cd /home/daytona/workspace && python3 -c " from pypdf import PdfReader reader = PdfReader('/home/daytona/workspace/attachments/f1da7f1d-663a-4e8f-915a-8f8b7cb5f139/11. Opthalmology MRCP II Pastest 2023.pdf') print(f'Total pages: {len(reader.pages)}') # Print first 3 pages to understand structure for i in range(min(3, len(reader.pages))): print(f'\\n=== PAGE {i+1} ===') print(reader.pages[i].extract_text()[:2000]) "

cd /home/daytona/workspace && python3 -c " from pypdf import PdfReader reader = PdfReader('/home/daytona/workspace/attachments/f1da7f1d-663a-4e8f-915a-8f8b7cb5f139/11. Opthalmology MRCP II Pastest 2023.pdf') # Extract ALL text from all pages full_text = '' for i, page in enumerate(reader.pages): full_text += f'\n\n=== PAGE {i+1} ===\n' full_text += page.extract_text() or '' with open('/home/daytona/workspace/ophthal_raw.txt', 'w') as f: f.write(full_text) print(f'Extracted {len(full_text)} chars, {len(reader.pages)} pages') " 2>&1

cd /home/daytona/workspace && python3 << 'EOF' from pypdf import PdfReader import re reader = PdfReader('/home/daytona/workspace/attachments/f1da7f1d-663a-4e8f-915a-8f8b7cb5f139/11. Opthalmology MRCP II Pastest 2023.pdf') # Extract all text cleanly all_text = [] for i, page in enumerate(reader.pages): t = page.extract_text() or '' all_text.append(t) full = '\n'.join(all_text) # Write clean version with open('/home/daytona/workspace/ophthal_full.txt', 'w') as f: f.write(full) print(f"Total chars: {len(full)}") print(f"Total pages: {len(reader.pages)}") # Try to count questions by looking for question patterns q_patterns = re.findall(r'What is the (most likely|best|correct|most appropriate|next|first)', full, re.IGNORECASE) print(f"'What is the...' patterns: {len(q_patterns)}") # Look for answer indicators answers = re.findall(r'Your answer was (correct|incorrect)', full, re.IGNORECASE) print(f"Answer markers: {len(answers)}") EOF

cd /home/daytona/workspace && python3 << 'EOF' # Let's look at the structure more carefully - each question appears to span ~3 pages # Let's read chunks to understand question boundaries with open('/home/daytona/workspace/ophthal_full.txt', 'r') as f: text = f.read() # Split by page markers we can infer from URL patterns import re # Find question index patterns in URLs indices = re.findall(r'questionIndex=(\d+)', text) print(f"Question indices found: {sorted(set(int(x) for x in indices))[:30]}") print(f"Total unique indices: {len(set(indices))}") print(f"All unique: {sorted(set(int(x) for x in indices))}") EOF

cd /home/daytona/workspace && python3 << 'EOF' import re with open('/home/daytona/workspace/ophthal_full.txt', 'r') as f: text = f.read() # Split by questionIndex= patterns - each question starts with URL containing questionIndex # Questions are separated by these URL markers parts = re.split(r'(?=https://mypastest\.pastest\.com/qbank/\d+\?[^\n]+questionIndex=\d+#Top \d+/\d+)', text) print(f"Parts after split: {len(parts)}") # Look at how questions are structured - each question has 2 URL entries (page 1/2 and 2/2) # Let's group by question index question_blocks = {} for part in parts: m = re.search(r'questionIndex=(\d+)#Top (\d+)/(\d+)', part) if m: qidx = int(m.group(1)) page = int(m.group(2)) total = int(m.group(3)) if qidx not in question_blocks: question_blocks[qidx] = {} question_blocks[qidx][page] = part print(f"Questions found: {sorted(question_blocks.keys())}") print(f"Total questions: {len(question_blocks)}") # Merge pages for each question questions = {} for qidx in sorted(question_blocks.keys()): merged = '' for pg in sorted(question_blocks[qidx].keys()): merged += question_blocks[qidx][pg] questions[qidx] = merged # Save structured questions with open('/home/daytona/workspace/ophthal_questions.txt', 'w') as f: for qidx in sorted(questions.keys()): f.write(f"\n\n{'='*60}\nQUESTION {qidx}\n{'='*60}\n") f.write(questions[qidx]) print("Saved structured questions") # Show first question q1 = questions.get(2, questions.get(1, '')) print("\n--- SAMPLE QUESTION ---") print(q1[:1500]) EOF

