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Painless neck lump 147
A3: What should one look for in the examination?
Perform a full head and neck examination including full nasendoscopy. It is important to visualize the
postnasal space in all patients with upper cervical lesions that might be neoplastic. The cranial nerves
should be examined carefully; numbness of the cheek is particularly important, as is any degree of
proptosis.
A4: What investigations would be most helpful and why?
Full blood count, U&Es, liver function tests, CT of the postnasal space and FNA cytology of the neck
lump
A5: What are the treatment options?
If the diagnosis is a postnasal space carcinoma, treatment is by radiotherapy plus a neck dissection
together with radiotherapy to the neck elds. A third of patients present with nasal symptoms, a
third with cervical metastases and a third with intracranial extension. This tumour can be particularly
aggressive. It occurs in a younger age group and is associated with the Epstein Barr virus (EBV). Levels of
the immunoglobulin IgA to EBV may indicate recurrent disease.
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148 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.18 –
The woman who has had the neck
biopsy that shows TB returns to clinic.
What advice would you give her?
Explain that TB is eminently treatable and that the chest physician or infectious diseases doctor will be
treating her. Say also that it will be important to screen the family to make sure that no other family
members have the disease and that if they do they will have to be treated. This should eradicate the
condition and the patient should be well for many years.
REVISION PANEL
The most common cause of cervical lymphadenopathy is reactive, this is typically related to an
underlying infection (acne, tonsillitis).
Painless lymphadenopathy especially if >2 cm is always concerning.
History and examination should focus at determining the underlying cause and excluding
laryngeal and pharyngeal carcinoma.
A FNA of cervical lymphadenopathy should always be performed.
Cross-sectional imaging can aid in determining the extent of disease and assist with diagnosis.
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Ophthalmology
Desirée Murray
OPHTHALMOLOGY
Questions 150
Clinical cases 150
OSCE Counselling cases 152
Glossary of terms 154
Answers 156
Clinical cases 156
Revision panel 162
Revision panel 165
Revision panel 170
Revision panel 172
OSCE Counselling cases 173
Revision panel 174
Revision panel 176
Revision panel 177
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150 Ophthalmology
OPHTHALMOLOGY
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the differential diagnosis?
Q2: What issues in the history support the diagnosis?
Q3: What additional features in the history would you seek to support a particular
diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
CASE 3.1 –
‘I have pain in my eye and I can’t see with it’
A 65-year-old woman presents with a 1-day history of pain, redness and reduced vision in one eye. She
has worn spectacles for reading since the age of 7 years.
CASE 3.2 –
‘I have suddenly lost the vision in one eye, but I have no
pain’
A 50-year-old patient presents with a 1-day history of sudden painless loss of vision. The patient has
diabetes and hypertension.
CASE 3.3 –
‘I have ashing lights and oaters in one eye’
A 40-year-old patient gives a 1-week history of sudden-onset ashing lights and oaters in one eye. The
patient has worn distance spectacles since the age of 12 years.
CASE 3.4 –
‘My vision has gradually become cloudy and dim, but there
is no pain in my eye’
A 60-year-old patient complains of a gradual deterioration in vision in both eyes over 1 year.
CASE 3.5 –
‘I have difculty seeing at night’
A 35-year-old patient presents with a 1-year history of difculty seeing at night. The patient also
complains of constriction of the visual eld.
CASE 3.6 –
‘I have double vision’
A 60-year-old patient presents with a 1-week history of double vision.
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Ophthalmology 151
CASE 3.7 –
‘I have intermittent loss of vision in one eye for a few
seconds and then my vision returns’
A 50-year-old patient complains of intermittent loss of vision in one eye like a ‘cloud’ or ‘curtain’
descending over the vision, which clears after a few seconds.
CASE 3.8 –
‘I have intermittent loss of vision in both eyes and then my
vision clears’
A 30-year-old woman complains of episodes of visual loss in both eyes associated with eye movements.
She has a 1-month history of intermittent headache.
CASE 3.9 –
‘My child’s eye has a turn’
A parent complains that her 2-year-old infant has developed a turn in one eye.
CASE 3.10 –
‘My baby has watery eyes’
A mother complains that her 4-month-old baby has had watery eyes since birth.
