USMLE PART3.1 (OPTHALMO)

A 1-year-old boy is brought to the clinic by his 28-year-old Caucasian mother for the evaluation of his eyes. For the past several months, he has been bumping into objects. His perinatal history is unremarkable. Physical examination of the eyes reveals a bilateral white reflex. The retina cannot be visualized properly. Fundal reflection is absent, and the pupil is white. What is the most likely diagnosis?

A 53-year-old man comes to the office because of difficulty reading fine print over the last year. He now has to hold books, menus, and magazines at an arm’s length in order to read them. He has never had visual problems before. Which of the following is most likely abnormal in this patient?

A 65-year-old white man is complaining of a sudden loss of vision in his left eye which resolved after 15 minutes. "It seemed like a curtain was falling down in my eye!" said the patient. He recalls having a similar episode 3 months ago. His past medical history is significant for hypertension, for which he takes lisinopril (20mg) and hydrochlorothiazide (25mg) daily. His pulse is 82/min, blood pressure is 140/90 mm Hg, respirations are 14/min, and temperature is normal. Fundoscopy reveals zones of whitened, edematous retina following the distribution of the retinal arterioles. What is the most likely diagnosis?

A 3-day-old female infant is noticed to have copious, purulent discharge from both eyes. Lid edema and chemosis are also noted. She was born by normal vaginal delivery. Her mother is a 20-year-old primigravida who had no prenatal care. Which of the following is the most likely diagnosis?

A 22-year-old Caucasian female presents to the office with several months history of decreased visual acuity and decreased brightness sensation in the right eye. Slight exophthalmos of the right eye is present on physical examination, and ophthalmoscopy shows pallor of the right optic disk. Several cafe-au-lait spots and intensive axillary freckling are present. Which of the following is the most likely cause of this patient's visual problems?

A 65-year-old African American man comes to the emergency department due to a sudden loss of vision in his right eye. He has had diabetes, and has been treated with metformin and glyburide for the past 10 years. Visual acuity is reduced to light perception in his right eye, and normal in his left. His vital signs are normal. Ophthalmoscopy reveals loss of fundus details, floating debris and a dark red glow. What is the most likely diagnosis?

A 62-year-old female is brought in by EMS due to a severe right-sided headache, nausea and eye pain. She was fixing a light bulb, when she suddenly felt pain in her right eye. She decided to rest, but the eye pain only got worse. In the next few minutes, she developed loss of vision, photophobia and redness in the same eye. She took medications to relieve the accompanying headache, but the eye pain persisted. She denies any trauma. Her past medical history is significant for diabetes and hypertension. She appears to be in intense pain with bouts of nausea. Her right eye is red, with conjunctival flushing and visual acuity of 20/200. Her right pupil is mid-dilated and non-reactive to light. The same eye feels hard on palpation. The one treatment that should be avoided in this patient is:

A 60-year-old woman complains of decreasing vision and a dull ache over her left eye for the past 12 hours. She had a successful surgical cataract extraction in her left eye five days ago. Her blood pressure is 140/90 mmHg, pulse is 92/min, respirations are 14/min, and temperature is 38.1C (101.7F). Examination of the left eye reveals a swollen eyelid, edematous conjunctiva, and exudates in the anterior chamber. Testing with Snellen's chart demonstrates decreased visual acuity in her left eye. What is the most likely diagnosis?

A 65-year-old male comes to the emergency department because of a sudden, painless loss of vision in his right eye that occured a half an hour ago. Five hours ago, he experienced a similar but transient loss of vision in the same eye, which lasted for five minutes. He has hypertension, diabetes, hypercholesterolemia, and peripheral vascular disease. He had an anterior wall myocardial infarction six years ago. His medications include glyburide, captopril, atenolol, simvastatin and aspirin. His temperature is 36.7C (98.0F), respirations are 16/min, pulse is 88/min, and blood pressure is 146/88 mmHg. Examination of the right eye reveals visual acuity of 20/60 and subtle retinal whitening. A right carotid bruit is heard. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old male complains of itching and excessive watering of both eyes since this morning. He denies blurring of vision. He uses albuterol inhaler regularly for his bronchial asthma. His vital signs are normal. On examination, both eyes are noted to have conjunctival edema, hyperemia, swollen eyelids, and profuse watery discharge. What is the most likely diagnosis?