You have access to the file /home/daytona/workspace/ophthal_questions.txt which contains 54 ophthalmology MCQs (MRCP II Pastest 2023) extracted from a PDF. Each question block starts with "QUESTION N" and contains the clinical vignette, answer options, the correct answer, and a detailed explanation. YOUR TASK: Read ALL question blocks from the file, analyze every MCQ, then generate a comprehensive topic-wise high-yield revision notes PDF using reportlab. ## STEP 1: Read the full questions file Read the file /home/daytona/workspace/ophthal_questions.txt in chunks (offset 0, 300, 600, 900, 1200, 1500, 1800, 2100, 2400, 2700, 3000 etc.) until you have read ALL content. There are roughly 3200 lines total. ## STEP 2: Identify all 54 questions and their topics Based on your reading, identify what topic each question tests. The questions cover these ophthalmology topics (you may discover more): - Questions 1: Episcleritis (IBD-related) - Questions 2: Giant Cell Arteritis / AION - Questions 3: Central Retinal Vein Occlusion - Questions 4: Glaucoma - Questions 5: Diabetic Retinopathy (pre-proliferative) - Questions 6: Age-related Macular Degeneration - Questions 7: Optic Neuritis / MS - Questions 8: Cataracts - Questions 9: Retinal Detachment - Questions 10: Retinitis Pigmentosa - Questions 11: Diabetic Maculopathy - Questions 12-58: various other ophthalmology topics ## STEP 3: Generate the PDF Write a Python script using reportlab to generate a PDF at /home/daytona/workspace/Ophthalmology_Revision_Notes.pdf ### PDF Requirements: - NO background colors anywhere (white background only - saves ink for printing) - ALL text must be black - Use ONLY bold, italic, or different font sizes to differentiate headings - Remove all excessive blank space - compact layout for minimal pages - Use bullet points, tables, and structure as specified below ### PDF Structure for EACH merged topic: **Topic Name** (large bold heading) **Merged Topics:** [one-line list of all questions/subtopics merged] - include all Q numbers **Questions:** Q1, Q5, Q12... (all question numbers under this topic) Then these exact sections: 1. **Stem Clues (High-yield presentation):** bullet list of classic vignette triggers, age/gender/symptoms 2. **Investigations (Key & Diagnostic):** key tests, gold standard, pathognomonic findings 3. **Treatment & Management:** first-line drugs/doses, stepwise management, surgical indications 4. **Specific Peculiarities & Red Flags:** unique pearls, pathognomonic signs, buzzwords, differentials 5. **Quick-Revision Memory Aids:** mnemonics, one-liner facts, high-yield numbers ### At the very end: - "MOST IMPORTANT TOPICS" section listing top 10-15 topics by MCQ frequency - A TABLE with two columns: "MCQ Number" | "Topic/Subtopic Number" - mapping every Q number to which topic section it appears in ### Topics to create (merged): **TOPIC 1: Episcleritis & Scleritis** Qs: 1 + any others about red eye inflammatory conditions from the file **TOPIC 2: Giant Cell Arteritis (GCA) & Anterior Ischaemic Optic Neuropathy (AION)** Qs: 2 + any others about GCA, temporal arteritis, AION **TOPIC 3: Retinal Vascular Occlusions** (Central Retinal Vein Occlusion, Branch RVO, Central Retinal Artery Occlusion, Branch RAO) Qs: 3 + any others **TOPIC 4: Glaucoma** (Open-angle, Closed-angle, Normal tension, Secondary) Qs: 4 + any others **TOPIC 5: Diabetic Retinopathy & Diabetic Eye Disease** (Background, Pre-proliferative, Proliferative, Maculopathy, Cataract in DM) Qs: 5, 11 + any others **TOPIC 6: Age-Related Macular Degeneration (AMD)** (Dry, Wet, Anti-VEGF) **TOPIC 7: Optic Nerve Disorders** (Optic Neuritis, Papilloedema, Optic Atrophy, NAION) **TOPIC 8: Uveitis & Inflammatory Eye Conditions** (Anterior Uveitis/Iritis, Posterior Uveitis, Panuveitis, associations with systemic disease) **TOPIC 9: Retinal Disorders** (Retinal Detachment, Retinitis Pigmentosa, Macular Hole, Epiretinal Membrane) **TOPIC 10: Cataracts** **TOPIC 11: Hypertensive Retinopathy** **TOPIC 12: Infections & External Eye** (Conjunctivitis - bacterial/viral/allergic, Keratitis, Herpes, Trachoma, Orbital Cellulitis) **TOPIC 13: Neuro-ophthalmology** (Horner syndrome, CN III/IV/VI palsies, Visual field defects, Internuclear ophthalmoplegia, Nystagmus) **TOPIC 14: Systemic Disease Eye Manifestations** (Sarcoidosis, Thyroid eye disease, Rheumatoid, SLE, Wilson's, etc.) **TOPIC 15: Drugs & Eye Toxicity** (Chloroquine/hydroxychloroquine, amiodarone, steroids, ethambutol, etc.) Assign each of the 54 questions to the most appropriate topic, and reference all Q numbers in each topic. ## STEP 4: Write the Python/reportlab script Here is a template to follow for the PDF generation: ```python from reportlab.lib.pagesizes import A4 from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import cm from reportlab.lib import colors from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable from reportlab.lib.enums import TA_LEFT, TA_CENTER doc = SimpleDocTemplate( '/home/daytona/workspace/Ophthalmology_Revision_Notes.pdf', pagesize=A4, rightMargin=1.5*cm, leftMargin=1.5*cm, topMargin=1.5*cm, bottomMargin=1.5*cm ) styles = getSampleStyleSheet() # Define custom styles - NO colors except black title_style = ParagraphStyle('title', fontSize=16, fontName='Helvetica-Bold', spaceAfter=4, spaceBefore=6, textColor=colors.black) topic_style = ParagraphStyle('topic', fontSize=13, fontName='Helvetica-Bold', spaceAfter=3, spaceBefore=8, textColor=colors.black) section_style = ParagraphStyle('section', fontSize=10, fontName='Helvetica-Bold', spaceAfter=2, spaceBefore=4, textColor=colors.black) body_style = ParagraphStyle('body', fontSize=8.5, fontName='Helvetica', spaceAfter=1, spaceBefore=1, textColor=colors.black, leading=11) bullet_style = ParagraphStyle('bullet', fontSize=8.5, fontName='Helvetica', spaceAfter=1, spaceBefore=0, leftIndent=12, textColor=colors.black, leading=11) merged_style = ParagraphStyle('merged', fontSize=8, fontName='Helvetica-Oblique', spaceAfter=2, spaceBefore=1, textColor=colors.black, leading=10) story = [] # ... build content doc.build(story) ``` Use `Paragraph("• bullet text", bullet_style)` for bullets. Use `HRFlowable(width="100%", thickness=0.5, color=colors.black)` as dividers between topics. Use `Spacer(1, 0.1*cm)` for minimal spacing only. For tables (like the MCQ mapping table at end), use: ```python data = [['MCQ Number', 'Topic/Section'], ['Q1', 'Topic 1: Episcleritis'], ...] t = Table(data, colWidths=[3*cm, 14*cm]) t.setStyle(TableStyle([ ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'), ('FONTSIZE', (0,0), (-1,-1), 8), ('GRID', (0,0), (-1,-1), 0.3, colors.black), ('BACKGROUND', (0,0), (-1,0), colors.white), ('TEXTCOLOR', (0,0), (-1,-1), colors.black), ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.white, colors.white]), ('TOPPADDING', (0,0), (-1,-1), 2), ('BOTTOMPADDING', (0,0), (-1,-1), 2), ])) ``` ## IMPORTANT CONTENT INSTRUCTIONS: - Every section must be data-rich and exam-focused - Include specific drug names and doses where relevant (e.g., prednisolone 40-60mg for GCA) - Include specific numerical values (e.g., IOP >21 mmHg for glaucoma, VA 6/60 etc.) - Keep bullets SHORT - max 10-12 words each - Include mnemonics where helpful - Make content based on what you actually read from the questions file ## EXECUTION: 1. Read the full questions file first 2. Write the complete Python script to /home/daytona/workspace/gen_ophthal_notes.py 3. Execute it with: python3 /home/daytona/workspace/gen_ophthal_notes.py 4. Verify the PDF was created 5. Return: confirmation that PDF was created at /home/daytona/workspace/Ophthalmology_Revision_Notes.pdf, along with a summary of all 54 Q numbers and which topic each was assigned to.

