Ans. 1. (b) PDR

10OPTHALMOLOGY

1.Which of the given disease correctly corresponds to the given fluoresceinangiography image:

a. NPDR b. PDRc. Familial dominant drusen d. Birdshot retinopathy

Explanation:This picture shows Fundus Fluorescein Angiography (FFA) of a patients.

Features seen in this picture are

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Ans. 2. (c) Staphyloma

a. Diffuse leak along superior arcade ( red circle) suggestive of NVEb. Multiple CNP (capillary non perfusion ) areas (yellow circle) c. Multiple pin pointed leaks ( green circle) suggestive of dot and blot hemorrhage

Above all findings suggestive of PDRIn NPDR, there will be no diffuse leak as circled in red circle.

PathologicPatternsofFluorescence

Pattern Cause Example Appearance on an-giogram

Hyper fluorescence Leakage AMD (CNVM)Neovascular tissueCSCR

Hyperfluorescence in-crease with time (both intensity of dye and size of lesion)

Staining Scar

Scleral show

Amount of dye visible increasesSize of lesion stays constant

Pooling Pigment epithelial defectTumor

Dye accumulating in a fluid-filled space (well-defined border, elevation o clinical exam)

Window defect Loss of RPERPE tear Drusen

Normal fluorescence of choroid accentuated (most apparent early, fades late)

Hypo fluorescence Blockage BloodPigmentFibrous tissue

Fluorescence of dye blocked by opaque medium

Nonperfusion Vascular occlusion

Coloboma

Vessels do not fill properly Absence of tissue/vessels

AMD, age-related macular degeneration; CNVM, chorodial neovascular membrane; CSCR, central serous chorioretinopathy; RPE, retinal pigment epithelium.

2.Themost likelycauseofbulgingofcornea inapatientofacutecongestiveglaucomais?a. Keratoconus b. Descemetocelec. Staphyloma d. Decreased corneal thickness

www.aim4aiims.in74Explanation:A staphyloma is an abnormal protrusion of the uveal tissue through a weak point in the eyeball. The protrusion is generalily black in colour, due to the inner layers of the eye. It occurs due to weakening of outer layer of eye (cornea or sclera) by an inflammatory or degenerative condition. It may be of 5 types, depending on the location on the eyeball (bulbus oculi). ANTERIOR (corneal) staphyloma In the anterior segment of the eye, involving the cornea and the nearby sclera. It is an ectasia of pseudocornea ( the scar formed from organised exudates and fibrous tissue covered with epithelium) which results after sloughing of cornea with iris plastered behind, it is known as anterior staphyloma. INTERCALARY staphyloma It is the name given to the localised bulge in limbal area, lined by the root of the iris. It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer. There may be associated secondary angle closure glaucoma, may cause progression of the bulge if not treated. Defective vision occurs due to marked corneal astigmatism. Treatment consists of localised staphylectomy under heavy doses of oral steroids. CILIARY Staphyloma As the name implies, it is the bulge of weak sclera lined by ciliary body, which occurs about 2–3 mm away from the limbus. Its common causes are thinning of sclera following perforating injury, scleritis & absolute glaucoma. it is part of anterior staphyloma EQUATORIAL staphyloma On the equator of the eye (region circumferencing the largest diameter orthogonal to the visual axis). Its causes are scleritis & degeneration of sclera in pathological myopia. It occurs more commonly in the regions of sclera which are perforated by vortex veins. POSTERIOR staphyloma Posterior staphyloma beneath the optic disc (right eye) In the posterior segment of the eye, typically diagnosed at the region of the macula, deforming the eye in a way that the eye-length is extended associated with myopia (nearsightedness). It is diagnosed by ophthalmoscopy, which shows an area of retinal excavation in the region of the staphyloma.