A 4-year-old boy is brought by his mother to a Medical Camp for the Uninsured for the evaluation of his inflamed right eye. He has had a nasal discharge for the past 10 days. His brother has similar symptoms. His vital signs are stable. There are follicles and inflammatory changes in the conjunctiva of his right eye. The cornea shows neovascularization. What is the most likely diagnosis?

A 60-year-old woman comes to the emergency department due to a sudden onset of severe pain in her left eye with blurred vision, nausea, and vomiting. The symptoms began a few minutes ago, while she was watching a movie in a nearby theatre. Her blood pressure is 140/90 mm Hg, pulse is 82/min, respirations are 14/min, and temperature is 98.4 F. Examination reveals decreased visual acuity. Her left eye appears red, with a hazy cornea, shallow anterior chamber, and dilated, fixed pupil. Her left eye is stony hard to touch. What is the most likely diagnosis?

A 32-year-old male construction worker presents with complaints of pain, watering, and redness in his left eye for the past 2 days. He reports having similar symptoms in the same eye a few months ago. Examination of his left eye reveals vesicles and dendritic ulcers in the cornea. His vital signs are stable. What is the most likely diagnosis?

A 30-year-old male comes to the emergency department screaming, "Something blew into my right eye while I was drilling I' He complains of a foreign body sensation in the right eye, photophobia, and excessive lacrimation. Gross examination of the right eye with a penlight after the application of a topical anesthetic is insignificant. What is the best next step in the management of this patient?

A 35-year-old HIV-positive male is complaining of deterioration of his vision over the past week. He initially experienced eye pain and mild conjunctivitis, followed by rapid progressive visual loss. Examination of his eyes reveals marked keratitis. Funduscopy shows widespread, pale, peripheral retinal lesions and central necrosis of the retina. Which of the following is the most likely causative organism of this patient's condition?

A 38-year-old man with AIDS (Acquired Immune Deficiency Syndrome) is complaining of diminished vision in both eyes. His CD4 count last month was 50 ells/uL. He has been on highly active antiretroviral therapy for the past several months. He is afebrile, and his vital signs are stable. Ophthalmoscopic examination reveals yellow-white patches of retinal opacification and retinal hemorrhages. What is the most likely diagnosis?

A 65-year-old man presents with complaints of decreased vision in both eyes. His visual impairment has been progressively worsening over the past five months. He was diagnosed with diabetes ten years ago. His current medications are metformin and glyburide. His blood pressure is 140/90 mm Hg, pulse is 82/min, respirations are 14/min, and temperature is 98.4F (36.88C). Examination shows decreased visual acuity in both eyes. Ophthalmoscopy reveals microaneurysms, dot and blot hemorrhages, hard exudates, and macular edema. Which of the following is the most likely diagnosis?

A 69-year-old white male presents to your office complaining of progressive bilateral loss of vision over the past several months. He only has problems with his central vision. His peripheral field and navigational vision are not affected. He denies smoking and alcohol intake. He does not have any history of diabetes or hypertension Two years ago, he had cataracts removed from both eyes. What is the most likely diagnosis?

A 57-year-old female with a history of type 2 diabetes mellitus complains of fatigue, urinary frequency, increasingly blurred vision and worsening leg cramps over the past week. She reports that the symptoms all began following an upper respiratory infection 7 or 8 days ago. She does not take any medications, but adheres to a diet low in saturated fat and simple carbohydrates to manage her diabetes. On physical examination, her blood pressure is 160/90 mmHg and her heart rate is 90/min. Her mucous membranes are dry. Her urine is positive for glucose but negative for ketones. Which of the following is the most likely cause of this patient's vision impairment?