"QUESTION 23" in /home/daytona/workspace

"QUESTION 40" in /home/daytona/workspace

~/gen_ophthal_notes.py

cd /home/daytona/workspace && python3 gen_ophthal_notes.py 2>&1

ls -lh /home/daytona/workspace/Ophthalmology_Revision_Notes.pdf

wc -l /home/daytona/workspace/ophthal_questions.txt && echo "---" && python3 -c " with open('/home/daytona/workspace/ophthal_questions.txt') as f: lines = f.readlines() print(f'Total lines: {len(lines)}') # Find all QUESTION markers qs = [(i+1, l.strip()) for i,l in enumerate(lines) if l.strip().startswith('QUESTION ')] for q in qs: print(q) "

python3 -c " with open('/home/daytona/workspace/ophthal_questions.txt') as f: content = f.read() import re # Split into question blocks blocks = re.split(r'\n={60}\nQUESTION (\d+)\n={60}\n', content) # blocks[0] = header, then alternating: question_num, question_text questions = {} i = 1 while i < len(blocks)-1: qnum = blocks[i] qtext = blocks[i+1] questions[int(qnum)] = qtext i += 2 print(f'Total questions parsed: {len(questions)}') print(f'Question numbers: {sorted(questions.keys())}') # Print first ~60 lines of each question to identify topic for qn in sorted(questions.keys()): lines = questions[qn].split('\n') # Get first non-URL, non-empty lines (the stem) stem_lines = [] for l in lines: l = l.strip() if l and not l.startswith('http') and not l.startswith('8/19') and not l.startswith('Your answer'): stem_lines.append(l) if len(stem_lines) >= 5: break print(f'Q{qn}: {\" | \".join(stem_lines[:3])}') " 2>&1 | head -80

python3 -c " with open('/home/daytona/workspace/ophthal_questions.txt') as f: content = f.read() import re blocks = re.split(r'\n={60}\nQUESTION (\d+)\n={60}\n', content) questions = {} i = 1 while i < len(blocks)-1: qnum = blocks[i]; qtext = blocks[i+1] questions[int(qnum)] = qtext i += 2 # For each question print: correct answer + key topic label from explanation for qn in sorted(questions.keys()): txt = questions[qn] # Find correct answer - look for answer repeated at end of options section # Look for the topic label at end (appears as standalone line) lines = txt.split('\n') topic_label = '' correct = '' for l in lines: l2 = l.strip() if not l2: continue # Topic appears as a clean line before 'Media Expanded' or 'Flashcards' if l2 in ['Episcleritis','Giant Cell Arteritis','Glaucoma','Diabetic Retinopathy', 'Optic Neuritis','Cataracts','Retinitis Pigmentosa','Age-related Macular Degeneration', 'Uveitis','Papilloedema','Retinal Detachment','Hypertensive Retinopathy', 'Central Retinal Vein Occlusion','Central Retinal Artery Occlusion']: topic_label = l2 if 'Retinitis Pigmentosa' in l2 and len(l2) < 30: topic_label = 'Retinitis Pigmentosa' if 'Optic Neuritis' in l2 and len(l2) < 20: topic_label = 'Optic Neuritis' if 'Episcleritis' in l2 and len(l2) < 15: topic_label = 'Episcleritis' print(f'Q{qn}: topic_label={repr(topic_label)}') " 2>&1

python3 -c " with open('/home/daytona/workspace/ophthal_questions.txt') as f: content = f.read() import re blocks = re.split(r'\n={60}\nQUESTION (\d+)\n={60}\n', content) questions = {} i = 1 while i < len(blocks)-1: qnum = blocks[i]; qtext = blocks[i+1] questions[int(qnum)] = qtext i += 2 # Print full text of unlabelled questions to identify topics unlabelled = [2,3,4,7,17,18,21,22,25,27,29,34,35,36,37,39,43,44,45,46,47,49,50,51,52,55] for qn in unlabelled: txt = questions[qn] # Extract explanation section lines = txt.split('\n') exp_start = -1 for idx, l in enumerate(lines): if 'Explanation' in l: exp_start = idx; break if exp_start >= 0: exp_lines = [l.strip() for l in lines[exp_start:exp_start+15] if l.strip() and not l.strip().startswith('http') and not l.strip().startswith('8/19')] print(f'Q{qn}: {\" | \".join(exp_lines[:4])}') else: # look for correct answer ans_lines = [l.strip() for l in lines if 'correct' in l.lower() or 'incorrect' in l.lower()] print(f'Q{qn} (no Explanation): {\" | \".join(ans_lines[:3])}') " 2>&1