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152 Ophthalmology
OSCE Counselling cases
OSCE COUNSELLING CASE 3.1 –
‘Why am I having difculty reading
since having my cataract surgery?’
A 60-year-old patient recently had uncomplicated cataract extraction with an intraocular lens implant.
The patient complains of difculty reading. The distance vision is good. The patient has not yet obtained
new spectacles.
Can you reassure the patient? Explain why the patient is experiencing problems with unaided
near vision and what can be done to correct the problem.
OSCE COUNSELLING CASE 3.2 –
‘Why can’t I see as well now as I did
after my cataract surgery 18 months
ago?’
A 60-year-old patient had successful cataract surgery 18 months ago. The patient complains of gradual
reduction in vision in the pseudophakic eye. There is no history of diabetes or hypertension. Ocular
examination is normal apart from the presence of posterior capsule opacication.
What is posterior capsule opacication? Explain this condition to the patient, including its
treatment.
OSCE COUNSELLING CASE 3.3 –
‘Why am I short of breath since starting
treatment for glaucoma?’
This 60-year-old-patient has been diagnosed with glaucoma. He was prescribed timolol 0.5 per cent
eyedrops.
Is it possible to develop dyspnoea in association with timolol use? Discuss the possible side
effects of this eyedrop.
OSCE COUNSELLING CASE 3.4 –
‘I have recently been diagnosed with
glaucoma. Can I still drive?’
Adequate standards of vision must be met for all drivers. Suitability to drive should be
considered at every consultation. Driving may be continued as long as the patient has been
conrmed to meet the visual acuity standard and recommended national guidelines for visual
eld. Any advice given should be well documented in the patient’s medical record.
OSCE COUNSELLING CASE 3.5 –
‘I have well-controlled diabetes. I have
no problems with my vision. I had my
eyes checked 1 year ago. When should I
next have my eyes examined?’
This 50-year-old patient has had diabetes for 5 years. The patient has normal distance (6/6) and reading
(N5) vision with glasses.
Explain to the patient why he needs a complete eye examination, including dilated
funduscopy to screen for diabetic retinopathy, at least once a year, in spite of normal vision.
What factors would you consider important when counselling this patient?
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Ophthalmology 153
OSCE COUNSELLING CASE 3.6 –
‘Will laser treatment make my vision
worse? My neighbour, who also has
diabetes, is now blind following laser
treatment’
This patient has had type 2 diabetes for 10 years. The ophthalmologist has recommended laser
treatment for her right eye.
What factors would you consider important when counselling this patient?
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154 Ophthalmology
Glossary of terms
Age-related macular
degeneration (ARMD)
Non-exudative ARMD – dry type: age-related macular changes
characterized by discrete whitish-yellow spots identied as drusen,
pigment changes (hyperpigmentation and hypopigmentation) and
atrophy of the retinal pigment epithelium.
Exudative ARMD – wet type: manifestations of choroidal
neovascularization and/or accumulation of uid or blood beneath
the retinal pigment epithelium in a patient with age-related
maculopathy.
Amblyopia Decreased visual acuity without detectable organic disease of the eye
or visual pathway, the eye having not developed normal vision during
early childhood..
Anisocoria Condition in which the pupils of the two eyes are of different sizes.
Astigmatism An optical condition in which the refractive power of the eye varies
in different meridians, usually caused by the cornea having a greater
curvature in one direction than in another (similar to a rugby ball as
opposed to the more even shape of a football). As a result, parallel
rays of light do not focus at a point and a distinct retinal image
cannot form. It may be associated with long-sightedness, short-
sightedness or both.
Cryotherapy Procedure carried out with a freezing probe.
Cycloplegic refraction Paralysis of the ciliary muscle by means of drugs, thus allowing
measurement of the refractive error uncomplicated by changes in
accommodation.
Dacryocystitis Inammation of the lacrimal sac.
Dacryocystorhinostomy Surgical procedure to (re-)establish lacrimal drainage.
Dacryostenosis Atresia of the nasolacrimal duct.
Degenerative (pathological)
myopia
Abnormality in which the axial length of the eye is excessive.
There is patchy choroidal atrophy. The sclera is bared in the region
surrounding the optic nerve and at the macula, and the choroid is
easily visible.