Ciliary

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Ans.3.(d)Intraocularantibniotic

3.Apatient onpost opday 5 after cataract surgerydeveloped the followingcomplication.Treatmentincludea/e:

a. Pars plana vitrectomy b. Topical antibioticc. Intravenous antibiotic d. Intraocular antibiotic

Explanation:Signs present in this picture are,

• Diffuse congestion• Corneal edema• Hypopyon

All this signs along with recent history of cataract surgery suggestive of endophthalmitis

EndophthalmitisIt is an inflammation of the internal layers of the eye resulting from intraocular colonization of infectious agents and manifesting with an exudation into vitreous cavity.It can be exogenous or endogenous.ClassificationPost surgical endophthalmitis

a. Fulminant (<4 days) • Gram negative bacteria• Streptococci• Staphylococcus Aureus

b. Acute (5-7 days)• Staph. Epidermidis• Coagulase negative cocci

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www.aim4aiims.in76c. Chronic (>4 weeks)

1. Delayed entry• Bleb related

2. Delayed onset• P. acne• Fungi• Staph epidermidis

Symptoms and signs in endophthalmitis• Pain• Rapid diminution of vision • Absent fundus glow• Anterior chamber reaction• Pupillary membrane• Hypopyon

ConfirmationofdiagnosisAll unexpected inflammatory response following intraocular surgery should be considered endophthalmitis unless proven otherwise.

Treatment Three most important determinant in outcome following endophthalmitis are-

a. Duration b. Virulence and loadc. Pharmacokinetics and spectrum of activity1. ANTIMICROBIAL THERAPY

a. Intravitreal antibiotics in post-surgical endophthalmitisb. Intravenous antibiotics in post-surgical bacterial endophthalmitis found to be

poor intraocular penetration.c. Topical and subconjunctival antibiotic can be considered

2. ANTI-INFLAMMATORY THERAPY: ROLE OF CORTICOSTEROIDS3. PARS PLANA VITRECTOMY

Close differential of endophthalmitis in a post surgical patient is TASS (Toxic Anterior Segment Syndrome)

77OPTHALMOLOGY

Ans.4.(a)Pterygium

TASS ENDOPHTHALMITISTiming The day after sx, 12-48 hrs Usually >2 day after surgery,

commonly 4-7 daysMild to moderate pain More pain (25% no pain)

Discharge Watery PurulentLid edema No Yes

Conjunctival chemosis

No Yes

Corneal edema Limbus to limbus Localized or segmental

4. Identify the given pathology:

a. Pterygium b. Pinguiculac. Chemical injury d. Fibrodysplasia

Explanation:PINGECULA

AA. Pinguecula B. Pinguecula with calci�cation

B

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Ans. 5. (a) Myopia

C. PinguculitisC

PTERYGIUM

A. Pterygium showing cap, head and body B. Stockers line in pterygium

C. Pseudopterygium secondary to chemical burn 5. Identify the refractive error:

a. Myopia b. Hypermetropia c. Compound astigmatism d. Mixed astigmatism

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79OPTHALMOLOGYExplanation:

Myopia corrected by minus lens Hyperopia correct by plus lens

(A) Simple hyperopic astigmatism; (B), (E) simple myopic astigmatism; (C) compound hyperopic astigmatism; (D) compound myopic astigmatism; (E) mixed astigmatism

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Ans. 6. (b) Myasthenia Gravis

6.ApatientpresentedwithdroopingofrightuppereyelidasshowninimageA.ThepatientwasgivenacertaindrugafterwhichtheconditionimprovedasshowninimageB.Whichofthefollowingisthepossiblediagnosis?

BeforeDrug AfterDrug

a. Tolosa-Hunt syndrome b. Myasthenia gravisc. Trigeminal neuralgia d. Multiple sclerosis

Explanation:

The image shows the Tensilon test used for the diagnosis of Myasthenia Gravis. The Tensilon test is used to diagnose Myasthenia Gravis. Patients positive for the disease should show an improvement in muscular strength following administration of Tensilon - Edrophonium - IV. Edrophonium is a very short acting Anticholinesterase and therefore increases the effective amount of acetylcholine at the neuromuscular junction in patients with Myasthenia Gravis.

Pathogenesis of Myasthenia Gravis

Axon

MitochondriaVesicle

A Normal

Nerveterminal

Muscle

AChE

AChR

B MG

THE NEUROMUSCULAR JUNCTION

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81OPTHALMOLOGYImportant points in myasthenia gravis

1. Most sensitive test: EMG (decremental response)

2. Most specific test: Antibody against Ach Esterase antibody

3. Treatment of Myasthenic crisis: Plasmapheresis and IVIG

4. Indications for thymectomy in MG

a. Anti < 15 years and > 55 years

b. Anti MuSK positive

c. Generalized MG

OssermanclassificationofMyastheniaGravis(MG)

● Occular MG ● Generalized MG

● Bullbar weakness ● Respiratory weakness/ crisis