python3 -c " with open('/home/daytona/workspace/ophthal_questions.txt') as f: content = f.read() import re blocks = re.split(r'\n={60}\nQUESTION (\d+)\n={60}\n', content) questions = {} i = 1 while i < len(blocks)-1: questions[int(blocks[i])] = blocks[i+1] i += 2 # Print remaining unlabelled: Q3, Q4, Q21, Q35, Q37, Q44, Q47 for qn in [3, 4, 21, 35, 37, 44, 47, 52]: txt = questions[qn] lines = [l.strip() for l in txt.split('\n') if l.strip() and not l.startswith('http') and not l.startswith('8/19') and not l.startswith('Rate')] print(f'\\nQ{qn}:') # Print key lines - options and explanations for l in lines[:30]: print(' ', l) "

cat > /home/daytona/workspace/gen_ophthal_notes.py << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import cm, mm from reportlab.lib import colors from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, KeepTogether from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY PAGE_W, PAGE_H = A4 doc = SimpleDocTemplate( '/home/daytona/workspace/Ophthalmology_Revision_Notes.pdf', pagesize=A4, rightMargin=1.2*cm, leftMargin=1.2*cm, topMargin=1.2*cm, bottomMargin=1.2*cm, title="Ophthalmology MRCP II - High-Yield Revision Notes" ) BLK = colors.black WHT = colors.white def sty(name, size, bold=False, italic=False, spaceB=2, spaceA=1, indent=0, leading=None): fn = 'Helvetica' if bold and italic: fn = 'Helvetica-BoldOblique' elif bold: fn = 'Helvetica-Bold' elif italic: fn = 'Helvetica-Oblique' return ParagraphStyle(name, fontSize=size, fontName=fn, spaceBefore=spaceB, spaceAfter=spaceA, leftIndent=indent, textColor=BLK, leading=leading or (size*1.25)) T_MAIN = sty('tmain', 15, bold=True, spaceB=6, spaceA=2) T_HEAD = sty('thead', 11, bold=True, spaceB=5, spaceA=1) T_SEC = sty('tsec', 9, bold=True, spaceB=3, spaceA=1) T_MERGE = sty('tmerge', 7.5, italic=True, spaceB=1, spaceA=1) T_BODY = sty('tbody', 8.2, spaceB=0, spaceA=0, leading=10.5) T_BULL = sty('tbull', 8.2, spaceB=0, spaceA=0, indent=10, leading=10.5) T_WARN = sty('twarn', 8.2, bold=True, spaceB=0, spaceA=0, indent=10, leading=10.5) T_CTR = sty('tctr', 13, bold=True, spaceB=4, spaceA=2) T_CTR.alignment = TA_CENTER def HR(): return HRFlowable(width="100%", thickness=0.5, color=BLK, spaceAfter=2, spaceBefore=2) def SP(h=0.08): return Spacer(1, h*cm) def H1(txt): return Paragraph(txt, T_MAIN) def H2(txt): return Paragraph(txt, T_HEAD) def H3(txt): return Paragraph(txt, T_SEC) def merged(txt): return Paragraph(f"<i>Merged Topics: {txt}</i>", T_MERGE) def qnums(txt): return Paragraph(f"<b>Questions:</b> {txt}", T_MERGE) def body(txt): return Paragraph(txt, T_BODY) def bull(txt, bold=False): if bold: return Paragraph(f"• <b>{txt}</b>", T_BULL) return Paragraph(f"• {txt}", T_BULL) def warnbull(txt): return Paragraph(f"<b>⚠ {txt}</b>", T_WARN) def section_block(label, bullets, warn_bullets=None): items = [H3(label)] for b in bullets: items.append(bull(b)) if warn_bullets: for w in warn_bullets: items.append(warnbull(w)) return items def mini_table(headers, rows, col_widths=None): data = [headers] + rows if col_widths is None: n = len(headers) w = (PAGE_W - 2.4*cm) / n col_widths = [w]*n t = Table(data, colWidths=col_widths) t.setStyle(TableStyle([ ('FONTNAME', (0,0),(-1,0), 'Helvetica-Bold'), ('FONTNAME', (0,1),(-1,-1), 'Helvetica'), ('FONTSIZE', (0,0),(-1,-1), 7.5), ('TEXTCOLOR', (0,0),(-1,-1), BLK), ('BACKGROUND', (0,0),(-1,-1), WHT), ('GRID', (0,0),(-1,-1), 0.3, BLK), ('TOPPADDING', (0,0),(-1,-1), 1.5), ('BOTTOMPADDING',(0,0),(-1,-1), 1.5), ('LEFTPADDING', (0,0),(-1,-1), 3), ('VALIGN', (0,0),(-1,-1), 'TOP'), ])) return t story = [] # ============================================================ # COVER / TITLE # ============================================================ story.append(SP(1)) story.append(Paragraph("<b>OPHTHALMOLOGY</b>", T_CTR)) story.append(Paragraph("MRCP II Pastest 2023 - Topic-wise High-Yield Revision Notes", sty('sub',10, spaceB=2, spaceA=4))) story[-1].style.alignment = TA_CENTER story.append(Paragraph("54 MCQs | 15 Merged Topics | Exam-Oriented | Print-Ready", sty('sub2',8.5, italic=True, spaceB=2,spaceA=2))) story[-1].style.alignment = TA_CENTER story.append(HR()) # ============================================================ # TOPIC 1: EPISCLERITIS & SCLERITIS # ============================================================ story += [HR(), H1("TOPIC 1: Episcleritis & Scleritis")] story.append(merged("Episcleritis, Scleritis, Red Eye in IBD, Inflammatory Bowel Disease ocular manifestations")) story.append(qnums("Q1, Q19, Q20")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Young adult, bilateral/unilateral RED EYE, NO purulent discharge", "History of IBD (Crohn's/UC), psoriatic arthritis, RA, ankylosing spondylitis", "Pain + grittiness; previous similar episode resolved with artificial tears", "Scleritis: SEVERE boring/aching pain, worse at night, reduced VA, scleral nodules", "Episcleritis: milder, self-limiting, NO vision loss, superficial redness", "Classic: 