CPD SPOT DIAGNOSIS ,

Self-Recorded CPD: Spot Dx – Ophthalmology – OPH001

You can self-report this CPD/PDP activity by logging it online with the RACGP/ACRRM. The activity has been allocated 1 hour (0.5 hour EA and 0.5 hour RP.)

Test your clinical knowledge by taking the 6 quizzes below. If you select the wrong answer, have another go — you can try as many times as you like.

RACGP Activity Number: OPH001

ACRRM Activity Number: OPH001

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1. Gaze at these fundal findings

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Janelle, a 75-year-old retired lawyer, presents to her GP with a two-month history of headaches. The headaches come most days, start at the back of her neck and radiate around her head, with an associated mild pressure feeling. She rates the pain as 2/10 severity, rarely takes paracetamol for it and has found remedial massage a useful form of treatment.</strong></p><p><strong>Janelle reports no associated nausea, vomiting or red flag symptoms. She is euthymic, although somewhat stressed as her eldest daughter is going through an acrimonious divorce, and she reports her headaches began after hearing this news. Janelle is normotensive and apyrexial. Her neurological examination is unremarkable.</strong></p><p><strong>Her visual acuity is normal, and she denies any ocular symptoms. A dilated fundal examination of her left eye is pictured, while her right eye appears normal. The opacities in her left eye move with ocular movement. Janelle has a background of well-controlled type 2 diabetes, for which she takes metformin and semaglutide.</strong></p><p><strong>The GP explains that her tension headaches are likely related to her daughter’s marital breakup. She declines a referral for counselling sessions and is appropriately safety netted.</strong></p></p> <ul> <li>a. Asteroid hyalosis</li> <li>b. Vitreous amyloidosis</li> <li>c. Vitritis</li> <li>d. Synchysis scintillans</li> </ul> </section> <p></p>Photo: EyeRounds.org University of Iowa

Author

Author: Dr Paul Muthiah is a GP and a former medical co-editor of Australian Doctor.

2. Diagnose this in the flash of an eye

What is the least likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Charlie is a three-month-old who is brought in by his dad with concerns about the appearance of his left eye.</strong></p><p><strong>In particular, his parents have noticed redness in the eye and that the pupil looks white in flash photographs.</strong></p><p><strong>Charlie is an otherwise-well and thriving child, delivered vaginally at term after an uneventful pregnancy. Immunisations are up to date.</strong></p><p><strong>His five-year-old sister has recently recovered from an URTI that involved mild bilateral conjunctivitis.</strong></p><p><strong>On examination, Charlie appears well with normal vital signs.</strong></p><p><strong>There is a reduced red reflex on the left. Macroscopic findings of the eye are pictured. The right eye examination is unremarkable.</strong></p></p> <ul> <li>a. Conjunctivitis</li> <li>b. Retinoblastoma</li> <li>c. Persistent fetal vasculature</li> <li>d. Congenital cataract</li> </ul> </section> <p></p>Photo: Reproduced from The BMJ, Zhang Z, Ding X. Vascularised iris in an infant BMJ 2022; 376 :e068232

Author

Author: Dr Kate Kelso is a GP and medical editor at Australian Doctor.

3. Is this a sinister dilated pupil?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Vicky is a 29-year-old office manager who presents with sudden-onset unilateral left-sided mydriasis. She had been gardening in the afternoon, and on coming inside noticed unequal pupils in the mirror, leading her to present to ED.</strong></p><p><strong>She denies fever, diplopia and neurological symptomatology, but is having some difficulty reading with her left eye, with associated discomfort. There is no significant past medical history or trauma.</strong></p><p><strong>On examination, the right and left pupils measure 3mm and 7mm respectively (figure 1). Her right pupil is responsive to light, accommodation and the consensual light reflex. The left responds minimally to light and accommodation.</strong></p><p><strong>There is no relative afferent pupil defect (RAPD) as evidenced by the lack of a reverse RAPD. The visual acuity is 6/6 bilaterally and pressures and slit lamp examination are normal. Eye movements are normal and there is no ptosis.</strong></p></p> <ul> <li>a. Ocular trauma</li> <li>b. Topical anticholinergic exposure</li> <li>c. Unilateral Argyll Robertson pupil</li> <li>d. Third nerve palsy</li> </ul> </section> <p></p>

Author

Author: Associate Professor Ian Francis is a consultant ophthalmologist at Prince of Wales Hospital and Northern Beaches Hospital, Sydney, NSW. This article was co-authored by Dr Grace Borchert, intern, Princess Alexandra Hospital, Brisbane, and Aleeza Fatima, medical student at the University of Newcastle, NSW.

4. What’s behind this painful red eye?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>Tim is a 35-year-old office worker who presents with a three-day history of a painful red eye. Two days ago, he self-started topical chloramphenicol, which he borrowed from a flatmate. But his symptoms have continued to worsen. Tim is usually very well. He has had no recent URTI, fever, arthralgia or systemic symptoms, although he has had some dysuria and urethral discharge in the past week. He has not had an STI screen in a while and has had unprotected casual sex since. Visual acuity in the left eye cannot be measured because of severe pain and tenderness. Pupils are equal and reactive to light and accommodation. The left eye findings are pictured.</strong></p></p> <ul> <li>a. Reiter’s syndrome</li> <li>b. Non-gonococcal urethritis with conjunctivitis</li> <li>c. Preseptal cellulitis</li> <li>d. Gonococcal conjunctivitis</li> </ul> </section> <p></p>Photo reproduced from BMJ, Chang C et. al., 2022;376:e064287 with permission from BMJ Publishing Group Ltd.

Author

Author: Dr Kate Kelso is a GP and medical editor at Australian Doctor.

5. What’s behind this aching eye?

What is the most likely diagnosis?

Author

Author: Dr Kate Kelso is a GP and medical editor at Australian Doctor.

6. What’s behind this painful eye and darkened iris?

What is the most likely diagnosis?

<section data-block="SingleChoice"> <h3>What is the most likely diagnosis?</h3> <p><p><strong>An 89-year-old man presents with a three day history of a red, painful right eye. He reports that over the last few months, the eye has become progressively darker in colour. He has a history of wet age-related macular degeneration in this eye, which had been treated with intravitreal anti-vascular endothelial growth factor injections until it became inactive four years ago, leaving him with long-standing poor vision. On examination, he is noted to have marked iris heterochromia.</strong></p></p> <ul> <li>a. Intraocular haemorrhage</li> <li>b. Fuchs heterochromic iridocyclitis</li> <li>c. Horner’s syndrome</li> <li>d. Ocular trauma</li> </ul> </section> <p></p>

Author

Article and case reproduced from Bobat bH, Lochhead J, Moradi P, Emergency eye colour change, Emerg Med J 2022;39:123-131, with permission from BMJ Publishing Group Ltd.

References on request from kate.kelso@adg.com.au