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C-42827

Anterior eye cases

A range of different clinical scenarios is presented to test the practitioner’s recognition and management skills. Readers are guided towards sources of reference to aid completion of the task.

Image A

imagea

A 67-year-old presents complaining of blurred vision, glare and haloes around lights. All symptoms are worse in the morning and VA corrects to 6/10.

01 What is the most likely diagnosis?

a) Fuchs’ corneal endothelial dystrophy 
b) Contact lens over wear
c) Corneal hydrops secondary to keratoconus
d) Posterior polymorphous dystrophy

02 What non-surgical treatment options can one consider?

a) Hypertonic 5% saline eye drops
b) Judicious use of a warm air source, such as a hair dryer
c) Therapeutic bandage contact lens
d) All of these

03 Which surgical option can be undertaken with simultaneous cataract surgery for this condition?

a) Intrastromal corneal ring segments
b) Corneal collagen crosslinking with Riboflavin
c) Descemet’s stripping automated endothelial keratoplasty
d) None of these

Image B

imageb

Slit-lamp examination shows iris hyperpigmentation in the inferior temporal region of the left eye which the 76-year-old patient reports having since birth.

04 Which of the following is the most likely diagnosis?

a) Iris melanocytosis associated with increased risk of developing a uveal melanoma and should be referred b) Iris melanocytosis which is not associated with increased risk of developing a uveal melanoma 
c) Primary iris cyst which should be monitored and only referred if it changes size or shape
d) None of these

05 What percentage of melanomas arise in the iris?

a) 80% b) 50%
c) 12%
d) 8%

06 Which other techniques may aid differential diagnosis?

a) Ultrasound biomicroscopy b) Fine needle aspiration biopsy 
c) Conventional trans-scleral biopsy
d) All of these

Image C

imagec

An asymptomatic patient attends for contact lens aftercare with vision of 6/5. The topography image shows the change to her left cornea within a six-week period. 

07 Which of the following is most likely to explain the degree of corneal change within the time period?

a) Corneal oedema due to over wear of a soft contact lens with a low Dk/t  b) Corneal warpage as a result of a poorly fitting RGP lens
c) Remoulding of the corneal shape using orthokeratology 
d) Modification to the corneal curvature using a scleral contact lens

08 Which refractive error is most suitable for correction with this type of contact lens?

a) -2.50DS/-1.00DC x 180 b) -2.25DS/-1.50DC x 90
c) -7.50DS
d) +1.00DS/-1.00DC x 90

09 Which condition would be contraindicated for this lens type?

a) Keratoconus b) Pellucid marginal degeneration
c) Epithelial basement membrane dystrophy
d) All of these

Image D

imaged

10 Which imaging technique is being utilised in this image?

a) Laser confocal meibography  b) Optical coherence tomographic meibography
c) Contact meibography
d) Non-contact infrared meibography

11 Considering eyelid anatomy, which of the following statements is true?

a) The meibomian gland, the Gland of Zeis and Gland of Moll are unilobar sebaceous glands b) The meibomian gland and the Gland of Moll are sebaceous glands, the Gland of Zeis is a modified sweat gland
c) There are approximately 30-40 meibomian glands in the upper lid and 15-20 in the lower lid
d) There are approximately 50-60 meibomian glands in the upper lid and 30-40 in the lower lid

12 Which of the following statements is false?

a) The tear film can be disrupted by either low production of meibum or excessive amounts of poor quality meibum  b) Hyposecretion can be due to a physical obstruction of the ducts by keratinised epithelium
c) Reduced meibum production can be influenced by hormone levels, age, contact lens wear and various medications
d) Hypersecretory changes are not commonly linked to dermatitis, acne rosacea and atopic disease

About the author

Craig McArthur is an optometrist working within independent practice. He is a visiting lecturer and clinical tutor to undergraduates at Glasgow Caledonian University where he also teaches the glaucoma module for the independent prescribing course. 

References

  1. Edwards, M. Fuchs' corneal endothelial dystrophy. Optometry Today. 15 December 2014
  2. https://www.college-optometrists.org/guidance/clinical-management-guidelines/fuchs-endothelial-corneal-dystrophy.html
  3. Cohen, V and Papastefanou, V. Uveal tract melanoma: Referral refinement part 1. Optometry Today. 8 April 2011
  4. www.reviewofoptometry.com/content/d/case_report/i/798/c/14849/
  5. Downie, L. Orthokeratology: a clinical overview. Optometry Today. 9 January 2015
  6. Bruce, G and Cameron, I. Blepharitis, but not as you know it. Optometry Today. 28 February 2014
  7. Doughty, M J. Eyelid and eyelid margin disorders: Management options for UK optometrists part 3. Optometry Today. 17 September 2010
  8. www.sciencedirect.com/science/article/pii/S1319453412001130