunctiva and pharyngeal mucosa, and nontender preauricular lymphadenopathy. The most appropriate treatment for Melissa at this time is which of the following?
penicillin to be taken four times a day by mouth
topical or systemic antiviral such as acyclovir
only symptomatic treatment required
instillation of a mast cell stabilizer to each eye
culture of ocular exudate
A 35-year-old man presents to your office complaining of a painless, localized swelling of his left lower eyelid that has developed over a period of weeks. He comes in today because it is now producing a foreign body sensation in his left eye. On physical examination, his visual acuity is normal and there is no evidence of injection or discharge. There is a nontender, localized nodule on the lower eyelid. What is the likely diagnosis?
A 50-year-old man presents with an acute and painless onset of a bright red blood patch along the lateral part of his sclera. His visual acuity is normal and blood pressure is within normal limits. He has had a cough, which is getting better. What is your diagnosis and the most appropriate treatment?
Subconjunctival hemorrhage - no treatment is needed
Subconjunctival hemorrhage - CT scan to rule out intracranial hemorrhage
Hyphema - complete blood cell count and bleeding studies
Hyphema - emergent consultation with an ophthalmologist
A 43-year-old man presents with complaint of a 3-day history of localized pain, redness, and swelling of his upper eyelid. He denies fever, visual changes, or photophobia. On physical examination, the patient's eyelid is diffusely red, with a tender, localized area of swelling, which points outward. He appears to have an infection of the glands of the upper eyelid. The most common pathogen associated with this infection is which of the following?
A 38-year-old man presents to the emergency department complaining of persistent double vision after being hit in the left eye during a fistfight the night before. On physical examination, his left perioribital area is markedly edematous and ecchymotic. On the basis of his history, what other abnormal finding might you expect to find as you complete your ophthalmic examination, and what diagnostic study would you order to best confirm your diagnosis?
hyphema; Schiotz tonometer
hyphema; plain radiograph
restricted ocular movement; CT scan
restricted ocular movement; plain radiograph
ruptured globe; retinal angiography
A 45-year-old woman presents with sudden onset of excruciating pain in the right eye, blurred vision, nausea, and vomiting. Physical examination reveals decreased visual acuity, intraocular pressure of 70 mm Hg, shallow anterior chamber, steamy cornea, and a moderately dilated right pupil that does not react to light. Which of the following is the most likely diagnosis?
retinal artery occlusion
primary open angle glaucoma
primary acute angle closure glaucoma
What is the leading cause of permanent vision loss in people older than 65 years in the United States?
age-related macular degeneration
A 75-year-old man presents with painless, sudden loss of vision in one eye. A careful history reveals previous episodes of vision loss that resolved spontaneously. A workup for these previous episodes included a carotid ultrasound, which confirmed a diagnosis of bilateral carotid stenosis. Given this patient's current symptoms and medical history, which of the following findings would be expected on funduscopic examination?
retinal lines that have the appearance of a “ripple on a pond” or a “billowing sail”
a pale or milky retina with a cherry-red fovea
enlarged physiologic cup, occupying more than half of the disc's diameter
swollen disc with blurred margins; physiologic cup is not visible
yellowish-orange to creamy-pink disc with sharp margins and a centrally located physiologic cup
A 35-year-old woman presents with a history of a self-limited upper respiratory illness 3 weeks prior to this clinic visit. She now complains of persistent weakness and malaise, which worsens near the end of the day. She complains that she has a difficult time keeping her right eye open during the later part of the day. Taking a nap often helps. You notice that her right eyelid covers the top portion of her pupil. Pupillary reactions are normal. A complete neurological evaluation is otherwise negative. Based on these findings, what is your diagnosis?
Brain stem lesion
None of the above
A 40-year-old man presents with a history of having a fleck of metal getting into the eye while the patient was pounding on a piece of metal scrap. The patient is complaining of extreme pain, photophobia, and his eyes are tearing like a faucet. How would you proceed with this patient?
Local anesthetic eye drops, fluorescein dye to visualize corneal foreign body, remove FB with needle, and apply polymyxin-B ointment.
