A 74-year-old man presents with a severe throbbing headache on the right side of his head. He has now had this pain for around 6-7 days but reports no obvious trigger. There have been no visual disturbances or episodes of limb weakness. Neurological examination is unremarkable. The right side of his head is tender to touch but he cannot remember falling.
Given the likely diagnosis what is the most important initial step?
Correct Answer A: This patient has temporal arteritis and requires high-dose oral steroids to prevent ocular complications.
Temporal arteritis:
Temporal arteritis is large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR). Histology shows changes which characteristically 'skips' certain sections of affected artery whilst damaging others.
Features:
Investigations:
Treatment:
A 47-year-old female with a history of rheumatoid arthritis presents with a painful and red left eye. Visual acuity is normal. Fundoscopy is also unremarkable.
What is the most likely diagnosis?
Correct Answer A: Scleritis is painful, episcleritis is not painful.
A key way to discriminate between scleritis and episcleritis is the presence of pain. Keratoconjunctivitis sicca is usually bilateral and associated more with dryness, burning and itch.
Rheumatoid arthritis: ocular manifestations:
Ocular manifestations of rheumatoid arthritis are common, with 25% of patients having eye problems.
Ocular manifestations:
Iatrogenic:
A 43-year-old who is noted to have a high-arched palate, arachnodactyly and a late-systolic murmur presents with visual problems.
Which one of the following eye disorders is most associated with his underlying condition?
Correct Answer A: This patient has features consistent with Marfan's syndrome. Whilst glaucoma and retinal detachment are seen they are not as common as superotemporal ectopia lentis (upwards lens dislocation), which is seen in around 50% of patients. Inferonasal ectopia lentis is characteristic of homocystinuria.
Mitral valve prolapse may cause a late-systolic murmur. This feature helps distinguish the above description from that of a patient with homocystinuria.
Marfan's syndrome:
Marfan's syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the fibrillin-1 gene on chromosome 15 and affects around 1 in 3,000 people.
The life expectancy of patients used to be around 40-50 years. With the advent of regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly over recent years. Aortic dissection and other cardiovascular problems remain the leading cause of death however.
A 40-year-old man presents with bilateral dry, gritty eyes. A diagnosis of blepharitis is considered.
Which one of the following is least likely to be associated with blepharitis?
Correct Answer E:
Blepharitis:
Blepharitis is inflammation of the eyelid margins. It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis).
Blepharitis is also more common in patients with rosacea.
The meibomian glands secrete oil on to the eye surface to prevent rapid evaporation of the tear film.
Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turns leads to irritation.
Management:
*An alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled.
Which one of the following best describes the action of latanoprost in the management of primary open-angle glaucoma?
Correct Answer D:
Primary open-angle glaucoma: management:
The majority of patients with primary open-angle glaucoma are managed with eye drops. These aim to lower intra-ocular pressure which in turn has been shown to prevent progressive loss of visual field.
Surgery in the form of a trabeculectomy may be considered in refractory cases.
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