OPHTHALMOLOGY

Questions&Answers
Q-1
A 45 year old woman has itchy, dry eyes. There is mild pain in the morning but
worsens during the day. She says her eyes feel gritty especially in an air
conditioning room. A Schirmer’s test was performed and results show 7 mm of
moisture on the filter paper. What is the SINGLE most appropriate management?

(A normal Schirmer’s test is considered to have more than 10 mm of moisture on

the filter paper)

A. Cyclopentolate
B. Steroids drops
C. Hypromellose drops
D. Topical ciclosporin
E. Scleral lenses

ANSWER:
Hypromellose drops
EXPLANATION:
Keratoconjunctivitis sicca is the diagnosis here which is described as decreased
lacrimal secretion characterised by conjunctival hyperaemia and itchiness. It occurs
commonly as part of Sjogren’s syndrome. Keratoconjunctivitis sicca is confirmed by
Schirmer’s test and the treatment always includes the use of artificial tears. Schirmer’s
test determines whether the eye produces enough tears to keep it moist. It is
considered negative or normal when there is more than 10 mm of moisture on the filter
paper in 5 minutes.
There are various tear sustitutes that can be used to treat dry eyes. They can be in the
form of drops, gels, and ointments.
Examples of drops include:
• Hypromellose
• Sodium chloride
• Sodium hyaluronate
Note that topical ciclosporin is also useful for dry eyes but it should not be used as first
line. Scleral lenses can also be used as they create a tear-filled reservoir which
prevents the feeling of dry eyes but again should not be used as first line. Scleral
lenses are expensive.
Q-2
A 25 year old man has a burning sensation in his left eye for the last 2 days. His
eye is red and has thick purulent discharge. His lids are often stuck shut on
waking. What is the SINGLE most appropriate initial management?

A. Oral antibiotic
B. Oral antihistamine
C. Topical antibiotics
D. Topical antibiotics and topical steroids
E. Clean discharge using cotton wool soaked in water

ANSWER:
Clean discharge using cotton wool soaked in water

EXPLANATION:
There has been a long debate regarding the use of topical antibiotics in bacterial
conjunctivitis. NHS has been moving towards using self care rather than antibiotics for
infective conjunctivitis. For most people, use of a topical ocular antibiotic makes little
difference to recovery from infective conjunctivitis and up to 10% of people treated with
topical ocular antibiotic makes little difference to recovery from infective conjunctivitis
and up to 10% of people treated with topical ocular antibiotics complain of adverse
reactions to treatment. Not to mention, that the risk of a serious complication from
untreated infective conjunctivitis is low.

Thus, one should only consider topical ocular antibiotics if the infective conjunctivitis is
severe, or likely to become severe, providing serious causes of a red eye can
confidently excluded. It would seem reasonable to consider infective conjunctivitis to be
severe when the person considers the symptoms to be distressing or signs are judged
to be severe from clinical experience. However, it is obvious that you will not be able to
tell based on the PLAB questions if it is severe conjunctivitis or mild conjunctivitis. So a
good guideline that you should follow is based on time. If the patient has infective
conjunctivitis for more than 7 days, then start the patient on topical antibiotics. If it is
less than 7 days, then choose the option that has self-care rather than topical
antibiotics.

Topical steroids is always going to be the wrong answer unless it is herpes simplex
virus conjunctivitis. It is only used if keratitis extends deep into the stoma.

Bacterial conjunctivitis management

• Most cases of infective conjunctivitis do not need medical treatment and clear up in
one to two weeks.
• Gently clean away sticky discharge from your eyelids and lashes using cotton wool
soaked in water.
• If the decision is made to use antibiotics → chloramphenicol drops is the drug of
choice. Chloramphenicol has a broad spectrum of activity and is the drug of choice
for superficial eye infections. It is bacteriostatic, with a relatively broad spectrum of
action against most Gram-positive and Gram-negative bacteria.
Types of conjunctivitis:
Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis
• Purulent discharge • Serous discharge • Bilateral symptoms
• Eyes may be ‘stuck • Recent URTI • Itch is prominent
together’ in the morning • Preauricular lymph • May give a history of
nodes atopy
• May be seasonal (due
to pollen) or perennial
(due to dust mite,
washing powder or
other allergens)

Q-3
A 35 year old HIV positive man presents with progressive visual deterioration. He
complains of blurred vision and floaters. On examination, multiple cotton wool
spots are seen in both eyes. What is the SINGLE most likely causative organism?

A. Herpes zoster
B. Cryptosporidium
C. Cytomegalovirus
D. Pneumocystis jiroveci pneumonia
E. Cryptococcus neoformans

ANSWER:
Cytomegalovirus

EXPLANATION:
One of the rare manifestations of cytomegalovirus includes retinitis. It is usually seen
inan immunocompromised host (e.g. a positive HIV patient) like in this stem. Although
itis rare, retinitis is still the most common manifestation of CMV disease in patients
whoare HIV positive. Very early CMV may resemble cotton wool spots.

Cytomegalovirus retinitis

Presentation:
- Decreased visual acuity, floaters, and loss of visual fields on one side
- Examination shows yellow-white cloudy retinal lesions. Lesions may appear atthe
periphery of the fundus, but they progress centrally.
- It begins as a unilateral disease, but in many cases it progresses to bilateral
involvement

Remembering the findings of the examination of the eye for cytomegalovirus retinitis is
less important as the question writers would have to give a history of HIV for this to be
cytomegalovirus retinitis. In view of that, if a patient with positive HIV attends with
visual deterioration, cytomegalovirus should be at the top of your differential.
Q-4
A 32 year old woman complains of dull pain in her right eye for the past one week
which worsens when moving her eye. Her past medical history includes multiple
sclerosis which was diagnosed 6 months ago. An opthalmoscopy shwos pallor
of the optic disc. Which anatomical site is most likely to be affected?
 A. Optic nerve
B. Sclera
C. Optic radiation
D. Trigeminal nerve
E. Oculomotor nerve

ANSWER:
Optic nerve

EXPLANATION:
Optic neuritis is a relatively common presenting symptoms of Multiple Sclerosis. It is
due to the demyelination of the optic nerve.