Provide local anesthetic eye drops that the patient can continue to use to relieve the pain at home
Have the patient flush their eye with water until the metal comes out
None of the above is effective
A 65-year-old woman fell down and bumped her head earlier in the evening. She now presents with a sensation of flashing lights and floaters in her right eye. She has a history of diabetic retinopathy. She now has decreased visual acuity and feels that there is a curtain over her visual field. Funduscopic examination is difficult and, therefore, nondiagnostic since the patient is on eye drops for glaucoma. What is the most appropriate disposition for this patient?
emergency referral to an ophthalmologist
fasting blood glucose level
CT scan of the head
admission to the hospital for head injury observation
A 24-year-old man is working in a factory and felt a speck of material get into his eye, which was quite painful. He flushed out his eye at work but still complains of pain. He states that blinking makes the pain worse. The eye is very red. What is your next step?
patch the eye and refer to the ophthalmologist
cycloplegics to reduce the patient's pain
evert the upper eyelid
A 10-year-old boy presents with a fibrous nodule under his upper eyelid. It has been present for a couple of months. There is no drainage or pain. What is the most likely diagnosis?
foreign body reaction
A 60-year-old man presents with long-standing poorly controlled hypertension. Which of the following is/ are generally not associated with hypertensive retinopathy?
AV nicking with focal arteriolar damage
copper wire arterioles
decreased AV ratio
microaneurysms and hard exudates
A 65-year-old man with a history of diabetes mellitus presents with an acute episode of left facial paralysis. He is still able to wrinkle and elevate both sides of his forehead. He denies recent viral illness or ear pain. His diabetes has been well controlled. Examination of the tympanic membranes and the external pinnae are normal. The Weber and Rinné tuning fork assessments are normal. Visual acuity, extraocular movement, and pupillary responses are all normal and equal bilaterally. Which of the following is the most likely diagnosis?
Ramsay– Hunt syndrome
peripheral facial nerve palsy
An elderly patient presents with slurred speech. You have her protrude her tongue and it deviates to the right. Which cranial nerve (CN) is involved?
Left CN XII
Right CN XII
Left CN X
Right CN X
Left CN IX
Your patient is a 28 year old male who presents with severely injected eyes with copious purulent drainage (buckets of pus). He admits to being very sexually active. What is the most likely diagnosis and etiology?
Bacterial Conjunctivitis - Gonococcal
Bacterial Conjunctivitis - MRSA
Viral Conjunctivitis - Adenovirus
Viral Conjunctivitis - Gonococcal
You just diagnosed your patient with gonococcal conjunctivitis. Which of the following is the most appropriate treatment plan?
Refer immediately to Ophthalmologist and treat with both topical and oral antibiotics
This condition is self-limiting and requires no treatment
Prescribe topical antibiotics and see if condition resolves
Your patient presents with a severely injected right eye with copious purulent discharge. Based on this presentation, which of the following is your diagnosis?
Your patient is a 16 year old girl complaining of itchy watery eyes. P/E findings include ropy discharge and cobblestoning of the eyelid. What is your diagnosis?
Your patient is a 10 year old boy who presents with bilateral collicular conjunctivitis, epithelial keratitis, and corneal vascularization (pannus). What is your diagnosis and treatment choice?
Chlamydial Keratoconjunctivitis - azithromycin and improvements in hygiene and living conditions
Viral Conjunctivitis - topical sulfonamide and cold compresses
Bacterial Conjunctivitis - topical sulfonamide or oral antibiotic
Allergic Conjunctivitis - H1 receptor antagonists
Your patient complains of a red, swollen, tender area on the upper eyelid. What is your diagnosis and treatment plan?
Pterygium - artificial tears
Dacrocystitis - systemic antibiotics
Chalizion - incision and curettage
Blepharitis - clean the lid margins
Hordoleum - antibiotic ointment
Your patient is an avid surfer and is frequently exposed to wind, sun, and sand. He comes into your office presenting with a fleshy, triangular encroachment of the conjunctiva onto the nasal side of the cornea. What is your diagnosis?
You just diagnosed your patient with ptyergium, which of the following would you use in your treatment plan?
short course of topical NSAIDs or weak corticosteroids
Excision if the growth threatens vision, induced astigmatism, or severe ocular irritation
All of the above should be used/considered in your treatment plan
Your patient presents with a hard, nontender swelling on the upper eyelid of the right eye. The adjacent conjunctiva is edematous and erythematous. What is your diagnosis?
You patient presents with scales (seborrhea) around the base of the eyelashes and redness of the eyelids. Based on this presentation, what is your diagnosis?
A 6 month old infant was taken into an urgent care clinic because the mother noticed swelling, redness and pus coming out of the infant's tear sac area. The infant seemed very agitated. What is your diagnosis and treatment plan?