Electroretinogram Action potential that follows stimulation of the retina.
Enophthalmos Recession of the eye within the orbit.
Exophthalmos Abnormal protrusion of one or both eyes. The term is often used
when there is an association with thyroid dysfunction.
Fundus uorescein
angiography
Intravenous sodium uorescein combined with serial black and white
photography to study the retinal circulation.
Hypermetropia/hyperopia/
long-sightedness/
far-sightedness
Condition in which parallel rays of light are brought to a point focus
behind the retina, because the eye is too short for its own focusing
power.
Hypopyon Pus in the anterior chamber.
Iridotomy Opening through all layers of the iris.
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Ophthalmology 155
Iritis Inammation of the iris.
Keratitis Inammation of the cornea.
Leukocoria White pupillary reex.
Myopia/short-sightedness/
near-sightedness
Condition in which parallel rays of light are brought to a point focus
in front of the retina, because the eye is too long for its own focusing
power.
Nasolacrimal duct Duct that connects the lower end of the lacrimal sac with the inferior
meatus of the nose.
Posterior synechiae Adhesions between the iris and the lens.
Posterior vitreous
detachment
Separation of the peripheral vitreous from the retina.
Presbyopia Loss of accommodation as a result of loss of elasticity of the lens with
increasing age, so that the near point recedes. The inability to focus
for near results in most people aged over 40 years needing reading
spectacles.
Proptosis Protrusion of the eyeball.
Relative afferent pupillary
defect
Transmission defect of the optic nerve demonstrated by the ‘swinging
ashlight test’. When light is directed into the eye on the normal
side both pupils react to light. When light is quickly switched to the
abnormal side, the pupil, instead of remaining constricted (from the
consensual reaction), dilates despite the light stimulation.
Rods Light-sensitive elements of the retina that function at low levels of
illumination. They are the main photoreceptors of the peripheral
retina.
Scintillations Visual hallucinations with ashing lights occurring in occipital lobe
disorders, particularly migraine.
Scleritis Inammation of the sclera.
Trabeculectomy A ltering operation for glaucoma, by creation of a stula between
the anterior chamber of the eye and the subconjunctival space.
Uveitis Inammation of the uveal tract.
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156 Ophthalmology
Answers
Clinical cases
CASE 3.1 –
‘I have pain in my eye and I can’t see with it’
A1: What is the differential diagnosis?
Acute angle-closure glaucoma
Iritis (anterior uveitis)
Keratitis – bacterial, viral, autoimmune peripheral ulcerative keratitis (PUK)
Scleritis/sclerokeratitis
A2: What issues in the history support the diagnosis?
The history of having worn reading spectacles since childhood suggests long-sightedness (hyperopia)
(Figure3.1). This increases the risk of developing acute angle-closure glaucoma because patients who
are long-sighted have small eyes with crowded anterior segments and narrow drainage angles.
Length of
normal eye
Retina
Parallel light rays
come to a point
focus behind the retina
Cornea
Parallel
light
Lens
Eyeball
Figure 3.1 Hypermetropia or hyperopia: long-sightedness.
A3: What additional features in the history would you seek to support a
particular diagnosis?
It is important to enquire about symptoms of haloes around lights and intermittent blurring of vision,
which suggest previous episodes of increased intraocular pressure with corneal oedema. Previous
attacks of angle closure may have resolved spontaneously. Is there any associated nausea and vomiting,
as this is often the case in acute glaucoma?
Enquire about photophobia – often quite marked in patients with iritis. Is there a history of
rheumatoid arthritis or other autoimmune disorder, which may be associated with PUK or scleritis?
Does the patient wear contact lenses? This may predispose to bacterial keratitis/corneal ulcer. Is there
a history of herpetic disease (cold sores or previous herpes simplex keratitis)?
A4: What clinical examination would you perform and why?
Visual acuity should be measured. Examine the red reex. A reduced or absent red reex is found in
corneal oedema. Compare the clarity of the cornea in the affected eye with that in the contralateral
eye. Palpate the globe to determine whether the intraocular pressure is elevated, but be gentle because
the eye may be quite tender. Examine the cornea with the aid of uorescein dye and cobalt blue light,
looking for staining, which would indicate corneal epithelial erosions, abrasion or ulcer. In patients with
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