OPTIC NEURITIS (ON)

Inflammation of the optic nerve

Presentation
- Classically there is a triad of clinical features which are:
o Reduced vision (of varying severity) → Usually unilateral. Progresses forless than 2
weeks and spontaneously improves within 3 weeks.
o Eye pain → Particularly on movement
o Impaired colour vision → Initially loss of red colour vision
- One of the most common cause of optic neuritis is multiple sclerosis → Seen
especially in caucasian populations
The stem would usually (but not always) include a female patient as multiplesclerosis
is more prevalent in the female gender
- Examination
o Swollen optic disc
o Optic disc becomes pale later (4 to 6 weeks after onset)
o Relative pupillary defect (RAPD) of affected eye → This is a need to know, so
google it and read about it to further your knowledge on this

Q-5
A 34 year old man has an acute painful, red right eye for the last 24 hours. He
complains of blurring of vision. He has a past medical history of cervical
spondylitis and is on chronic diclofenac treatment for the past 4 years for back
pain and stiffness. On examination, his pupil is irregular in shape and he is very
sensitive to light. What is the SINGLE most likely clinical diagnosis?

A. Acute close-angle glaucoma

B. Conjunctivitis
C. Episcleritis
D. Iridocyclitis
E. Keratitis

ANSWER:
Iridocyclitis
EXPLANATION:
Because of this patient’s past medical history of cervical spondylitis, iridocyclitis is
themost likely answer.
Please note the following for PLAB 1:
1. Anterior uveitis is also referred to as iritis and iridocyclitis
2. Intermediate uveitis is also known as pars planitis or viritis
3. Posterior uveitis is also called chorioretinitis
4. In the UK, the most common cause of chronic anterior uveitis is sarcoidosis
5. In the UK, the most common form of uveitis is anterior uveitis

Anterior uveitis
- Also referred to as iritis. It is one of the important differentials of a red eye.
Presentation
- Symptoms may develop over hours or days (acute anterior uveitis), or onsetmay be
gradual (chronic anterior uveitis).
Features
Acute anterior uveitis:
- Progressive (over a few hours/days) unilateral, painful red eye
- Visual acuity in the affected eye is reduced
- Photophobia
- Pupil may be abnormally shaped or of a different size to the unaffected eye(small
pupil, initially from iris spasm; later it may be irregular or dilateirregularly due to
adhesions between lens and iris)
- Excess tear production
- Characteristic sign is the presence of cells in the aqueous humour seen on slitlamp
• Aqueous humour is normally clear but in anterior uveitis it may be seen as cloudy,
giving the appearance of a 'flare'. This appears rather like a shaft of light shining
through a darkened, smoky room. Anterior chamber flare is due to inflamed
vessels leaking protein. Due to the cloudiness, as the slitlamp beam of light is
shone through, the beam disperses hence the term flare
Chronic anterior uveitis:
- Presents as recurrent episodes, with less acute symptoms
- Patients may find that one symptom predominates (this tends to be blurredvision)
Associated conditions
- Ankylosing spondylitis
- Reactive arthritis
- Ulcerative colitis, Crohn's disease
Management:
- Prednisolone eye drops to reduce inflammation
- Cyclopentolate to prevent adhesions between lens and iris by keep pupildilated
Q-6
A 45 year old man with type 1 diabetes mellitus has his annual checkups.
Ophthalmoscopy shows dot and blot haemorrhage with hard exudates. What is
the SINGLE most likely diagnosis?
A. Macular degeneration
B. Retinal detachment
C. Multiple sclerosis
D. Diabetic background retinopathy
E. Diabetic proliferative retinopathy
ANSWER:
Diabetic background retinopathy

EXPLANATION:
The diagnosis here is background retinopathy. Remember how to distinguish the
typesof diabetic retinopathy. Also remember that type I diabetes mellitus is a common
causeof retinopathy.

Background retinopathy (nonproliferative)

- Microaneurysms (dots)
- Haemorrhage (blots)
- Hard exudates

Preproliferative retinopathy
- Addition of Cotton wool spots

Proliferative retinopathy
- Addition of new vessel formation (neovascularization)
- More serious. Progresses rapidly to blindness. Neovascularization. May lead to
vitreous haemorrhage
- Floaters in vision
- Laser photocoagulation is needed

Q-7
A 33 year old man presents to clinic with a history of early morning back pain,
stiffness and a painful red right eye. The pain in the eye started last night. On
examination, his right pupil is seen to have a distorted pupil shape. His visual
acuity is unaffected. What is the SINGLE most likely affected anatomical
structure?

A. Optic nerve
B. Iris
C. Cornea
D. Conjunctiva
E. Sclera

ANSWER:
Iris

EXPLANATION:
A middle age man with early morning back pain and stiffness is suggestive of
seronegative arthritis likely ankylosing spondylitis where anterior uveitis (iritis) is a
known association.

It is also important to note that visual acuity for iritis is initially normal but can worsen as
time passes.

The abnormally shaped pupil is another give away.

Q-8
A 4 year old child is taken by his mother to the Emergency Department as he is
having pain around his right eye. He is febrile with a temperature of 38.5 C. This
swelling started two days ago with a gradual onset. On examination, there is a
tender, erythematous swelling around his right eye. What is the SINGLE most
likely diagnosis?

A. Allergic reaction
B. Foreign body
C. Conjunctivitis
D. Periorbital cellulitis
E. Uveitis

ANSWER:
Periorbital cellulitis

EXPLANATION:
Periorbital cellulitis (also known as preseptal cellulitis) presents similar to this stem
whereby there is an acute onset of swelling, redness, increased warmth and tenderness
of the eyelid. Fever is often a feature.

Periorbital cellulitis is also commonly seen in children.

Do not confuse periorbital cellulitis with orbital cellulitis which involves orbital signs such
as gaze restriction, proptosis and pain on eye movements. Orbital cellulitis is an
emergency and requires intravenous antibiotics.

Q-9
A 33 year old female complains of double vision which started yesterday. On
examination, a fixed dilated pupil which does not accommodate and drooping
eyelid can be seen on the left eye. Her left eye is displaced outward and
downwards. She has no significant past medical history. There was no history of
trauma. What is the SINGLe most appropriate investigation to perform?

A. Ophthalmoscopy
B. Computed tomographic angiography
C. Thyroid function test
D. Visual field test
E. Red reflex examination

ANSWER:
Computed tomographic angiography

EXPLANATION:
This is a case of oculomotor nerve palsy. Diplopia, mydriasis, ptosis, outward
downwarddeviation of the eye as described here are clinical features of oculomotor
nerve [Link] oculomotor nerve palsy can be associated with vascular disorders such
as diabetes,or particularly posterior communicating artery aneurysm. Other causes
include spaceoccupying tumours, infarction. abscess and trauma.

Angiographic imaging studies are often necessary in the evaluation of acute

oculomotornerve palsy. A computed tomographic angiography would be a good option
here to help exclude a posterior communicating artery aneurysm. Note that this can also
be done with a magnetic resonance angiography. MRI would also be useful as it is a
more sensitive imaging technique than CT scan for picking out a small intraparenchymal
brainstem lesion, such as infarction, small abscess, or tumor however CT scan is more
sensitive than MRI to demonstrate subarachnoid hemorrhage. All of these have
potential to cause an oculomotor nerve palsy.