Congenital Dacrocystitis - probing of the nasolacrimal system
Chronic Dacrocystitis - systemic antibiotics
Blepharitis - baby shampoo to cleanse eye
Ectropion - surgical correction
Your patient is a 50 year old woman complaining of pain, swelling, and redness near the tear sac of her right eye. She also complains of tearing and purulent discharge. You diagnose her with chronic dacryocystitis. What pathogens are likely causing this condition and how would you treat it?
S. epidermidis, anaerobic streptococci, or candidida albicans - recommend dacryocystorhinostomy (surgical correction)
S. epidermidis, anaerobic streptococci, or candidida albicans - systemic antibiotics will cure this condition
Staphylococcus aureus, or beta-hemolytic streptococci - recommend dacryocystorhinostomy (surgical correction)
Staphylococcus aureus, or beta-hemolytic streptococci - systemic antibiotics will cure this condition
Your patient is an 80 year old male complaining of excessive tearing, dryness, and general irritation of his left eye. P/E findings include the outward turning of the lower eyelid on the affected eye only. What is your diagnosis?
Your patient is a 27 year old female who wears contact lenses and frequently forgets to take them out before going to sleep. She is now presenting with a hazy cornea, central ulcer with adjacent stromal abscess and hypopyon. You scraped the ulcer for culture and found Pseudomonas aeurginosa. What is your diagnosis and treatment plan?
Bacterial Keratitis - high concentration topical antibiotic drops (tobramycin)
Corneal Ulcer - emergent referral to ophthalmologist
Dacryocysitis - systemic oral antibiotics
Conjunctivitis - self-limiting condition, no treatment necessary
Blepharitis - use baby shampoo for eye hygiene
Your patient is complaining of pain, photophobia, tearing, and reduced vision. P/E findings include circumcorneal injection. What is your diagnosis and treatment plan?
Corneal Ulcer - emergent referral to ophthamologist
Dacryocystitis - systemic antibiotics
Bacterial Keratitis - levofloxacin antibiotic drops
Viral Conjunctivitis - no treatment necessary
Your patient presents with a pool of blood at the bottom of the iris which appears to be contained by the cornea. What is your diagnosis?
You just diagnosed your patient with hyphema, what is the most appropriate treatment option?
No treatment is needed, the body with reabsorb the hemorrhage
Emergent referral to ophthalmologist because this condition may lead to intractable glaucoma with permanent visual loss
Excise and drain the blood
None of the above
Your patient presents with peri-limbic irritation (around the iris), pain, ciliary flush (inflamed ciliary body), severe photophobia, vision loss, and hypopyon in the left eye. The pupil of the left eye is smaller than the right eye and is irregular in shape. What is your diagnosis?
Bacterial Corneal Ulcer
Your patient recently had cataract surgery and is now complaining of redness, swelling, blurred vision, and photophobia. P/E findings include decreased visual acuity and hypopyon. What is the most likely diagnosis?
Which of the following is true regarding the cranial nerves that innervate the eye muscles?
CN IV (trochlear) innervates the superior oblique muscle
CN VI (abducens) innervates the lateral rectus muscle
CN III (oculomotor) controls all eye muscles except the ones mentioned above
All of the above are true
None of the above are true
Your patient presents with malaise, fever, headache, and periorbital burning and itching for the past two days. Today they developed a vesicular rash. P/E findings include conjunctivitis, keratitis, episcleritis, anterior uveitis and increased intraocular pressure. What is your diagnosis and treatment plan?
Herpes Zoster Opthalmicus - high-dose oral acylcovir and emergent referral to ophthalmologist
Herpes Zoster Opthalmicus - viral cause that will resolve on its own
Herpes Simplex Keratitis - high-dose oral acylcovir and emergent referral to ophthalmologist
Herpes Simplex Keratitis - viral cause that will resolve on its own
Your patient complains of vision loss and has 20/20 visual acuity in the left eye and 20/200 in the right eye. Using fluorescein dye, you see a dendritic ulcer over the cornea. What is your diagnosis?
Herpes Simplex (Viral) Keratitis
Herpes Zoster Opthalmicus
Patient complains of rapid loss of vision in the right eye due to a "curtain-like" covering of visual field. This occurrence lasted for a few minutes and then subsided. What is the most likely diagnosis?
Amaurosis Fugax (ocular TIA)
Branch retinal artery occlusion
Acute angle closure glaucoma
Your patient is a 70 year old male complaining of rapid loss of vision in the left eye due to a “curtain-like” covering of visual field. Patient also notes a sudden onset of floaters and photopsia. Pt history includes cataract surgery and myopia (nearsightedness). P/E findings include the retina hanging in the vitreous, appearing as a gray cloud. What is your diagnosis?