'recurrent bilateral red eye in IBD patient - no discharge'", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Clinical diagnosis - slit-lamp examination key", "Phenylephrine test: episcleritis blanches (vessels), scleritis does NOT blanch", "Investigations for underlying cause: ANA, ANCA, RF, ESR, CRP, urate", "Scleritis: USS B-scan to assess posterior scleritis", ]) story += section_block("Treatment & Management", [ "Episcleritis 1st episode: artificial tears / NSAIDs topical", "Episcleritis recurrent/resistant: <b>topical corticosteroids</b> (preferred over oral NSAIDs when IBD)", "Resistant episcleritis: oral NSAIDs (naproxen) - BUT avoid if IBD", "Severe/resistant: oral prednisolone", "Scleritis: systemic NSAIDs → systemic steroids → immunosuppressants (methotrexate)", "Treat underlying systemic disease", ]) story += section_block("Specific Peculiarities & Red Flags", [ "IBD → episcleritis (NOT scleritis usually) - activity may parallel gut disease", "In IBD: prefer TOPICAL therapy over oral NSAIDs (GI risk)", "Episcleritis vs Conjunctivitis: no discharge, no follicles, sectoral redness", "Scleritis can cause scleral perforation - urgent ophthalmology referral", "Necrotising scleritis = most severe; associated with RA, Wegener's (GPA)", "KEY: No antibiotic needed (chloramphenicol wrong here)", ]) story += section_block("Quick-Revision Memory Aids", [ "IBD eye complications: Episcleritis, Uveitis (anterior), Scleritis", "Epi-scleritis = superficial = Epi(mild) = eye drops work", "SCLERITIS = Severe, Can cause Leakage, Erythema (deep), Red flag, Intense pain, Treat Systemically", "Numbers: episcleritis - 30% IBD patients; scleritis - 33% have systemic disease", ]) story.append(HR()) # ============================================================ # TOPIC 2: GIANT CELL ARTERITIS, AION, BRANCH RETINAL ARTERY OCCLUSION (GCA-related) # ============================================================ story += [H1("TOPIC 2: Giant Cell Arteritis (GCA) & Ischaemic Optic Neuropathy")] story.append(merged("GCA, Temporal Arteritis, Anterior Ischaemic Optic Neuropathy (AION), Polymyalgia Rheumatica, Branch Retinal Artery Occlusion (GCA-related)")) story.append(qnums("Q2, Q44")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Age >50 (almost exclusively), female > male (3:1)", "PMR history + incomplete headache control on low-dose steroids", "Sudden unilateral vision loss on waking, NO pain, chalky white disc", "Temporal headache, jaw claudication, scalp tenderness, tender temporal artery", "Q2: PMR on prednisolone 2.5mg → left eye VA 6/36, pale fundus, disc swelling", "Q44: Age 75, temporal headaches, tender temporal arteries, upper field loss → Branch RAO", "AION fundus: pale oedematous (chalky white) optic disc, NO cherry-red spot", ]) story += section_block("Investigations (Key & Diagnostic)", [ "ESR >50 mm/hr (key investigation - Q44), CRP elevated", "Temporal artery biopsy: GOLD STANDARD - skip lesions, do NOT delay treatment", "FBC: normocytic anaemia, raised platelets", "In patients >50 with BRAO + temporal headaches → ESR is first-line investigation", "PET-CT: for large vessel vasculitis assessment", ]) story += section_block("Treatment & Management", [ "START STEROIDS IMMEDIATELY - do not wait for biopsy result", "AION/Visual loss: IV methylprednisolone 500mg-1g/day x3 days → oral pred 1mg/kg", "No visual symptoms: oral prednisolone 40-60mg/day", "Biopsy within 2 weeks (skip lesions mean negative biopsy doesn't exclude)", "Long-term: slow steroid taper over 1-2 years, add PPI + bisphosphonate", "Aspirin 75mg: added to prevent stroke/MI in GCA", "Tocilizumab (IL-6 inhibitor): steroid-sparing agent in GCA", ]) story += section_block("Specific Peculiarities & Red Flags", [ "50% of GCA patients develop visual symptoms; AION is commonest cause of visual loss", "GCA-AION: chalky white disc (posterior ciliary artery ischaemia) - NO cherry red spot", "CRAO: pale retina + CHERRY RED SPOT at macula (central artery)", "BRAO in >50 + headache: think GCA → ESR first; in <50: think thrombophilia → thrombophilia screen", "Bilateral blindness can occur within days if untreated", "Never: misdiagnose as CRVO (haemorrhages, cotton-wool spots would be present in CRVO)", ]) story += section_block("Quick-Revision Memory Aids", [ "GCA TRIAD: Temporal headache + Jaw claudication + Visual loss", "JAW claudication = pathognomonic buzzword for GCA in MCQs", "ESR in GCA typically >50, often >100 mm/hr", "PMR + eye symptoms = GCA until proven otherwise", "Biopsy: 'treat first, biopsy later' - steroids don't affect biopsy for 2 weeks", ]) story.append(HR()) # ============================================================ # TOPIC 3: RETINAL VASCULAR OCCLUSIONS # ============================================================ story += [H1("TOPIC 3: Retinal Vascular Occlusions")] story.append(merged("Central Retinal Vein Occlusion (CRVO), Branch Retinal Vein Occlusion (BRVO), Central Retinal Artery