Oculomotor nerve palsy

- The initial sign is often a fixed dilated pupil which does not accommodate
- Then ptosis develops
- Unopposed lateral rectus causes outward deviation of the eye. Characteristicdown
and out position of the affected eye.

The simple method to remember this for the exam is:

CN III - Oculomotor nerve
- Will have features of either ptosis and/or a dilated pupil on the nerve on thesame side
as the affected eye
- Mnemonic: Letter “O” for oculomotor which with good imagination canrepresents a
dilated pupil.

Q-10
A 48 year old man who has been taking medications for asthma for several years
has now presented with decreased vision on his right eye. He complains of glare
especially during the night. What SINGLE medication is most likely to cause his
visual deterioration?

A. Inhaled salbutamol
B. Inhaled steroids
C. Aminophylline
D. Theophylline
E. Oral steroids

ANSWER:
Oral steroids

EXPLANATION:
The diagnosis here is steroid induced cataracts. Long term use of steroids can cause
[Link] corticosteroids have more of a systemic effect compared to
inhaledcorticosteroids. Thus, oral steroids are more likely to be the cause of his
cataracts.

There are certain keywords or hints that you may find on the PLAB test that would
leanyou towards cataracts. These are:
- Exposure to great amounts of UV light i.e. Person from Australia who neverwears
sunglasses
- Long term use of steroids (They may not say the words “steroids” but they maygive a
scenario with someone who is with a long standing condition that needsthe use of
steroids)
- A high myopia
- Trauma to eye
Q-11
A 52 year old man presents with sudden complete loss of vision from the right
eye. He also had been complaining of right sided headaches which would come
up more on chewing. On fundoscopy, the retina was pale and a cherry red spot
could be seen in the macular region. What is the SINGLE most likely cause of
vision loss?

A. Central retinal artery occlusion

B. Central retinal vein occlusion
C. Branch retinal artery occlusion
D. Branch retinal vein occlusion
E. Open angle glaucoma

ANSWER:
Central retinal artery occlusion

EXPLANATION:
The most important diagnosis here to exclude would be giant cell arteritis. An old man
with symptoms of headache and pain on chewing are classic features.
Central retinal artery can be affected by giant cell arteritis. Approximately 10% of
patients with ocular involvement in giant cell arteritis experience a central retinal artery
occlusion.
The sudden loss of vision in one eye and the pale retina with cherry red spots seen in
the macula are diagnostic for central retinal artery occlusion.

Central retinal artery occlusion

Central retinal artery occlusion occurs when the central retinal artery occludes before
itbranches out as it emerges from the optic nerve, resulting in almost complete
hypoxiaof the inner retina.

Presentation
- Sudden (over a few seconds)
- Unilateral painless visual loss
- In 94% of cases, vision is usually reduced to counting fingers (worse suggeststhat the
ophthalmic artery may also be affected
- There may be a history of amaurosis fugax (amaurosis fugax precedes loss ofvision in
up to 10% of patients)
- There is no redness of the eye

Examination:
- An afferent pupil defect appears within seconds and may precede retinalchanges by 1
hour. Ophthalmoscopy reveals:
o A retina that appears white or pale
o Cherry red spot at the macula
o Attenuation of the vessels

What is an afferent pupillary defect?

Afferent defects (absent direct response) is when the pupil won’t respond to light,
butconstricts to a beam in the other eye (consensual response). Constriction
toaccommodation still occurs.
Investigations
In the acute setting, diagnosis is usually clinical and investigations are aimed atruling
out underlying diseases. The most important cause to rule out is giantcell arteritis
because, with appropriate and timely intervention, the visual loss isreversible and the
fellow eye will be protected.

Management
If the patient presents within 90-100 minutes of onset of symptoms, you couldtry firm
ocular massage. The idea behind this is to try to dislodge theobstruction. However, this
only works very occasionally and immediate referralis mandatory.

Q-12
A 48 year old man attends clinic for a routine eye check up as he has a history of
type 1 diabetes. Fundoscopy shows neovascularization at the retina. What is the
SINGLE most appropriate management?

A. Strict blood glucose control

B. Review in 12 months
C. Non urgent referral to specialist
D. Insulin
E. Laser photocoagulation

ANSWER:
Laser photocoagulation

EXPLANATION:
The diagnosis here is proliferative retinopathy. Remember how to distinguish the
typesof diabetic retinopathy. Also remember that type I diabetes mellitus is a common
causeof retinopathy. Laser photocoagulation is needed for proliferative retinopathy.

Background retinopathy (nonproliferative)

- Microaneurysms (dots)
- Haemorrhage (blots)
- Hard exudates

Preproliferative retinopathy
- Addition of Cotton wool spots
Proliferative retinopathy
- Addition of new vessel formation (neovascularization)
- More serious. Progresses rapidly to blindness. Neovascularization. May lead to
vitreous haemorrhage
- Floaters in vision
- Laser photocoagulation is needed

Q-13
A 44 year old hypertensive male, loses vision in his left eye overnight. There is
no pain or redness associated with his visual loss. On fundoscopy, venous
dilation, tortuosity, and retinal haemorrhages are observed on his left eye. No
abnormalities are found on his right eye on fundoscopy. What is the SINGLE
most likely cause of his unilateral visual loss?
 A. Hypertension retinopathy
B. Central Retinal Artery Occlusion
C. Central Retinal Vein Occlusion
D. Background retinopathy
E. Retinal detachment

ANSWER:
Central Retinal Vein Occlusion

EXPLANATION:
Central Retinal Vein Occlusion (CRVO)
Clinical Presentation
These patients have a clinical presentation similar to those with retinal artery
[Link] is the sudden loss of vision without pain, redness, or abnormality in
pupillarydilation.

Ocular examination by funduscopy reveals disk swelling, venous dilation, tortuosity,and

retinal haemorrhages.

Diagnosis
Retinal haemorrhages are the main way of distinguishing venous obstruction
fromarterial obstruction. You cannot have a hemorrhage in the retina if you don't
haveblood getting into the eye.

Treatment
Treatment of CRVO is beyond the scope of what you need to know for the PLAB 1
exam but it involves immediate referral to an ophthalmologist and/or intra-vitreal
steroids.

Q-14
A 49 year old man has sudden complete loss of vision from his left eye over a
couple of seconds. There was no pain associated with it and there is no redness
of the eye. Ophthalmoscopy reveals a pale retina with a cherry red spot at the
macula and attenuation of the vessels. What is the SINGLE most likely
diagnosis?

