DFT-EMREE-OPHTHALMOLOGY-14-10-2025

A 27 Y/O F presents to the ED from a movie theatre with acute, severe R eye pain, blurred vision, and nausea. O/E, the R eye is erythematous, the cornea is hazy, and the pupil is fixed in a mid-dilated position. Ocular tonometry reveals an intraocular pressure (IOP) of 55 mmHg (Normal: 10-21 mmHg). A diagnosis of acute angle-closure glaucoma is made. What is the most appropriate initial pharmacological management for this patient?

• Intravenous mannitol and topical pilocarpine

• Topical atropine and oral ibuprofen

• Oral amoxicillin and topical corticosteroids

• Intravenous acyclovir and topical lubricants

• Topical latanoprost monotherapy

Answer explanation

Intravenous mannitol is a hyperosmotic agent that draws fluid out of the vitreous humor, rapidly reducing IOP. Topical pilocarpine is a miotic agent that constricts the pupil, pulling the peripheral iris away from the trabecular meshwork and helping to open the drainage angle. Combining a systemic agent to decrease aqueous volume with a topical miotic to address the mechanical obstruction is the standard initial management.

A 65 Y/O M with Hx of HTN presents to the clinic. He reports a single episode yesterday of sudden, painless vision loss in his right eye that he described as "a black curtain coming down from above." The episode lasted about 2 minutes and his vision is now completely back to normal. O/E: BP 155/90 mmHg. Visual acuity 20/20 in both eyes. What is the most likely diagnosis?

• Amaurosis fugax

• Central retinal artery occlusion

• Acute angle-closure glaucoma

• Retinal detachment

• Optic neuritis

Answer explanation

The vignette describes the classic presentation of amaurosis fugax: a transient, painless, monocular vision loss, often described as a "curtain" or "shade." This is considered a transient ischemic attack (TIA) of the retina.

A 68 Y/O M with Hx of DM & HTN c/o acute, painless L eye vision loss. He reports preceding flashes of light and a shower of new floaters, which was followed by the appearance of a progressive peripheral shadow. The underlying pathophysiology of this patient's most likely condition involves a tear in the retina allowing what substance to seep behind it?

• Vitreous fluid

• Aqueous humor

• Subretinal exudate

• Blood

• Cerebrospinal fluid

Answer explanation

The classic symptoms of photopsia, floaters, and a peripheral field defect strongly suggest a rhegmatogenous retinal detachment. This condition occurs when a retinal tear allows liquefied vitreous humor to pass from the vitreous cavity into the subretinal space, separating the neurosensory retina from the underlying retinal pigment epithelium (RPE).

A 65 Y/O F presents to the ED with a 3-hour Hx of sudden, severe right eye pain, headache, and nausea. O/E, her R eye is injected, the pupil is mid-dilated and fixed, and the cornea appears hazy. Intraocular pressure (IOP) is 55 mmHg. The Dx of Acute Angle-Closure Glaucoma is made. What is the most appropriate initial combination of pharmacological agents for this patient?

• IV Acetazolamide + Topical Timolol + Topical Pilocarpine

• Topical Atropine + Topical Corticosteroid

• Oral Amoxicillin + Topical Cyclopentolate

• IV Mannitol + Topical Tropicamide

• Topical Prostaglandin analogue + Oral NSAIDs

Answer explanation

 The immediate goal is to rapidly lower the IOP to prevent optic nerve damage. This is achieved with a multi-pronged approach:

A 58 Y/O M with a long Hx of poorly controlled T2DM undergoes a routine fundoscopy. VA is 6/9 bilaterally. O/E, fundus shows multiple dot-blot hemorrhages, hard exudates, and venous beading. Notably, there are also fine new vessels originating directly from the optic disc. Which finding classifies this condition as high-risk proliferative diabetic retinopathy?