Occlusion (CRAO), Branch Retinal Artery Occlusion (BRAO), Thrombophilia-related ocular events")) story.append(qnums("Q3, Q43, Q47, Q50, Q51, Q52, Q55")) story.append(SP()) story += [H3("Comparison Table")] story.append(mini_table( ['Feature', 'CRVO', 'BRVO', 'CRAO', 'BRAO'], [ ['Pain', 'No', 'No', 'No', 'No'], ['Visual loss', 'Sudden, severe central', 'Sectoral upper/lower field', 'Sudden TOTAL monocular', 'Sectoral field loss'], ['Fundus', '4-quadrant flame haem, disc swelling, CWS', 'Sectoral flame haem', 'Pale retina, cherry-red spot macula', 'Pale wedge of retina'], ['APD', 'May be present', 'No', 'Present', 'Absent/mild'], ['RF', 'HTN, DM, thrombophilia', 'HTN, DM, thrombophilia', 'AF, carotid emboli, GCA (>50)', 'Emboli, GCA (>50), thrombophilia (<50)'], ['Treatment', 'Anti-VEGF intravitreal, laser; treat HTN', 'Anti-VEGF/laser if macula involved', 'No proven Rx; ocular massage, carbogen', 'Treat cause; ESR if >50'], ], col_widths=[2.8*cm, 4.2*cm, 3.5*cm, 3.5*cm, 3.3*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q3: DM + HTN, sudden upper field loss, 4-quadrant haemorrhages, disc swelling → CRVO", "Q43: AF + HTN, sudden monocular vision loss, cherry-red spot → CRAO", "Q47/Q55: Young woman, DVT history, upper field loss → BRVO + thrombophilia", "Q51: Sudden painless visual loss, extensive flame haemorrhages, recurrent miscarriages → CRVO + thrombophilia (APS)", "Q52: HTN, progressive visual loss, widespread haemorrhages → CRVO", "Q50: Glaucoma + DM, sudden painless visual loss, cherry red spot → CRAO", "Valsalva (exercise, straining) can precipitate BRVO", ]) story += section_block("Investigations (Key & Diagnostic)", [ "FBC, ESR, CRP, lipids, glucose, HbA1c, BP measurement", "Thrombophilia screen (in young patients or recurrent events): Factor V Leiden, protein C/S, antithrombin III, lupus anticoagulant, anti-cardiolipin Ab (APS), homocysteine", "CRVO: Fluorescein angiography - gold standard to classify ischaemic vs non-ischaemic", "CRAO: Urgent carotid Doppler (emboli), Echo (cardiac source), ECG (AF)", "OCT: assess macular oedema in CRVO/BRVO", "Age >50 with BRAO + headache: ESR (GCA); Age <50: thrombophilia screen", ]) story += section_block("Treatment & Management", [ "CRVO: Anti-VEGF intravitreal injections (ranibizumab, bevacizumab) for macular oedema", "CRVO: Laser photocoagulation for neovascularisation", "CRAO (Q43, Q50): No proven treatment; ocular massage, anterior chamber paracentesis, carbogen (95% O2 + 5% CO2), immediate ophthalmology referral", "BRVO + thrombophilia (Q47, Q55): <b>Warfarin</b> long-term (antiplatelet drugs ineffective for venous thrombosis)", "CRVO + APS (Q51): Thrombophilia screen → anticoagulation if positive", "Treat underlying HTN, DM, hyperlipidaemia", "Q55: Warfarin over aspirin/clopidogrel for thrombophilia-related BRVO", ]) story += section_block("Specific Peculiarities & Red Flags", [ "CRVO fundus: 'storm-cloud' or 'blood and thunder' - all 4 quadrants haemorrhages", "CRAO: cherry-red spot = fovea appears red against pale ischaemic retina (fovea has no inner layers)", "CRAO + AF → cardiac emboli; CRAO + age >50 headache → GCA (ESR)", "Young patient + venous occlusion = thrombophilia until proven otherwise", "APS: recurrent miscarriages + DVT + ocular venous occlusion", "BRVO vs CRVO: BRVO = sectoral (one quadrant), CRVO = all 4 quadrants", "Triamcinolone (intravitreal): treats macular oedema but NOT future thrombosis", ]) story += section_block("Quick-Revision Memory Aids", [ "CRVO = like 4-quadrant storm (all haemorrhages everywhere)", "CRAO = Cherry Red; Artery = Atheroembolism", "DVT + young + ocular venous occlusion = thrombophilia → Warfarin", "AF + sudden monocular loss = CRAO (embolic)", "Anti-VEGF for CRVO macular oedema; Warfarin for thrombophilia-BRVO", ]) story.append(HR()) # ============================================================ # TOPIC 4: GLAUCOMA # ============================================================ story += [H1("TOPIC 4: Glaucoma")] story.append(merged("Acute Angle Closure Glaucoma (AACG), Primary Open Angle Glaucoma (POAG), Normal Tension Glaucoma, Secondary Glaucoma, Onchocerciasis (river blindness)")) story.append(qnums("Q8, Q12, Q13, Q28, Q30, Q39, Q57")) story.append(SP()) story += [H3("Comparison Table: AACG vs POAG")] story.append(mini_table( ['Feature', 'Acute Angle Closure (AACG)', 'Primary Open Angle (POAG)'], [ ['Onset', 'Acute, dramatic', 'Chronic, insidious'], ['Pain', 'SEVERE (headache, nausea, vomiting)', 'None'], ['IOP', '>21 mmHg (often >50)', '>21 mmHg (gradual)'], ['Pupil', 'Fixed, mid-dilated, oval', 'Normal initially'], ['Cornea', 'Cloudy/steamy', 'Normal'], ['Visual fields', 'Sudden loss', 'Peripheral loss first (arcuate scotoma)'], ['Risk factors', 'Hypermetropia, Asian/female, dark rooms, mydriatics', 'Myopia, FH, Black race, age, DM, steroid use'], ['Treatment', 'Pilocarpine drops + IV acetazolamide + laser iridotomy', 'Topical prostaglandins (latanoprost) 1st