A. Central retinal artery occlusion

B. Central retinal vein occlusion
C. Branch retinal artery occlusion
D. Branch retinal vein occlusion
E. Open angle glaucoma

ANSWER:
Central retinal artery occlusion

EXPLANATION:
Please see Q-11

Q-15
A 41 year old man presents with visual symptoms and a headache. An
ophthalmoscopic examination shows papilloedema. Which anatomical site is
most likely to be affected?
 A. Retina
B. Optic disc
C. Optic radiation
D. Macula
E. Optic chiasma

ANSWER:
Optic disc

EXPLANATION:
Papilloedema is optic disc swelling resulting from raised intracranial pressure.

Q-16
A 39 year old woman has been having gradual loss of vision in both eyes over the
past 6 months. She has a diagnosis of rheumatoid arthritis and has been on
treatment for it for the past 4 years. Her intraocular pressure is within normal
limits and red reflex is absent in both eyes. What is the SINGLE most likely
diagnosis?

A. Cataract
B. Diabetic retinopathy
C. Hypermetropia
D. Macular degeneration
E. Hypertensive retinopathy
ANSWER:
Cataract
EXPLANATION:
The diagnosis here is steroid induced cataracts. Long term use of steroids as seen
insomeone with an autoimmune condition like rheumatoid arthritis can cause
[Link] are certain keywords or hints that you may find on the PLAB test that
would leanyou towards cataracts. These are:
- Exposure to great amounts of UV light i.e. Person from Australia who neverwears
sunglasses
- Long term use of steroids (They may not say the words “steroids” but they maygive a
scenario with someone who is with a long standing condition that needsthe use of
steroids)
- A high myopia
- Trauma to eye
Q-17
A 37 year old lady has been suffering from early morning stiffness of her small
joints for several months. She takes regular NSAIDs to manage the pain of her
joints. She attends clinic with a painful red eye. What is the SINGLE most likely
affected anatomical structure?
A. Iris
B. Ciliary body
C. Cornea
D. Sclera
E. Conjunctiva
ANSWER:
Sclera

EXPLANATION:
One of the ocular manifestation of rheumatoid arthritis is scleritis which presents with an
erythematous, painful eye.

Ocular manifestations of rheumatoid arthritis

Ocular manifestations of rheumatoid arthritis are common

Remember these 4:
- Keratoconjunctivitis sicca → is the most common
- Episcleritis → presents with erythema (pain is also present but less severe than
scleritis)
- Scleritis → presents with erythema and pain
- Iatrogenic steroid-induced cataracts

Q-18
A 45 year old woman had her visual acuity checked at her local optician. Several
hours later she presents to the emergency department with severe ocular pain
and redness in her eye. She also complains of seeing coloured halos. What
SINGLE anatomical structure is most likely to be involved?

A. Iris
B. Ciliary body
C. Anterior chamber
D. Posterior chamber
E. Cornea

ANSWER:
Anterior chamber

EXPLANATION:
This question is testing your knowledge of acute angle closure glaucoma. It is
importantto remember the symptoms of acute angle closure glaucoma worsen when the
pupilsare dilated (e.g. in a dark room).

The history of having her eyes checked but the optician gives us the idea that either:
1. A mildly illuminated room like of an opticians room would dilate the pupils enough to
worsen symptoms.
2. Topical mydriatics was applied in which case led to pupillary dilation which can push
the iris into the angle and precipitate AAC in anyone with narrow angles.

Angle closure glaucoma (ACG) is associated with a physically obstructed

anteriorchamber angle.

Acute angle closure glaucoma

Also called acute glaucoma or narrow-angle glaucoma

In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to

animpairment of aqueous outflow. Factors predisposing to AACG include:
- hypermetropia (long-sightedness)
- pupillary dilatation

It presents with an eye that is red, severely painful,and associated with a semi-
dilatednon-reacting pupil. Headaches and decreased visual acuity are common.
Symptomsworsen with mydriasis (e.g. watching TV in a dark room). Coloured haloes
around lightsmay be seen by patients. Palpation of the globe will reveal it to be hard.
Cornealoedema results in dull or hazy cornea. Systemic upset may be seen, such as
nausea andvomiting and even abdominal pain.

Note: The acute attack is usually unilateral; however, long-term management will be
toboth eyes.

Medical
Initial medical treatment typically involves all topical glaucoma medications that are
notcontra-indicated in the patient, together with intravenous acetazolamide.

Topical agents include:

- Beta-blockers - eg, timolol, cautioned in asthma.
- Steroids - prednisolone 15 every 15 minutes for an hour, then hourly
- Pilocarpine 1-2%
- Acetazolamide is given intravenously (500 mg over 10 minutes) and a further250 mg
slow-release tablet after one hour
- Offer systemic analgesia ± antiemetics.
This should tide the patient over until they are able to be seen by a dutyophthalmologist
who will assess the situation at short intervals until the acute attack isbroken. These
treatments may be repeated depending on the IOP response and acombination of these
medications will be given to the patient on discharge. The patientwill remain under close
observation (eg, daily clinic reviews or as an inpatient).Subsequent treatment is aimed
at specific mechanism of closure.
Surgical
Peripheral iridotomy (PI)
This refers to (usually two) holes made in each iris with a laser. This is toprovide a free-
flow transit passage for the aqueous. Both eyes are treated, asthe fellow eye will be
predisposed to an AAC attack too. This procedure canusually be carried out within a
week of the acute attack, once corneal oedemahas cleared enough to allow a good
view of the iris.
Surgical iridectomy
This is carried out where PI is not possible. It is a less favoured option, as it ismore
invasive and therefore more prone to complications.
Q-19
Which of the following is not a degenerative corneal disease?
A. Band keratopathy
B. Pelluci marginal degeneration
C. Mooren’s ulcer
D. Terrien marginal degeneration
E. Keratoconus
ANSWER:
Mooren’s ulcer

EXPLANATION:
Mooren’s ulceration is characterized by painful peripheral corneal ulceration of unknown
aetiology. It is not a degenerative corneal disease. Pain is almost always associated
with the onset of Mooren’s ulcer. The eye is usually red and the vision may or may not
be affected.

Q-20
A 20 year old man comes with a 3 day history of a burning red left eye with sticky
greenish discharge. For the past few mornings, he says that his eyelids are stuck
shut on waking. What is the SINGLE most likely affected anatomical structure?

A. Iris
B. Ciliary body
C. Cornea
D. Conjunctiva
E. Sclera

ANSWER:
Conjunctiva

EXPLANATION:
The given scenario is a clinical presentation of bacterial conjunctivitis. The term itself
gives away the anatomical location of the infection – conjunctiva.