An 80-year-old white male comes to the emergency department due to a sudden loss of vision in his left eye that occurred this morning upon waking up. He has had hypertension for the past several years. Current medications include ramipril and atenolol. His blood pressure is 140/90 mm Hg, pulse is 86/min, respirations are 14/min, and temperature is 36.8°C (98.4.F). Examination of the left eye reveals no abnormalities. Funduscopic examination shows swelling of the optic disk, retinal hemorrhages, dilated and tortuous veins, and cotton wool spots. Which of the following is the most likely diagnosis?

A 32-year-old woman comes to the office distraught because "the colors look washed out I" She has had this vision impairment since yesterday. She also complains of pain on eye movements. Her vital signs are stable, and she is afebrile. Examination reveals decreased visual acuity, sluggish afferent pupillary response to light, and changes in color perception. Fundoscopy reveals a swollen disc. What is the most likely diagnosis?

A 34-year-old obese Caucasian female complains of periodic visual obscurations. She has episodes during which she "goes blind" for several seconds when standing up or stooping forward abruptly. She also describes frequent morning headaches over the last two months for which she has had to take ibuprofen or aspirin almost every morning. She takes no other medications. Past medical history is insignificant aside from one uncomplicated vaginal delivery. She denies use of alcohol, tobacco, or illicit drugs. She is afebrile with a blood pressure of 138/88 mmHg and pulse of 93/min. Visual field testing shows enlarged blind spots. There are no other significant findings on neurologic examination. Which of the following is the most likely cause of this patient's symptoms?

A 34-year-old obese Caucasian female complains of periodic visual obscurations. She has episodes during which she "goes blind" for several seconds when standing up or stooping forward abruptly. She also describes frequent morning headaches over the last two months for which she has had to take ibuprofen or aspirin almost every morning. She takes no other medications. Past medical history is insignificant aside from one uncomplicated vaginal delivery. She denies use of alcohol, tobacco, or illicit drugs. She is afebrile with a blood pressure of 138/88 mmHg and pulse of 93/min. Visual field testing shows enlarged blind spots. There are no other significant findings on neurologic examination. Which of the following is the most likely cause of this patient's symptoms?

An 85-year-old man presents with a rash over his forehead, tip of nose and left eye. He also complains of pain and decreased vision. He has had fever, malaise, and a burning sensation around his left eye for the past 5 days. His blood pressure is 140/90 mm Hg, pulse is 92/min, respirations are 14/min, and temperature is 38.1C (101F). Physical examination reveals a vesicular rash on the periorbital region and lid margins. The left eye is red, with chemosis of the conjunctiva. Dendriform ulcers are seen on the cornea. What is the most likely diagnosis?

A 33-year-old man presents with a 1-day history of localized, small swelling along the margin of the upper eyelid. He feels pain, which does not seem to come from the conjunctival surface. He has a 10-pack year smoking history. He occasionally drinks alcohol. He is sexually active, and does not use condoms regularly. He is worried about the swelling. What is the best next step in the management of this patient?

A 30-year-old man is concerned about "floating spots" and blurred vision in his right eye. He had a serious injury of his left eye several weeks ago, which eventually led to vision loss in that eye. Inspection reveals a moderate perilimbal flush. What is the most probable cause of this patient's condition?

A 65-year-old female is complaining of seeing a sudden burst of flashing lights and blurred vision in her left eye. These symptoms started this morning. She now sees small spots in her field of vision. She felt "like a curtain came down" over her eye. She had a successful cataract extraction in her left eye 4 months ago. Her vital signs are stable. Examination shows a sluggish left pupil. Ophthalmoscopy reveals retinal tears and a grayish-appearing retina. What is the most probable diagnosis?

A 67 -year-old Caucasian male complains of progressive visual loss in his right eye over the past several months. He has a history of hypertension and type 2 diabetes mellitus. Current medications include a daily baby aspirin, hydrochlorothiazide, lisinopril, and metformin. There is no family history of visual problems. He has a 35 pack year smoking history and admits to occasional alcohol use. He is afebrile with a blood pressure of 137/82 mmHg and pulse of 73/min. Cardiac and pulmonary examinations are unremarkable. A neurologic examination demonstrates no focal motor or sensory abnormalities. The patient is asked to cover his left eye and to look at a small spot on a grid made of parallel vertical and horizontal lines. He describes the vertical lines as being bent and wavy. Which of the following is the most likely cause of this patient's complaints?

