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Eye Pain and Visual Change
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1.A 24-year-old woman presents to the emergency department (ED) complaining of right eye pain and blurry vision since waking up this morn- ing. She states that the pain began after taking out contact lenses that were in her eyes for over 1 Her blood pressure (BP) is 120/75 mm Hg, heart rate (HR) is 75 beats per minute, temperature is 99.1°F, and respira- tory 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 slit- lamp examination reveals a large area of fluorescein uptake over the visual axis. Which of the following is the most appropriate therapy?
- Call the ophthalmology consult for an emergent corneal transplant.
- Prescribe a systemic analgesic for pain control and advise the patient to not wear her contact lenses for the next week.
- Prescribe ciprofloxacin eye drops, oral analgesia, update tetanus prophylaxis, and arrange for ophthalmology follow-up.
- Prescribe oral amoxicillin, a topical anesthetic, such as tetracaine, and have patient follow-up with an ophthalmologist.
- Prescribe ciprofloxacin eye drops and have patient strictly wear an eye patch until her pain resolves.
2. 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 On physical examination, you notice a patch of grouped vesicles on an ery- thematous base located in a dermatomal distribution on her scalp and fore- head. 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 exami- nation. Which of the following is the most concerning complication of this patient’s clinical presentation?
- Central nervous system (CNS) involvement leading to meningitis
- Ophthalmic involvement leading to anterior uveitis or corneal scarring
- Cardiac involvement leading to endocarditis
- Permanent scarring of her face
- Nasopalatine involvement leading to epistaxis
3. A 31-year-old nurse in your hospital has noticed a lesion in her left eye. She denies change in vision, pain, fevers, or A picture of her eye is shown below. Which of the following is the most likely diagnosis?
4. A 72-year-old man presents with right eye pain for 1 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 oph- thalmic medication. However, he does remember that the eye drop has a yellow cap. Which class of ophthalmic medication is the patient taking?
- Mydriatic/cycloplegic agent
5. A 35-year-old woman presents with a right-sided red eye for 3 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 examina- tion, 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?
- Gonococcal conjunctivitis
- Bacterial conjunctivitis
- Viral conjunctivitis
- Allergic conjunctivitis
- Pseudomonal conjunctivitis
6. A 24-year-old woman presents to the ED at 4 AM with severe left eye pain that woke her up from 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 visual- ized in the anterior chamber. What is the most appropriate treatment for this condition?
- Immediate ophthalmology consult
- Tobramycin ophthalmic ointment
- Erythromycin ophthalmic ointment
- Eye patch
- Proparacaine ophthalmic drops
7. A 45-year-old woman presents with right eye pain and redness for 1 She has photophobia and watery discharge from the eye. She does not wear glasses or contact lenses and has no prior eye problems. On examina- tion, 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 epi- thelial 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?
- Admission for intravenous (IV) antibiotics
- Admission for IV antiviral agents
- Topical steroids
- Topical antiviral medication
- Immediate ophthalmology consultation
8. A 21-year-old man presents to the ED with a red The patient complains of rhinorrhea and a nonproductive cough but has no eye pain or discharge. He also has no associated ecchymosis, bony tenderness of the orbit, or pain on extraocular eye movement. His vision is normal, extraocu- lar movements are intact, and intraocular pressure (IOP) is 12. A picture of his eye is shown below. What is the most appropriate management of this condition?
- Call ophthalmology immediately.
- Administer 1% atropine.
- Elevate patient’s head.
- Administer ophthalmic timolol.
- Reassurance only.
9. 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 He is complaining of extreme pain and tearing from his eye. Which of the fol- lowing is the most appropriate next step in management?
- Call ophthalmology now.
- Check visual acuity.
- Check the pH of the tears.
- Irrigate with normal saline.
- Apply erythromycin ointment.
10. A 45-year-old man lacerated his right forehead after an altercation in a local 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 open- ing his right eye. What is the most appropriate treatment of this patient?
- Call ophthalmology immediately.
- Wash eye with acetone.
- Wash eye with normal saline.
- Use forceps to remove all the glue from the eye.
- Apply erythromycin ointment.
11. The local sorority house recently installed a sun-tanning Two days later three sorority girls present to the ED with bilateral eye pain, tearing, and photophobia. After ophthalmic anesthesia instillation, a com- plete 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 examina- tion under cobalt blue light illuminates small dots throughout the cornea. What is the most likely diagnosis?
- Ultraviolet keratitis
- Anterior uveitis
- Herpes simplex keratitis
- Allergic conjunctivitis
- Corneal ulcer
12. A 12-year-old girl presents to the ED for left eye pain and swelling for 2 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?
- Administer diphenhydramine.
- Administer amoxicillin/clavulanate.
- Administer vancomycin IV.
- Perform computed tomographic (CT) scan of orbits and sinuses.
- Administer artificial tears.
13. A 60-year-old man with a history of hypertension and migraine head- aches presents to the ED with a 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 exami- nation 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?
- Administer hydromorphone.
- Perform head CT scan.
- Check IOP.
- Check erythrocyte sedimentation rate (ESR).
- Discharge patient.
14. A 22-year-old man presents to the ED for left eye 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 acu- ity is normal. On testing extraocular movements, you find he is unable to look upward with his left eye. He also complains of diplopia when look- ing upward. Funduscopic examination is normal. What is the most likely diagnosis?
- Orbital blowout fracture
- Ruptured globe
- Retinal detachment
- Cranial nerve III palsy
- Traumatic retrobulbar hematoma
15. You are examining the pupils of a 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?
- Argyll Robertson pupil
- Afferent pupillary defect
- Horner syndrome
- Normal pupil reaction
16. A 65-year-old man with a history of diabetes, hypertension, coronary artery disease, and atrial fibrillation presents with loss of vision in his left eye since he awoke 6 hours The patient denies fever, eye pain, or eye discharge. On physical examination of the left eye, vision is limited to counting fingers. His pupil is 3 mm and reactive. Extraocular movements are intact. Slit-lamp examination is also normal. The dilated funduscopic examination is shown below. Which of the following is the most likely diagnosis?
- Retinal detachment
- Central retinal artery occlusion
- Central retinal vein occlusion
- Vitreous hemorrhage
- Acute angle-closure glaucoma