It is important to rememeber the management of bacterial conjunctivitis as this can be

asked.

Q-21
A 68 year old patient attends for retinal screening. He is found to have hard
exudates, macular oedema and arteriovenous nipping. He is on long term
treatment with nifedipine. What is the SINGLE most likely diagnosis?

A. Macular degeneration
B. Hypertension retinopathy
C. Non-proliferative diabetic retinopathy
D. Proliferative diabetic nephropathy
E. Open angle glaucoma

ANSWER:
Hypertension retinopathy

EXPLANATION:
Hypertensive retinopathy
Most patients with hypertensive retinopathy have no symptoms.

Chronic hypertension (blood pressure > 140/90 mmHg):

- Usually asymptomatic
- Fundoscopy reveals bilateral attenuation of arterial vessels ('copper or silverwiring'),
arteriovenous nipping (where the arteries cross the veins) and,eventually,
haemorrhage and exudates

Malignant (accelerated) hypertension (clinic blood pressure >180/110 mmHg):

- May have headaches and decreased vision
- On fundoscopy, hard exudates appear as a 'macular star' (thin white streaksradiating
around the macula), disc swelling, cotton wool spots, flamehaemorrhages and arterial
or venous occlusions.

Key phrases in the exam that help you pick Hypertensive retinopathy as the
answer:
- Copper or silver wiring
- Arteriovenous nipping
- Flamed shaped haemorrhage - also found in diabetic retinopathy
Usually one of these 3 terms would appear in the stem

Management
- Aimed at controlling the hypertension

Q-22
A 60 year old man experienced sudden painless loss of vision. On
ophthalmoscopy, multiple flame shaped haemorrhages were seen scattered
throughout his fundus with optic disc and macular oedema. What is the SINGLE
most likely diagnosis?

A. Central retinal artery occlusion

B. Central retinal vein occlusion
C. Acute glaucoma
D. Retinitis pigmentosa
E. Optic neuritis

ANSWER:
Central retinal vein occlusion

EXPLANATION:
Please see Q-13

Q-23
A 52 year old man has a painful, red, photophobic right eye with slightly blurred
vision and watering for 2 days. He has no similar episodes in the past. On slit
lamp examination, there are cells and flare in the anterior chamber. The pupil is
also sluggish to react. What is the SINGLE most appropriate clinical diagnosis?

A. Acute close-angle glaucoma

B. Acute conjunctivitis
C. Acute dacrocystitis
D. Acute iritis
E. Corneal foreign body

ANSWER:
Acute iritis
EXPLANATION:
Please see Q-5

Q-24
A 34 year old homosexual man attends clinic with a history of weight loss and
progressive visual deterioration. A fundoscopic examination reveals retinal
haemorrhages and yellow-white areas with perivascular exudates. What is the
SINGLE most appropriate causative organism?

A. Mycobacterium avium
B. Herpes simplex virus
C. Haemophilus influenzae
D. Cytomegalovirus
E. Pneumocystis jiroveci

ANSWER:
Cytomegalovirus

EXPLANATION:
The hint here is the homosexual man. For a very inapproprite reason, question writers
tend to use the phrase homosexual to hint to you for the possibility of AIDS like in this
case. The combination of weight loss is another clue towards the diagnosis of HIV.

One of the rare manifestations of cytomegalovirus includes retinitis. It is usually seen

inan immunocompromised host (e.g. a positive HIV patient) like in this stem. Although
itis rare, retinitis is still the most common manifestation of CMV disease in patients
whoare HIV positive.

Retinal haemorrhoage is a recognized association with cytomegalovirus retinitis.

Q-25
A 40 year old man has pain, redness and swelling over the nasal end of his right
lower eyelid. The eye is watery with some purulent discharge. The redness
extends to the nasal peri-orbital area and mucoid discharge can be expressed
from the lacrimal punctum. What is the SINGLE most appropriate clinical
diagnosis?

A. Acute conjunctivitis
B. Acute dacrocystitis
C. Acute iritis
D. Retrobulbar neuritis
E. Scleritis

ANSWER:
Acute dacrocystitis

EXPLANATION:
Acute dacrocystitis
Acute dacrocystitis is an acute inflammation of the lacrimal sac, often as a result of
infection.
Presentation
Symptoms and signs are over the region of the lacrimal sac (but may spread to the
nose and face with teeth pain being experienced by some). Therefore, look just lateral
and below the bridge of the nose for:
• Excess tears (epiphora)
• Pain
• Swelling and erythema at the inner canthus of the eye
Immediate antibiotic therapy may resolve the infection.
Q-26
A 48 year old woman presents with severe left-sided headaches, ocular pain and
a red, watering eye. She has intermittent blurring of vision and sees coloured
haloes. What is the SINGLE most appropriate next step of action?
A. Measure intraocular pressure
B. Relieve pain with aspirin
C. Administer 100% oxygen
D. Computed tomography
E. Relieve pain with sumatriptan
ANSWER:
Measure intraocular pressure
EXPLANATION:
The case here is one of acute angle closure glaucoma. Measurement of intraocular
pressure would help establish the diagnosis.
Q-27
A 67 year old man has deteriorating vision in his left eye. He complains that his
vision has been slowly getting more blurry over the last few months. Glare from
the headlights of cars is particularly a problem when driving at night. He has a
history of longstanding COPD and is on multiple drugs for it. What SINGLE
medication is most likely to cause his visual deterioration?
A. Salmeterol
B. Oral corticosteroid
C. Tiotropium
D. Theophylline
E. Inhaled corticosteroid
ANSWER:
Oral corticosteroid
EXPLANATION:
Please see Q-10
Q-28
A 49 year old woman complains of reduction of vision and dull pain in her left eye
for the past 2 weeks. Her past medical history includes multiple sclerosis which
was diagnosed 2 years ago. On examination, both pupils constrict when light is
directed to the right eye but both pupils fail to constrict fully when light is
directed to the left eye. What is the SINGLE most likely defect to accompany her
diagnosis?
 A. Paracentral scotoma
B. Monocular visual field loss
C. Biltemporal hemianopsia
D. Central scotoma
E. Homonymous hemianopia

ANSWER:
Monocular visual field loss

EXPLANATION:
Optic neuritis is the likely diagnosis here. It usually presents with acute or
subacuteunilateral decrease in vision and eye pain particularly on movement. The fact
that shehas multiple sclerosis is a huge hint. Visual field loss is a known feature of optic
[Link] may argue that scotoma can also be present in optic neuritis, but in
reality
monocular visual field loss is more frequently seen.