A 35-year-old white female is complaining of blurry vision and pain with eye movements. She is on no medications and denies any trauma. Last year, she developed bladder incontinence and an episode of leg weakness, which both improved without therapy. Physical examination reveals reduced vision and swollen optic discs. The one diagnosis that may explain her symptoms is·

A 65-year-old woman presents with complaints of pain and swelling over the inner aspect of her right eye for the past two days. Examination of the eye reveals tenderness, edema, and redness over the medial canthus. Slight pressure over the area causes expression of purulent material. Visual acuity is normal. What is the most likely diagnosis?

A 65-year-old man complains of gradual onset blurred vision for the past two months. He also has difficulty driving at night and reading fine print. He has diabetes and hypertension. His medications include ramipril and metoprolol. His vital signs are stable. His best corrected vision is OD (right eye) 20/80, OS (left eye) 20/100, with full fields. Ophthalmoscopic examination with good pupillary dilatation reveals a loss of transparency of lens in both eyes. The red fundal reflex is normal, but retinal details are difficult to visualize. What is the most likely diagnosis?

A 24-year-old woman presents to the emergency department (ED) complaining of right eye pain and blurry vision since waking up this morning. She states that the pain began after taking out contact lenses that were in her eyes for over 1 week. Her blood pressure (BP) is 120/75 mm Hg, heart rate (HR) is 75 beats per minute, temperature is 99.1°F, and respiratory rate (RR) is 16 breaths per minute. Her right and left eye visual acuity is 20/60 and 20/20, respectively. Her conjunctivae are injected. The slitlamp examination reveals a large area of fluorescein uptake over the visual axis. Which of the following is the most appropriate therapy?

A 60-year-old woman presents to the ED complaining of pain in her right eye and burning sensation over half of her forehead and scalp. On physical examination, you notice a patch of grouped vesicles on an erythematous base located in a dermatomal distribution on her scalp and forehead. There are also a few vesicles located at the tip of the patient’s nose. Her visual acuity is 20/20 bilaterally, heart is without murmurs, lungs are clear, abdomen is soft, and there are no gross findings on neurologic examination. Which of the following is the most concerning complication of this patient’s clinical presentation?

A 72-year-old man presents with right eye pain for 1 day. The patient has a history of diabetes, hypertension, and “some type of eye problem.” He does not recall the name of his eye problem or the name of his ophthalmic medication. However, he does remember that the eye drop has a yellow cap. Which class of ophthalmic medication is the patient taking?

A 35-year-old woman presents with a right-sided red eye for 3 days. She denies pain and notes that she has watery discharge from the eye. She has been coughing and congested for the past 5 days. On examination, the patient has a temperature of 98.4°F, HR of 72 beats per minute, BP of 110/70 mm Hg, and RR of 14 breaths per minute. Her visual acuity is 20/20. On inspection, the conjunctiva is erythematous with minimal chemosis and clear discharge. The slit-lamp, fluorescein, and funduscopic examinations are otherwise unremarkable. The patient has a nontender, preauricular lymph node and enlarged tonsils, without exudates. What is the most likely diagnosis?

A 24-year-old woman presents to the ED at 4 AM with severe left eye pain that woke her up from sleep. She wears soft contact lenses and does not routinely take them out to sleep. She is in severe pain and wearing sunglasses in the examination room. You give her a drop of proparacaine to treat her pain prior to your examination. On examination, her vision is at baseline and she has no afferent pupillary defect. There is some perilimbic conjunctival erythema. On fluorescein examination, a linear area on the left side of the cornea is highlighted when cobalt blue light is applied. No underlying white infiltrate is visualized. No white cells or flare are visualized in the anterior chamber. What is the most appropriate treatment for this condition?

