A 45-year-old asthmatic man presented with bilateral blurry vision of gradual onset over the last two months



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A 45-year-old asthmatic man presented with bilateral blurry vision of gradual onset over the last two months.

On examination he was found to have bilateral posterior subcapsular cataract, more so in the right than the left.

His other past medical history was that he had galactosaemia when he was still a baby, but this has since been treated. He is on bronchodilator inhalers and steroid inhalers to control his asthma. His oral medication includes amiodarone, aspirin and simvastatin.

What is the most likely cause of his cataracts?



(Please select 1 option)



Amiodarone



Galactosaemia Incorrect answer selected



Inhaled bronchodilators



Inhaled steroids This is the correct answer



Simvastatin

Inhaled steroids can cause cataracts.

Amiodarone causes vortex keratopathy.

Galactosaemia also does cause cataracts, but if the galactosaemia is treated, the cataract is reversible.

Inhaled bronchodilators and simvastatin are not known to cause cataracts.

A 42-year-old lady presented with a two week history of noticing both her eyes were skewed towards the temporal side. She denied ocular pain and headaches. Her visual acuity was 6/6 on the Snellen chart in both eyes. She was not able to adduct both eyes, but up and down gaze was fine. She had two previous episodes of optic neuritis in the right eye. The last episode happened four months ago. Her walking was normal, and her deep tendon reflexes were present. She also just recovered from gastroenteritis three weeks ago.

What is the most likely condition that the patient had presented with?

(Please select 1 option)



Chronic progressive external ophthalmoplegia



Internuclear ophthalmoplegia Correct



Miller Fisher syndrome



Ocular myasthenia



Parinaud's syndrome

This is a case of walled eye bilateral internuclear ophthalmoplegia, (WEBINO). The history suggests a demyelinating process, and failure of ocular adduction in such cases should prompt the diagnosis of internuclear ophthalmoplegia.

26-year-old tall, thin, lady with a known cardiac valvulopathy, was reported to have skin laxity and folds on the back of the neck and her underarms.

Fundoscopy revealed bilateral angioid streaks with optic disc drusens.

What is the most likely diagnosis?

(Please select 1 option)



Ehlers-Danlos syndrome



Marfan's syndrome



Menke's syndrome



Osteogenesis imperfecta



Pseudoxanthoma elasticum Correct

Pseudoxanthoma elasticum with angioid streaks is also known as Gronblad-Strandberg syndrome.

Ehlers-Danlos and Marfan's syndrome are not associated with laxity and folds of skin on the back of the neck.

Menke's syndrome and osteogenesis imperfecta are not associated with angioid streaks.

A 34-year-old man, who has just recovered from gastroenteritis following a recent trip to Turkey, suddenly developed progressive gait ataxia and restriction of eye movements in all directions of gaze.

There was no nystagmus.

What is the most likely diagnosis?

(Please select 1 option)



Acute cerebellar degeneration



Millard-Gubler syndrome



Miller-Fisher syndrome Correct



Parinaud's syndrome



Subacute combined degeneration of the spinal cord

Miller-Fisher syndrome is a variant/spectrum of Guillain-Barre syndrome (GBS).

GBS is associated with Campylobacter jejuni infection, which can trigger this syndrome.

Miller-Fisher is classically described as a triad of:

- external ophthalmoplegia

- ataxia and

- areflexia,

so the above history would be most in keeping with Miller-Fisher syndrome

A 75-year-old man developed a gradual problem of not being able to look down over the last eight months. Then about two months ago, he was also not able to look up. He denied any diplopia, ocular pain or headaches.

There was no evidence of convergence retraction nystagmus, proptosis or ptosis.

What is the most likely diagnosis?



(Please select 1 option)



Chronic progressive external ophthalmoplegia This is the correct answer



Ocular myasthenia Incorrect answer selected



Ocular myositis



Parinaud's syndrome



Thyroid eye disease

The history itself suggests a chronic progressive limitation of eye movements without any diplopia, proptosis or ptosis. Therefore, the most likely diagnosis is chronic progressive external ophthalmoplegia.

Ocular myasthenia usually presents with diplopia and ptosis.

Parinaud's syndrome usually manifests as up gaze palsy with convergence retraction nystagmus.

A 61-year-old emmetropic female nurse presented with a three day history of missing steps when walking down the stairs as she was seeing double of each of the steps. She reported no such problems when walking up the stairs.

She admitted to bumping her head moderately hard when trying to get out of her car four days ago. She denied any deterioration of her visual acuity.

No horizontal diplopia was elicited.

What is the most likely cause of her problems?

(Please select 1 option)





Right inferior oblique palsy



Right inferior rectus palsy



Right superior oblique palsy This is the correct answer



Right superior rectus palsy



This patient needs glasses for distance Incorrect answer selected

This patient essentially suffered from vertical diplopia following bumping her head moderately hard.

The fourth cranial nerve can be affected in such a situation resulting in superior oblique palsy.

A patient presents with deteriorating vision.

On examination, fundoscopy reveals retinitis pigmentosa.

Which of the following conditions would be unlikely to be responsible for this presentation?

(Please select 1 option)





Abetalipoproteinaemia



Friedreich's ataxia Correct





Kearns-Sayre syndrome



Laurence-Moon-Biedl syndrome



Refsum's disease

Causes of pigmentary retinopathy include Usher's syndrome and mitochondrial myopathy.

Abetalipoproteinaemia is autosomal recessive and is associated with:



  • Hypocholesterolaemia syndrome resembling Friedreich's ataxia

  • Abnormally shaped red blood cells (RBC) (acanthocytes)

  • Steatorrhoea and

  • Fatty liver.

Friedreich's is associated with optic atrophy.

A 24-year-old lady presented with anisocoria, with the right pupil larger than the left, both in a brightly lit room and in a dim lit room.

Her mother noticed this only five days ago.

The anisocoria was less marked in the dim lit room.

Deep tendon reflexes were present and brisk throughout.

She occasionally noted horizontal diplopia with a right sided headache. There was no ptosis. Visual acuity was 6/6 on the Snellen chart in both eyes.

Which one of the following statements is most accurate?

(Please select 1 option)





The diagnosis is Holmes Adie's syndrome



The diagnosis of a brain tumour needs to be excluded urgently



The diagnosis of a posterior communicating artery aneurysm needs to be excluded urgently Correct



The pathological (diseased) pupil is actually the left pupil, diagnosis being Argyll Robertson pupil



When doing a swinging light test of the pupils, a right relative afferent papillary defect is to be expected

The history of anisocoria, with headaches and diplopia should ring alarm bells, in that a life-threatening posterior communicating artery aneurysm/berry aneurysm needs to be excluded urgently.

Anisocoria being an efferent problem will not give a relative afferent papillary defect

A 47-year-old man, otherwise fit and healthy, complained of a one week history of not being able to see objects placed at the centre of his visual fields, even with both eyes opened.

An objective visual fields test revealed an incongruous binasal hemianopia.

What is the most likely diagnosis?

(Please select 1 option)





Carotid-cavernous sinus fistula



Craniopharyngioma



External carotid artery dissection



Internal carotid artery displacement Correct



Pituitary tumour
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