To understand the reason behind the patient’s pupils dilating when the light stimulus
isdirected to the affected eye (left eye), one has to understand the principles of
theMarcus Gunn test. In the Marcus Gunn test, light stimulation of the normal
eyeproduces full constriction in both pupils. Immediate subsequent stimulus of
theaffected eye produces an apparent dilation in both pupils since the stimulus
carriedthrough that optic nerve is weaker. The affected eye still senses light and
producespupillary sphincter constriction to some degree but it’s less compared to the
normaleye. This is specifically seen in optic neuropathy such as optic neuritis.

Both central scotoma and monocular visual loss can be seen in optic neuritis and in
actual fact, central scotoma is more common. The rationale behind monocular visual
loss as the more more appropriate answer compared to central scotom is that this
patient presents with a relative afferent pupillary defect (RAPD). This tells us that it is
likely the whole optic nerve that has been damaged rather than a part of it. Central
scotomas are dependent on which part of the optic nerve is affected. If the whole optic
nerve is affected, this would result in monocular visual loss.

Q-29
A 33 year old woman started seeing tiny black dots followed by a painless
sudden loss of vision in her left eye a few hours ago. She says that it initially felt
like a curtain was falling down. On fundoscopy, the optic disc is normal. What is
the SINGLE most likely underlying pathology?

A. Iritis
B. Glaucoma
C. Vitreous chamber
D. Retinal detachment
E. Central retinal artery occlusion

ANSWER:
Retinal detachment
EXPLANATION:
Causes of sudden painless loss of vision:
- Retinal detachment
- Vitreous haemorrhage
- Retinal vein occlusion
- Retinal artery occlusion
- Optic neuritis
- Cerebrovascular accident

Among all the causes of painless loss of vision, retinal detachment fits as they give
clueslike the tiny black dots which are “floaters” and the typical description of a “curtain
falling down”.

If you cannot see an retinal detachment on ophthalmoscopy but suspect it, refer
thepatient on for a slit-lamp examination (direct ophthalmoscopy offers only a narrow
fieldof view).

RETINAL DETACHMENT
Retinal detachment is usually spontaneous, but it may result from trauma. It occurs
when the force that holds the retinal detachment fails which results in accumulation of
fluid in the subretinal spaces. The two most common predisposing factors are extreme
myopia and surgical extractionof cataracts. It is associated with age and it is rarely
seen under 40 years old.

Clinical Presentation
• The classic symptom is photopsia (flashing lights).
• A common presentation is blurry vision developing in one eye without pain or
redness.
• The patient may complain of seeing "floaters;' as well as flashes at the periphery of
vision.
• A good descriptive term used by patients is "it feels like a curtain coming down" or
“it feels like a dark shadow across my vision” – this occurs as the retina falls off the
sclera behind it.

Remember this:
Detachment presents with 4 ‘F’s :
• Floaters
• Flashes
• Field loss
• Fall in acuity

Diagnosis
• Direct ophthalmoscopy
o Grey opaque and wrinkled retina that balloons forward.

Treatment
• Patients should lean their heads back to promote the chance that the retina will fall
back into place.
• The retina can be mechanically reattached to the sclera surgically, by laser
photocoagulation, cryotherapy, or by the injection of expansile gas into the vitreal
cavity (gas will press the retina back into place)
• Scleral buckling is another option where a "buckle," or belt, can be placed around
the sclera to push the sclera forward so that it can come into contact with the retina.

Q-30
A 62 year old hypertensive man comes into clinic with blurred vision. He usually
takes amlodipine to manage his blood pressure and has been taking it for the
past 10 years. His blood pressure currently ranges between 150/90 mmHg to
160/100 mmHg. An ophthalmoscope reveals dot blot haemorrhages, ischaemic
changes and hard exudates. What is the SINGLE most likely diagnosis?

A. Macular degeneration
B. Central retinal vein occlusion
C. Hypertensive retinopathy
D. Proliferative diabetic retinopathy
E. Non-proliferative diabetic retinopathy

ANSWER:
Hypertensive retinopathy

EXPLANATION:
This patient has uncontrolled blood pressure. The major risk for
arteriosclerotichypertensive retinopathy is the duration of elevated blood pressure which
is seen hereas 10 years. Retinal haemorrhages develop when necrotic vessels bleed
into either thenerve fiber layer (flame shaped hemorrhage) or the inner retina (dot blot
hemorrhage).Ischaemic changes and hard exudates are also seen in hypertensive
retinopathy.

The clinical appearance on a dilated fundoscopic exam and the coexisting

hypertensiongives the diagnosis of hypertensive retinopathy.

It is important to note that background retinopathy (non-proliferative) may also

havemany similar findings on the fundoscopy which include microaneurysms
(dots),haemorrhage (flame shaped or blots) and hard exudates (yellow patches) but
thehistory of uncontrolled hypertension makes hypertensive retinopathy a better choice.

Q-31
A 54 year old myopic develops flashes of light and then sudden painless loss of
vision. He says that it initially felt like a curtain that was falling down.
Ophthalmoscope shows a grey opalescent retina, ballooning forward. What is
the SINGLE most appropriate treatment?

A. Pilocarpine
B. Peripheral iridectomy
C. Scleral buckling
D. IV acetazolamide
E. Surgical extraction of lens

ANSWER:
Scleral buckling
EXPLANATION:
Diagnosis here is retinal detachment. Treatment options include scleral buckling.
Among all the causes of painless loss of vision, retinal detachment fits as they give
clues like the description of a “curtain falling down”. Myopia is also another hint as it is
a predisposing factor.

Q-32
A 62 year old man complains of headaches and decreased vision. He has a blood
pressure of 170/95 mmHg. Fundoscopy reveals disc swelling and a flame shaped
haemorrhage. What is the SINGLE most likely diagnosis?