A 45-year-old woman presents with right eye pain and redness for 1 day. She has photophobia and watery discharge from the eye. She does not wear glasses or contact lenses and has no prior eye problems. On examination, the patient’s visual acuity is 20/20 in the left eye and 20/70 in the right eye. She has conjunctival injection around the cornea and clear watery discharge. On slit-lamp examination, the lids, lashes, and anterior chamber are normal. When fluorescein is applied, a branching, white-colored epithelial defect is seen. The remainder of the head examination is normal and the patient has no cutaneous lesions. Which of the following is the most appropriate treatment for this patient?

A 45-year-old woman presents with right eye pain and redness for 1 day. She has photophobia and watery discharge from the eye. She does not wear glasses or contact lenses and has no prior eye problems. On examination, the patient’s visual acuity is 20/20 in the left eye and 20/70 in the right eye. She has conjunctival injection around the cornea and clear watery discharge. On slit-lamp examination, the lids, lashes, and anterior chamber are normal. When fluorescein is applied, a branching, white-colored epithelial defect is seen. The remainder of the head examination is normal and the patient has no cutaneous lesions. Which of the following is the most appropriate treatment for this patient?

A 28-year-old mechanic with no past medical history presents to the ED after a small amount of battery acid was splashed in his right eye. He is complaining of extreme pain and tearing from his eye. Which of the following is the most appropriate next step in management?

A 45-year-old man lacerated his right forehead after an altercation in a local bar. Instead of seeking medical attention, the patient applied super glue to his wound. He successfully stopped the bleeding, but some of the glue got into his right eye and now he comes to the ED with difficulty opening his right eye. What is the most appropriate treatment of this patient?

The local sorority house recently installed a sun-tanning station. Two days later three sorority girls present to the ED with bilateral eye pain, tearing, and photophobia. After ophthalmic anesthesia instillation, a complete eye examination is performed. Visual acuity is normal. Extraocular eye movements are intact and pupils are equal, round, and reactive to light. IOP is normal. Slit-lamp examination is normal, but fluorescein examination under cobalt blue light illuminates small dots throughout the cornea. What is the most likely diagnosis?

A 12-year-old girl presents to the ED for left eye pain and swelling for 2 days. The patient has had cough, congestion, and rhinorrhea for the last week that is improving. On examination, her temperature is 100.8°F, HR 115 beats per minute, RR 12 breaths per minute, and BP 110/70 mm Hg. On eye examination, there is purple-red swelling of both upper and lower eyelids with injection of the conjunctiva. Pupils are equal and reactive to light. There is restricted lateral gaze. Visual acuity is 20/70 in the left eye and 20/25 in the right eye. The rest of the physical examination is normal. What is the most appropriate next step in management?

A 60-year-old man with a history of hypertension and migraine headaches presents to the ED with a headache. He describes left-sided headache and eye pain that is associated with nausea and vomiting. The patient has a long history of migraines, but says his migraines do not usually include eye pain. On examination, his temperature is 97.6°F, HR 84 beats per minute, RR 12 breaths per minute, and BP 134/80 mm Hg. His neurologic examination is normal. His left eye is mid-dilated and nonreactive. His cornea is cloudy. His corrected visual acuity is 20/50 in the left eye and 20/20 in the right eye. What is the most appropriate next step in management?

A 22-year-old man presents to the ED for left eye pain. He was in an altercation yesterday and was punched in the left eye. On examination, his left eye is ecchymotic and the eyelids are swollen shut. He has tenderness over the infraorbital rim but no step-offs. You use an eyelid speculum to examine his eye. His pupils are equal and reactive to light. His visual acuity is normal. On testing extraocular movements, you find he is unable to look upward with his left eye. He also complains of diplopia when looking upward. Funduscopic examination is normal. What is the most likely diagnosis?

You are examining the pupils of a patient. On inspection, the pupils are 3 mm and equal bilaterally. You shine a flashlight into the right pupil and both pupils constrict to 1 mm. You then shine the flashlight into the left pupil and both pupils slightly dilate. What is this condition called?