Red eye, keratitis and uveitis flashcards
16 high-yield MRCP Part 1 cards from the Intellect Medicos Ophthalmology course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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A 28-year-old man with inflammatory back pain has a painful red right eye, photophobia, ciliary flush and a small irregular pupil. What is the first-line treatment after urgent ophthalmology review?
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Topical steroid (e.g. prednisolone acetate 1%) plus a topical cycloplegic (e.g. cyclopentolate).
Why? This is acute anterior uveitis; associations include ankylosing spondylitis, reactive arthritis, IBD, Behçet's and sarcoidosis. Systemic steroids or immunosuppressants are for resistant or recurrent disease.
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What is the first-line treatment for herpes simplex keratitis with a dendritic ulcer?
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Topical antiviral — in the UK, ganciclovir 0.15% eye gel (aciclovir 3% eye ointment is the classic alternative).
Why? HSV keratitis gives a unilateral painful red eye with a branching (dendritic) ulcer on fluorescein, reduced corneal sensation and usually no skin rash.
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Which class of eye drop must be avoided in herpes simplex epithelial keratitis?
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Topical corticosteroids.
Why? Steroids increase viral replication and can lead to a geographic ulcer and corneal perforation.
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In shingles of the forehead, what is the significance of vesicles on the tip or side of the nose?
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Hutchinson's sign: the nasociliary branch is involved, which strongly predicts eye involvement.
Why? The nasociliary nerve supplies both the nasal tip and the globe, so these patients need urgent ophthalmology and slit-lamp review plus oral antivirals.
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A contact-lens wearer has a painful red eye with a corneal ulcer. What is the first-line management?
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Stop lens wear and refer same day for slit-lamp examination (± corneal scrape), then intensive topical fluoroquinolone drops.
Why? Pseudomonas aeruginosa is the classic organism in contact-lens keratitis; Acanthamoeba is the other one to remember. Cycloplegics help the pain.
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Three days after cataract surgery, a 72-year-old man has a painful red eye, sharply reduced vision and a fluid level of pus in the anterior chamber. What is the first-line management?
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Same-day ophthalmology: vitreous (± aqueous) tap, then intravitreal vancomycin plus ceftazidime.
Why? Painful red eye + reduced vision + hypopyon after eye surgery is endophthalmitis. Staphylococcus epidermidis is the commonest cause after surgery.
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What is the most common ocular complication of rheumatoid arthritis?
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Keratoconjunctivitis sicca (dry eye).
Why? It causes gritty, burning eyes. Scleritis (deep boring pain) and peripheral ulcerative keratitis are rarer but sight-threatening.
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Which HLA type links acute anterior uveitis with ankylosing spondylitis and reactive arthritis?
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HLA-B27.
Why? HLA-B27-associated uveitis is typically acute, unilateral and recurrent, sometimes alternating between eyes.
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Give two reasons cycloplegic drops (e.g. cyclopentolate) are used in anterior uveitis.
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They relieve pain from ciliary spasm, and they dilate the pupil to prevent posterior synechiae (iris sticking to the lens).
Why? They also help maintain anterior chamber depth. Topical steroid treats the inflammation itself.
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A 60-year-old woman with rheumatoid arthritis has a red eye with severe, deep, boring pain that wakes her at night and is worse on eye movement. Vision is slightly reduced. What is the most likely diagnosis?
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Scleritis.
Why? Episcleritis is the milder lookalike: little or no pain, normal vision, self-limiting. Scleritis is sight-threatening and needs same-day ophthalmology review.
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What is the usual first-line systemic drug treatment for non-necrotising scleritis?
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Oral NSAIDs; systemic steroids or immunosuppressants if NSAIDs fail or the scleritis is necrotising.
Why? Scleritis is managed by ophthalmology, often with rheumatology, because it is frequently linked to systemic vasculitis or RA.
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When a topical antibiotic is needed for bacterial conjunctivitis, which is first-line in UK primary care?
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Chloramphenicol (0.5% drops or 1% ointment).
Why? Infective conjunctivitis usually settles on its own, so advice or a delayed prescription is reasonable first. Fusidic acid is an alternative when chloramphenicol is unsuitable.
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What is the most common cause of a hypopyon?
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Bacterial keratitis (infective corneal ulcer).
Why? Corneal ulcer + hypopyon = bacterial keratitis; recent eye surgery + hypopyon = endophthalmitis; sterile hypopyons occur in anterior uveitis and Behçet's. Slit-lamp examination is essential.
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A 30-year-old Turkish man has recurrent painful mouth and genital ulcers. He now has a painful red eye with a hypopyon that shifts with head position. What is the most likely underlying diagnosis?
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Behçet's disease.
Why? Behçet's causes recurrent, often bilateral uveitis that can produce a sterile hypopyon. It is associated with HLA-B51.
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What is the first-line drug treatment for herpes zoster ophthalmicus?
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Oral antiviral (e.g. aciclovir 800 mg five times daily for 7 days, or valaciclovir/famciclovir), ideally within 72 hours of rash onset.
Why? Antivirals reduce eye complications. Refer the same day for slit-lamp examination if the eye may be involved; give IV aciclovir if severe or immunocompromised.
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A contact-lens wearer who swims in her lenses develops keratitis with pain out of proportion to the signs. Which organism should you suspect?
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Acanthamoeba.
Why? Acanthamoeba lives in tap water, pools and hot tubs. A ring-shaped stromal infiltrate is classic, and it needs specialist anti-amoebic drops.