A. Macular degeneration
B. Hypertensiion retinopathy
C. Non-proliferative diabetic retinopathy
D. Proliferative diabetic retinopthy
E. Open angle glaucoma

ANSWER:
Hypertension retinopathy

EXPLANATION:
Please see Q-21
Q-33
A 30 year old woman has a sudden acute headache with nausea and vomiting.
She has a red, painful left eye. The symptoms started when she was watching
television in a dark room. Palpation of the globe reveals it to be hard. What is the
SINGLE most likely visual symptom?
A. Paracentral scotoma
B. Peripheral visual field loss
C. Coloured halos
D. Floaters
E. Glares
ANSWER:
Coloured halos
EXPLANATION:
In acute angle closure glaucoma, coloured halos around lights are often a complaint by
patients. Nausea and vomiting are common and may be the main presenting feature in
some patients.
Q-34
A 24 year old has a marked eye pain, sticky red eye with a congested conjunctiva
for the past 7 days. He says that his eyes feel stuck together in the morning.
What is the SINGLE most appropriate treatment?
A. Oral antibiotic
B. Oral antihistamine
C. Antibiotic drops
D. Steroid and antibiotic drops
E. Saline drops
ANSWER:
Antibiotic drops

EXPLANATION:
There has been a long debate regarding the use of topical antibiotics in bacterial
conjunctivitis. NHS has been moving towards using self-care rather than antibiotics
forinfective conjunctivitis. For most people, use of a topical ocular antibiotic makes
littledifference to recovery from infective conjunctivitis and up to 10% of people
treatedwith topical ocular antibiotics complain of adverse reactions to treatment. Not
tomention, that the risk of a serious complication from untreated infective conjunctivitisis
low.

Thus, one should only consider topical ocular antibiotics if the infective conjunctivitis
issevere, or likely to become severe, providing serious causes of a red eye can
beconfidently excluded. It would seem reasonable to consider infective conjunctivitis
tobe severe when the person considers the symptoms to be distressing or signs
arejudged to be severe from clinical experience. However, it is obvious that you will not
beable to tell based on the PLAB questions if it is severe conjunctivitis or
mildconjunctivitis. So a good guideline that you should follow is based on time. If
thepatient has infective conjunctivitis for more than 7 days, then start the patient
ontopical antibiotics. If it is less than 7 days, then choose the option that has self-
carerather than topical antibiotics.

Topical steroids is always going to be the wrong answer unless it is herpes simplex
virusconjunctivitis. It is only used if keratitis extends deep into the stroma.

Q-35
An 82 year old woman has developed a painful blistering rash on one side of her
forehead and anterior scalp. She also has a red eye, decreased visual acuity and
epiphora alongside the forehead tenderness. What is the SINGLE most likely
nerve affected?

A. Accessory nerve
B. Facial nerve
C. Olfactory nerve
D. Optic nerve
E. Trigeminal nerve

ANSWER:
Trigeminal nerve

EXPLANATION:
Herpes zoster ophthalmicus
Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zostervirus
in the area supplied by the ophthalmic division of the trigeminal nerve. It accountsfor
around 10-20% of case of [Link] herpes is a danger to sight and
thepatient should see an ophthalmologist the same day.
Features
- Vesicular rash around the eye, which may or may not involve the actual eyeitself
- Hutchinson's sign: rash on the tip or side of the nose. Indicates nasociliaryinvolvement
and is a strong risk factor for ocular involvement
Management
- Oral antiviral treatment
- Oral corticosteroids may reduce the duration of pain
- Ocular involvement requires urgent ophthalmology review

Complications
- Ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
- Ptosis
- Post-herpetic neuralgia

Keratitis is a condition in which the eye's cornea, the front part of the eye,
becomesinflamed. Another infectious cause of keratitis is Herpes simplex keratitis in
which casepresents with a dendritic corneal ulcer. For herpes simplex keratitis, topical
acyclovir isused

Q-36
A 17 year old has acute pain around his right eye that started a week ago with
blistering inflamed rashes in the dermatome distribution of the ophthalmic
division of the trigeminal nerve. What is the SINGLE most likely diagnosis?

A. Postherpetic neuralgia
B. Herpes simplex
C. Ramsay Hunt syndrome
D. Cellulitis
E. Herpes zoster ophthalmicus

ANSWER:
Herpes zoster ophthalmicus

EXPLANATION:
Please see Q-35

Q-37
A 38 year old female has reduced vision and eye pain worse on her right eye that
has progressed over the past few days. She has had a similar episode about a
year ago which resolved completely within 3 months. The pain is worse on eye
movement. She says that the red colour appears “washed out”. On physical
examination, mild weakness of right upper limb was appreciated and exagerrated
reflexes were appreciated. What is the SINGLE most appropriate management?

A. Panretinal photocoagulation
B. Pilocarpine eye drops
C. Corticosteroids
D. Peripheral iridectomy
E. Surgical extraction of lens

ANSWER:
Corticosteroids
EXPLANATION:
Optic neuritis is diagnosed clinically by symptoms of acute unilateral decrease in vision,
eye pain-especially with movement and decreased color vision/contrast/brightness
sense and documentation of a visual field defect. The pain is worse on eye movements
because the rectus muscle contraction pulls on the optic nerve sheath.
The focal neurological symptoms and exagerrated reflexes all points towards multiple
sclerosis which is probabbly cause of optic neuritis in which case corticosteroids would
be used as part of the management.
Q-38
A 33 year old man has an acute painful, red right eye for the last 24 hours. He
complains of blurring of vision. He had a similar episode a year ago. His pupil is
irregular in shape and he is very sensitive to light. He has been taking diclofenac
for three years now because of back pain and stiffness. What is the SINGLE most
likely clinical diagnosis?

A. Acute close-angle glaucoma

B. Conjunctivitis
C. Episcleritis
D. Iritis
E. Keratitis

ANSWER:
Iritis
EXPLANATION:
Please see Q-5
Q-39
A 58 year old female presented to her GP with the complaint of double vision.
She describes it as seeing two images overlapped with each other when she
looks up. She has no family history of thyroid disease or malignancy. On
examination, she appears to be nervous and agitated. Both her eyes are seen
bulging anteriorly out of the orbit. An eye examination revealed restricted eye
movements that evoked pain. When the patient was asked to follow a pen slowly
with her eyes from upper to the lower field of vision, lid lag was noticed.
Her vitals are as follows:
Temperature 37.1 C
Respiratory rate 18 breaths/min
Heart rate 110 beats/min
Blood pressure 145/92 mmHg
What is the SINGLE most appropriate investigation to aid in the diagnosis of this
patient?
A. Tensilon test
B. Visual field test
C. Thyroid function test
D. Free T4 test
E. Facial X-ray
ANSWER:
Thyroid function test

EXPLANATION:
The findings in this patient (diplopia, tachycardia, lid lag, restricted eye movements) all
point towards thyroid eye disease. 90% of thyroid eye disease are associated with
Graves’ disease. Most cases of lid lag are seen in thyroid ophthalmopathy which is
known as Graves’ ophthalmopathy. Lid lag is seen in up to 50% of adults with Graves’
disease. The inferior rectus muscle is the most commonly affected muscle in Graves’
ophthalmopathy which leads to experiencing vertical diplopia on upgaze with difficulty in
elevating eyes due to fibrosis of the muscle.

The best investigation to do in this patient would be a thyroid function test.