line'], ], col_widths=[3.5*cm, 8*cm, 6.2*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q8: Chinese woman, severe nausea/vomiting admitted under surgeons, progressive RIGHT eye visual loss at night → AACG", "Q12: Severe right eye pain 3h, coloured halos, headache, unilateral, left unaffected → AACG", "Q13: Right orbital pain evenings while reading, halos around lights, resolves in bed → AACG (subacute)", "Q28: Asian woman, sudden headache leaving cinema (dark→light), altered vision, vomiting, fixed dilated pupil → AACG", "Q30: Eye pain + vision loss driving through DARK TUNNEL → AACG triggered by mydriasis", "Q39: Tall thin young man, learning disability, marfanoid → Homocystinuria → lens dislocation → secondary glaucoma", "Q57: Elderly man with glaucoma + DM on CCU → drug interactions with glaucoma treatment", "Coloured halos around lights = pathognomonic buzzword for AACG", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Tonometry: IOP (normal <21 mmHg; AACG often >50 mmHg)", "Gonioscopy: GOLD STANDARD to classify open vs closed angle", "Slit-lamp: corneal oedema, shallow anterior chamber", "Visual field testing (Humphrey): arcuate scotoma, nasal step in POAG", "OCT: retinal nerve fibre layer (RNFL) thinning in POAG", "Optic disc: cup:disc ratio >0.6 suspicious; disc haemorrhages, notching", ]) story += section_block("Treatment & Management", [ "AACG Emergency: Pilocarpine 4% (miotic - opens drainage angle) + IV/oral acetazolamide + topical beta-blocker (timolol) + IV mannitol", "Definitive AACG: Laser peripheral iridotomy (bilateral - prevents fellow eye AACG)", "POAG 1st line: Prostaglandin analogues (latanoprost, bimatoprost once daily PM)", "POAG alternatives: beta-blockers (timolol), CAIs (dorzolamide), alpha-2 agonists (brimonidine)", "Target IOP: reduce by ≥30% from baseline", "Surgical: Trabeculectomy for uncontrolled POAG", "Normal tension glaucoma: treat as POAG; exclude GCA, carotid disease", ]) story += section_block("Specific Peculiarities & Red Flags", [ "AACG precipitants: DARK rooms, emotional stress, mydriatic drops, anticholinergic drugs", "Misdiagnosed as: migraine, acute abdomen (nausea/vomiting), meningitis", "Q8: Surgeons thought bowel obstruction - classic AACG masquerade as GI emergency", "Drugs causing mydriasis → AACG: anticholinergics, antidepressants (TCAs), antihistamines", "Homocystinuria (Q39): lens dislocates DOWNWARD (vs Marfan: lens dislocates UP)", "Normal tension glaucoma: IOP normal (<21) but optic nerve damage occurs", "Charles Bonnet syndrome (Q33): elderly glaucoma patient - visual hallucinations (well-formed) with poor vision - NOT psychiatric", ]) story += section_block("Quick-Revision Memory Aids", [ "AACG = Acute, Asian, Acute pain, halos Around lights", "Pilocarpine = Pupil constriction = opens angle", "AACG trigger: 'left the cinema (dark)' - classic MCQ phrase", "Latanoprost = 1st line POAG = once daily at night = brown iris pigmentation SE", "POAG screen: IOP + disc + visual fields (all 3 needed)", "Lens dislocation: DOWN = Homocystinuria; UP = Marfan/Weill-Marchesani", ]) story.append(HR()) # ============================================================ # TOPIC 5: DIABETIC RETINOPATHY & DIABETIC EYE DISEASE # ============================================================ story += [H1("TOPIC 5: Diabetic Retinopathy & Diabetic Eye Disease")] story.append(merged("Background DR, Pre-proliferative DR, Proliferative DR, Diabetic Maculopathy, Cataract in DM, Vitreous haemorrhage, Rubeosis iridis")) story.append(qnums("Q5, Q6, Q11, Q24, Q26, Q56, Q58")) story.append(SP()) story += [H3("Staging of Diabetic Retinopathy")] story.append(mini_table( ['Stage', 'Features', 'Action'], [ ['Background (mild NPDR)', 'Microaneurysms, dot haemorrhages', 'Annual review'], ['Moderate NPDR', 'Blot haem, hard exudates, CWS', '6-monthly review'], ['Pre-proliferative (severe NPDR)', 'CWS, IRMA, venous beading/looping, large blot haem', 'Urgent ophthalmology referral'], ['Proliferative DR (PDR)', 'New vessels (disc NVD, elsewhere NVE), vitreous haem, TRD', 'Urgent: Pan-retinal photocoagulation (PRP)'], ['Maculopathy', 'Hard exudates/oedema/ischaemia at macula; VA loss', 'Anti-VEGF intravitreal injections'], ], col_widths=[3.5*cm, 8*cm, 6.2*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q5: 65yo Asian woman, DM, HbA1c raised, bilateral VA loss improving with pinhole (refractive) + nuclear sclerosis + pre-proliferative features on fundus", "Q6: Poor DM compliance, HbA1c 65 mmol/mol, sudden worsening VA → DM maculopathy", "Q11: 54yo T2DM 11yr, difficulty reading, gradual onset, obese smoker → DM maculopathy", "Q24: Poorly controlled DM, floaters + decreased vision, PDR + macular oedema + extensive new vessels", "Q26: T1DM 40yr, HbA1c 69, BP 155/90, blurring right eye → proliferative DR", "Q56: T2DM 11yr, difficulty reading → maculopathy (as Q11)", "Q58: T1DM 8yr, insulin-dependent, annual review → screening", "VA improving to 6/9 with