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AK Khurana Comprehensive Ophthalmology toxic amblyopia epiphora orthophoria questions

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Short viva answers from A. K. Khurana - Comprehensive Ophthalmology

1. Causes of watering of eyes

Watering occurs due to either:

A. Hyperlacrimation - excessive tear secretion due to ocular irritation:

Conjunctivitis
Corneal foreign body, abrasion or ulcer
Keratitis
Anterior uveitis/iritis
Acute congestive glaucoma
Trichiasis, entropion
Dry eye, paradoxically causing reflex tearing
Allergy, smoke, dust, strong light, wind

B. Epiphora - defective drainage of normally secreted tears:

Punctal stenosis or eversion
Canalicular obstruction
Lacrimal sac disease, especially chronic dacryocystitis
Nasolacrimal duct obstruction
Facial nerve palsy causing defective lacrimal pump
Lid laxity or ectropion

2. Causes of red eye

Conjunctivitis
Keratitis/corneal ulcer
Anterior uveitis
Acute angle-closure glaucoma
Episcleritis
Scleritis
Subconjunctival haemorrhage
Trauma or foreign body
Chemical injury

Important painful red-eye conditions: keratitis, anterior uveitis, acute angle-closure glaucoma, and scleritis.

3. Causes of painful eye

Corneal abrasion, foreign body, keratitis or corneal ulcer
Acute anterior uveitis
Acute angle-closure glaucoma
Scleritis
Orbital cellulitis
Trauma and chemical injury
Optic neuritis, especially pain on eye movements

4. Hyperlacrimation

Definition: Excessive secretion of tears due to stimulation/irritation of the lacrimal gland.

Causes: conjunctivitis, keratitis, corneal foreign body, trichiasis, acute iritis, acute glaucoma, allergy, smoke, dust, and emotional crying.

5. Epiphora

Definition: Overflow of tears over the lid margin due to obstruction of the lacrimal drainage passages or failure of the lacrimal pump, despite normal tear secretion.

Causes:

Punctal stenosis
Canaliculitis/canalicular block
Chronic dacryocystitis
Nasolacrimal duct obstruction
Ectropion
Facial nerve palsy
Lid laxity in elderly persons

6. Types of discharge in conjunctivitis

Type of discharge	Common cause
Watery/serous	Viral conjunctivitis, allergic conjunctivitis
Mucoid/ropy	Allergic or vernal conjunctivitis
Mucopurulent	Bacterial conjunctivitis
Purulent/copious	Hyperacute gonococcal conjunctivitis
Membranous/pseudomembranous	Diphtheritic or adenoviral conjunctivitis

7. Why is wound healing delayed in diabetes mellitus?

Diabetes delays healing because of:

Microangiopathy causing reduced blood supply and tissue oxygenation
Impaired leukocyte chemotaxis and phagocytosis, causing increased infection
Reduced fibroblast proliferation and collagen formation
Poor glycaemic control and defective cellular metabolism
Associated neuropathy and malnutrition in some patients

Thus, diabetic patients have greater risk of postoperative infection and delayed wound healing.

8. Why is hypertension a contraindication/concern before eye surgery?

Uncontrolled hypertension is a relative contraindication for elective ocular surgery because it can cause:

Intraoperative and postoperative bleeding
Suprachoroidal haemorrhage during intraocular surgery
Retinal vascular events
Cardiovascular or cerebrovascular complications during surgery or anaesthesia
Marked fluctuation in blood pressure from anxiety or pain

Control blood pressure before elective cataract or other intraocular surgery.

9. Drugs causing macular toxicity and complaints

Important drugs:

Chloroquine
Hydroxychloroquine
Phenothiazines, especially thioridazine
Tamoxifen

In AK Khurana, the classic toxic maculopathies are chloroquine-induced and phenothiazine-induced maculopathy. Chloroquine/hydroxychloroquine can produce a bull's-eye maculopathy, as also described in the Wills Eye Manual extract.

Symptoms/complaints in chloroquine maculopathy:

Gradual painless diminution of vision
Difficulty in reading and near work
Blurring of central vision
Defective colour vision, particularly red-green
Central or paracentral scotoma
Glare and difficulty in dark adaptation

Fundus: Bull's-eye maculopathy in advanced disease.

10. Why is family history important in ophthalmology?

Family history helps identify hereditary and familial eye diseases, such as:

Primary open-angle glaucoma
Congenital glaucoma
Retinitis pigmentosa
Colour blindness
High myopia
Keratoconus
Congenital cataract
Strabismus and amblyopia
Retinoblastoma
Leber hereditary optic neuropathy

It is particularly important in glaucoma screening and inherited retinal diseases.

11. Chemical in tobacco causing toxic amblyopia

Cyanide is the toxic chemical in tobacco responsible for tobacco amblyopia.

Tobacco amblyopia, also called tobacco-alcohol amblyopia, causes papillomacular bundle involvement, bilateral central/centrocaecal scotoma, impaired colour vision, and gradual painless visual loss. The AK Khurana text identifies cyanide as the toxic agent. A current review similarly describes papillomacular bundle injury with central/cecocentral scotoma in tobacco-alcohol amblyopia.

12. Why is anaemia important in cataract surgery?

Anaemia is important because it:

Reduces oxygen delivery to tissues
Increases risk of perioperative hypoxia and cardiovascular stress
May delay postoperative wound healing
May be associated with poor nutritional status or systemic disease
Requires assessment and correction if severe before elective surgery

Cataract surgery is usually low blood-loss surgery, but significant anaemia should be evaluated and medically optimized, especially in elderly patients or those with cardiac disease.

13. Orthophoria

Orthophoria means normal ocular alignment.

It is the condition in which there is no manifest deviation and no latent deviation of the visual axes when binocular vision is interrupted. Both eyes remain aligned under normal binocular viewing conditions.

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