A free T4 level alone is not the best option to diagnose thyrotoxicosis. Usually in
thyrotoxicosis, TSH will be low and free T4 will be high.

A tensilon test is a test in which intravenous edrophonium is given to differentiate

myasthenia gravis from cholinergic crisis and Lambert-Eaton syndrome. It is no longer
used due to the risk of cardiac arrhythmia.

The visual field test is not used to reach a final diagnosis. It is a mandatory part of the
examination of a patient who presents with thyroid symptoms and should not be done in
isolation for diagnostic purposes.

Q-40
A 49 year old hypertensive man has sudden complete loss of vision from his left
eye. There was no pain associated with it and there is no redness of the eye.
Ophthalmoscopy reveals a pale retina with a cherry red spot at the macula and
attenuation of the vessels. What is the SINGLE most appropriate management?

A. Firm ocular massage

B. Corticosteroids
C. Scleral buckling
D. Panretinal photocoagulation
E. Surgical extraction of lens

ANSWER:
Firm ocular massage

EXPLANATION:
The likely diagnosis here is central retinal artery occlusion. An ocular massage
candislodge the embolus to a point further down the arterial circulation and
improveretinal perfusion.

Q-41
A 55 year old man presents with a mild headache, ocular pain and a red eye. He
also complains of nausea. He has intermittent blurring of vision with halos.
There was no history of trauma. Palpation of the globe of the eye reveals it to be
hard. What is the SINGLE most appropriate management?
 A. Panretinal photocoagulation
B. Pilocarpine eye drops
C. Propranolol
D. Scleral buckling
E. Analgesia and rest
ANSWER:
Pilocarpine eye drops
EXPLANATION:
Please see Q-18
Q-42
A 70 year old man who has a medical history of diabetes mellitus and
hypertension experiences acute painless monocular blindness which resolved
completely after 30 minutes. He describes this as a curtain coming down
vertically into the field of vision of one eye. What is the SINGLE most likely
diagnosis?
A. Giant cell arteritis
B. Optic neuritis
C. Lacunar infarct
D. Pontine haemorrhage
E. Amaurosis fugax
ANSWER:
Amaurosis fugax
EXPLANATION:
A painless transient loss of vision is termed amaurosis fugax. They occur when a
thrombotic embolus passes through the retinal circulation. This patient would need to
be referred for a cardiovascular work up and antiplatelet treatment. As the thrombus
most likely originates from the carotid artery, he would require a carotid artery doppler
and possibly an endarterectomy.
AMAUROSIS FUGAX
• Painless transient monocular visual loss (i.e. loss of vision in one eye thatis not
permanent)
• It is indicative of retinal ischaemia, usually associated with emboli orstenosis of the
ipsilateral carotid artery
Presentation:
• Sudden, unilateral vision loss; “black curtain coming down”
• Duration: 5-15 minutes; resolves within < 24 hours
• Associated with stroke or transient ischaemic attack (TIA) and its riskfactors (i.e.
hypertension, atherosclerosis)
• Has an association with giant cell arteritis
Q-43
A 63 year old woman has progressive decrease in her visual acuity and peripheral
visual field loss. She is shortsighted and needs to wear glasses. On
examination, she has normal pupils on both eyes. What is the SINGLE most
likely diagnosis?
 A. Cataract
B. Glaucoma
C. Retinal detachment
D. Iritis
E. Giant cell arteritis

ANSWER:
Glaucoma

EXPLANATION:
The symptoms and progressive decrease in vision and myopia point towards open-
angle glaucoma.

Simple (primary) open-angle glaucoma

is present in around 2% of people older than 40years. Other than age, risk factors that
need to be known for PLAB include:
- family history
- black patients
- myopia

Note: The incidence increases with age, most commonly presenting after the age of
65(and rarely before the age of 40).
Unfortunately, in the vast majority of cases, patients are asymptomatic. Because
initialvisual loss is to peripheral vision and the field of vision is covered by the other
eye,patients do not notice visual loss until severe and permanent damage has
occurred,often impacting on central (foveal) vision. By then, up to 90% of the optic
nerve fibresmay have been irreversibly damaged
Open-angle glaucoma may be detected on checking the IOPs and visual fields of
thosewith affected relatives. Suspicion may arise during the course of a routine eye
check byan optician or GP, where abnormal discs, IOPs or visual fields may be noted.

Features may include

- peripheral visual field loss - nasal scotomas progressing to 'tunnel vision'
- decreased visual acuity
- optic disc cupping

Q-44
A 44 year old man has sudden severe eye pain, red eye, visual blurring. It started
when he went to watch a movie in the theatre. It was accompanied by nausea and
vomiting. Slit-lamp findings include shallow anterior chambers in both eyes with
corneal epithelial oedema. What is the SINGLE most likely diagnosis?

A. Central retinal vein occlusion

B. Acute closed angle glaucoma
C. Uveitis
D. Iritis
E. Open angle glaucoma

ANSWER:
Acute closed angle glaucoma
EXPLANATION:
The slit-lamp findings are consistent with acute closed angle glaucoma. This is
supported by the history of entering a dark room (movie theatre) when symptoms
started along with the severe painful red eye.

Q-45
A 27 year old female was brought to the emergency department by her friend
from a movie theatre. She complains of sudden severe pain in the eye followed
by vomiting. She sees coloured halos, has blurry vision and a red eye. She gives
a past history of recurrent headaches which used to resolve spontaneously.
Examination shows fixed, dilated ovoid pupils. What is the SINGLE most initial
investigation?

A. CT head
B. MRI orbits
C. Blood culture and sensitivity
D. Toxicology screen
E. Ocular tonometry

ANSWER:
Ocular tonometry

EXPLANATION:
The history is consistent with acute angle closure glaucoma. Headaches and blurry
vision are common. Symptoms tend to worsen with pupil dilation as seen in this stem
when she is watching a movie in a dark theatre. Vomiting is also a common feature of
acute glaucoma.

Ocular tonometry is needed to determine the intraocular pressure to help diagnose

glaucoma.

Q-46
A 60 year old woman has decreased vision over the past year. She is not able to
see well at night. She has change her spectacles several times recently due to
refraction changed but she still complains of glare. She has a normal pupil on
examination. What is the SINGLE most likely diagnosis?

A. Cataract
B. Glaucoma
C. Retinal detachment
D. Iritis
E. Giant cell arteritis

ANSWER:
Cataract

EXPLANATION:
The key to note here is the frequent change spectacles due to change of refraction.
This on top of the complaints of glare and reduced vision points towards cataracts.
Sometimes in PLAB, they will also give a history of long term steroid which may be the
aetiology behind cataracts formation.