Open Angle Glaucoma
Retinal artery occlusion
Which of the following would predispose someone to a retinal detachment?
Neovascular age-related macular degeneration
Retinal vein occlusion
All of the above
Your patient is complaining of sudden onset of unilateral facial paralysis and post auricular pain. You diagnose your patient with Bell's Palsy. Which of the following best represents the pathophysiology of this condition?
CN 7 (facial) nerve compression likely due to herpes simplex virus
CN 7 (facial) nerve blockage due to stroke
Your patient presents with ptosis, divergent and slightly depressed left eye. Extra ocular movements are restricted in all directions except laterally. The pupil is dialed and does not respond to light. What is your diagnosis?
CN III Palsy (oculomotor)
CN IV Palsy (trochlear)
CN VI Palsy (abducens)
Your patient recently experienced head trauma and is now presenting with an upward deviation of the left eye with failure of depression on adduction. Based on this presentation what is the most likely diagnosis?
CN VI palsy (abducens)
Your patient recently experienced head trauma and is now presenting with a convergent squint in the right eye with failure of abduction, producing horizontal diplopia that increases on gaze and looking into the distance. The patient has increased intraocular pressure. Based on this presentation what is the most likely diagnosis?
Which of the following are true about lesions of the optic tract?
A lesion in the left optic tract will cause right-sided homonymous hemianopsia
A lesion in the right optic tract will cause left-sided homonymous hemianopsia
Stroke, congenital defects, tumors, infection, and surgery are all possible causes of optic tract damage
You diagnose your patient with acute angle glaucoma. Which of the following is the best treatment plan for this condition?
Reduce intraocular pressure with IV acetazolamide, apply topical pilocarpine, and recommend peripheral iridotomy in both eyes
Reduce intraocular pressure with IV acetazolamide, apply topical pilocarpine, and recommend peripheral iridotomy in the affected eye only
once a day dose of a prostaglandin analog (bimatoprost)
Topical beta-adrenergic blocking agent (timolol)
Which of the following may predispose a patient to acute angle-closure glaucoma?
shallow anterior chamber depth
farsightedness or short stature
enlargement of crystalline lens with age
Inheritance (usually in Inuit and Asian populations)
All of the above
Your patient is a 65 year old male complaining of progressive bilateral loss of peripheral vision (tunnel vision). P/E findings include cupping of the optic discs, and increased intraocular pressure. What is your diagnosis and treatment plan?
Chronic (open angle) Glaucoma - prescribe a prostaglandin analog, recommend laser trabeculoplasty and refer to an ophthalmologist
Chronic (open angle) Glaucoma - reduce intraocular pressure with IV acetazolamide, apply topical pilocarpine, and recommend peripheral iridotomy in both eyes
Acute angle closure glaucoma - no treatment is necessary at this time
Acute angle closure glaucoma - urgent referral to an ophthalmologist
Your patient is complaining of sudden visual loss and abrupt onset of floaters. The eye is not injected and the patient denies any pain. Fundoscopic exam findings include a collection of blood in front of the retina. What is your diagnosis?
Your patient has diabetes mellitus and during their annual physical you perform an eye exam. Fundoscopic exam findings of your patient include microaneruisyms, retinal hemorrhages, venous beading, retinal edema, and hard exudates. What is your diagnosis?
Central retinal artery occlusion
Your patient is a 65 year old female complaining of progressive, bilateral central vision loss. She denies any pain and her eyes are non-injected. Based on this presentation, what is your diagnosis?
You suspect your patient has a corneal abrasion, using a slit-lamp and fluorescein dye, you inspect the cornea and notice there is damage into Bowman's layer. What is your diagnosis?
Your patient is a 65 year old female with a Hx of diabetes and smoking. She is complaining of gradually progressive blurred vision with monocular diplopia. Patient denies any pain, and the eyes are non-injected. P/E findings include an absent red reflex in both eyes and white-looking pupils. What is your diagnosis and treatment plan?
Cataracts - refer to ophthalmologist for surgical correction
Corneal abrasion - prescribe antibiotic ointment
Acute Glaucoma - decrease intraocular pressure with IV acetazolamide
Your patient has papilledema (optic disc swelling due to increased intracranial pressure). Which of the following would be included in your differential diagnosis?
Optic disc drusen
central retinal vein occlusion
all of the above