• Hard exudates

• Venous beading

• Dot-and-blot hemorrhages

• Neovascularization of the disc (NVD)

• Macular edema

Answer explanation

The correct answer is D. Neovascularization (the growth of new vessels) is the hallmark of proliferative diabetic retinopathy (PDR). When it occurs on or within one disc diameter of the optic nerve head, it is termed NVD and is a high-risk characteristic for severe vision loss from vitreous hemorrhage or tractional detachment. Options A, B, and C are signs of non-proliferative retinopathy, although venous beading suggests it is severe. Macular edema (E) can occur at any stage and does not define the proliferative status.

A 62 Y/O M with a long Hx of T2DM & HTN c/o progressive vision loss x1Y, now with significant glare & "halos" around lights at night. O/E, visual acuity is 6/18 bilaterally with a diminished red reflex. Fundoscopy is unremarkable for proliferative changes. What is the most likely diagnosis explaining his primary visual symptoms?

• Open-angle glaucoma

• Proliferative diabetic retinopathy

• Cataract

• Age-related macular degeneration

• Presbyopia

Answer explanation

The combination of gradual, painless vision loss, glare, and halos in an elderly patient with long-standing diabetes are classic features of cataract formation. Diabetes is a major risk factor that accelerates this process. The diminished red reflex further supports lenticular opacity.

A 54 Y/O F is diagnosed with acute dacryocystitis, presenting with a tender, erythematous swelling over the lacrimal sac. She is afebrile and systemically well. You have arranged an urgent referral to ophthalmology. What is the most appropriate initial outpatient prescription to start immediately?

• Topical neomycin-polymyxin B-dexamethasone drops

• Oral acyclovir

• Oral amoxicillin-clavulanate

• Topical erythromycin ointment

• Intravenous vancomycin

Answer explanation

 Acute dacryocystitis is a cellulitis of the lacrimal sac and surrounding tissues, most commonly caused by gram-positive organisms like Staphylococcus aureus and Streptococcus pneumoniae. Systemic oral antibiotics with good coverage for these pathogens, such as amoxicillin-clavulanate or cephalexin, are the first-line treatment for mild-to-moderate, non-orbital cases.

58 Y/O M with a 10-year Hx of poorly controlled HTN presents for a routine exam. He denies any visual changes. O/E: BP is 175/105 mmHg. Fundoscopy is performed. Which of the following findings on fundoscopy is most specific for chronic hypertensive retinopathy in this patient?

• Cotton-wool spots

• Hard exudates

• Dot and blot hemorrhages

• Arteriovenous (AV) nipping

• Neovascularization

Answer explanation

Arteriovenous (AV) nipping, the apparent "nicking" or tapering of a venule where an arteriole crosses over it, is a pathognomonic sign of chronic hypertensive retinopathy. It is caused by the thickening and sclerosis of the arterial wall (arteriosclerosis) which compresses the underlying, thinner-walled venule.

34 Y/O M with HIV, non-compliant with ART, presents for a routine exam. He is visually asymptomatic. CD4 count is 80 cells/mm³. O/E: Fundoscopy shows multiple cotton-wool spots without associated hemorrhage or vitritis. What is the most likely Dx?

• Cytomegalovirus (CMV) retinitis

• Progressive outer retinal necrosis (PORN)

• HIV retinopathy

• Toxoplasma retinochoroiditis

• Syphilitic chorioretinitis

Answer explanation

 HIV retinopathy is a non-infectious microvasculopathy, and its most common sign is cotton-wool spots. The absence of symptoms, hemorrhage, or inflammation (vitritis) in the setting of HIV points to this diagnosis, which is one of exclusion.

45 Y/O M currently on Rx for pulmonary TB c/o severe R eye pain, photophobia, and redness x3D. O/E: Vision is blurred in the R eye. There is a marked ciliary flush (redness concentrated around the cornea). The pupil is constricted and poorly reactive to light. What is the most likely diagnosis?

• Acute angle-closure glaucoma

• Anterior uveitis

• Infectious keratitis

• Episcleritis

• Viral conjunctivitis

Answer explanation

The triad of pain, photophobia, and redness (specifically ciliary flush), combined with a constricted, poorly reactive pupil (miosis) in a patient with a known systemic inflammatory disease like TB, is a classic presentation for anterior uveitis. Ocular TB is a well-known cause.