pinhole = refractive/lens opacity (cataract), NOT maculopathy", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Fundal photography: UK screening method (optometrist/optician based)", "Fluorescein angiography: GOLD STANDARD for DR staging; shows microaneurysms, capillary non-perfusion, leakage", "OCT: measures macular oedema precisely", "HbA1c, BP, lipids, renal function (assess DM control and systemic risk)", "Pinhole test: VA improvement with pinhole → refractive error / cataract (NOT retinal)", ]) story += section_block("Treatment & Management", [ "Pre-proliferative: Urgent ophthalmology referral, optimise glycaemic/BP control", "PDR (Q24): Pan-retinal photocoagulation (PRP) = laser ablation of peripheral retina", "PDR + macular oedema (Q24): Anti-VEGF intravitreal injections (ranibizumab, bevacizumab, aflibercept)", "Intravitreal triamcinolone: macular oedema (2nd line, steroid SE: cataract, IOP rise)", "Maculopathy 1st line: Anti-VEGF injections", "Vitreous haemorrhage: vitrectomy", "Systemic: tight glycaemic control (HbA1c <53 mmol/mol), BP <130/80, statin, ACEI", "Screening: Annual retinal photos for ALL diabetics", ]) story += section_block("Specific Peculiarities & Red Flags", [ "CWS (cotton wool spots) = retinal ischaemia = neovascularisation stimulus → proliferative", "Hard exudates near macula = REFER (lipid-laden macrophages = maculopathy risk)", "Any VA loss in DM = maculopathy until proven otherwise → immediate ophthalmology", "IRMA = intraretinal microvascular abnormalities = pre-proliferative feature", "Rapid improvement in glycaemic control can WORSEN retinopathy short-term", "Hypertriglyceridaemia → lipaemia retinalis (milky vessels) - only when very high", "Rubeosis iridis (iris new vessels) → neovascular glaucoma", ]) story += section_block("Quick-Revision Memory Aids", [ "MICRO to MACRO: Microaneurysms → Haemorrhages → Exudates → CWS → New vessels", "PRP for PDR; Anti-VEGF for maculopathy", "4-2-1 rule (Pre-proliferative): >4 quadrant blot haem, >2 quadrant venous beading, >1 quadrant IRMA", "Pinhole improves VA = cataract/refractive (NOT maculopathy which doesn't improve)", "Floaters + DM = vitreous haemorrhage from new vessels → URGENT", ]) story.append(HR()) # ============================================================ # TOPIC 6: HYPERTENSIVE RETINOPATHY # ============================================================ story += [H1("TOPIC 6: Hypertensive Retinopathy")] story.append(merged("Hypertensive Retinopathy grades 1-4, Keith-Wagener-Barker classification, Malignant hypertension, Polycystic kidney disease, Papilloedema in hypertension")) story.append(qnums("Q17, Q21, Q22, Q35")) story.append(SP()) story += [H3("Keith-Wagener-Barker Grading")] story.append(mini_table( ['Grade', 'Features', 'Clinical significance'], [ ['1', 'Silver wiring of arterioles (thickened walls)', 'Hypertension, low risk'], ['2', 'AV nipping (arteriovenous compression)', 'Significant HTN'], ['3', 'CWS, flame haemorrhages, hard exudates', 'Severe HTN, end-organ damage'], ['4', 'Grade 3 + DISC OEDEMA (papilloedema)', 'Malignant/accelerated hypertension - EMERGENCY'], ], col_widths=[1.8*cm, 9*cm, 6.9*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q17: Reduced vision noticed while taking photo, APD, disc oedema + CWS + A-V nipping + flame haem → Grade 4", "Q21: 32yo, severe headache, BP 190/110, bilateral flank masses (PKD), retinal photo shows grade 4", "Q22: Severe frontal headache + N&V building over week, markedly raised BP → Grade 4, malignant HTN", "Q35: As Q17 (same presentation) - grade 4 HTN retinopathy - next step = BP measurement", "Grade 4 = optic disc oedema = malignant hypertension = medical emergency", "Macula star = hard exudates radiating from fovea in spoke pattern", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Fundoscopy: grade the retinopathy", "BP measurement: FIRST priority (Q35)", "Urinalysis + renal function: end-organ damage", "ECG + Echo: LVH, cardiac involvement", "CXR: pulmonary oedema", "Renal USS + renin/aldosterone: secondary causes", "Q21: bilateral renal masses + family history → ADPKD", ]) story += section_block("Treatment & Management", [ "Grade 1-3: oral antihypertensives, treat gradually", "Grade 4/Malignant HTN (Q21, Q22): IV therapy - sodium nitroprusside OR labetalol (titratable)", "PKD + HTN (Q21): ACE inhibitors are mainstay for long-term; IV for acute control", "Target: reduce BP gradually (not too fast - risk of watershed infarcts)", "Target: reduce diastolic to ~100 mmHg over first hour, then more slowly", "Investigate for secondary causes of HTN", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Grade 4 retinopathy = disc oedema = malignant HTN → IV antihypertensive URGENT", "Macula star = pathognomonic of grade 3/4 hypertensive retinopathy", "Q35: Next investigation = BP measurement (not fluorescein angiography)", "PKD: bilateral renal masses + family history of renal failure + HTN = ADPKD", "Do NOT reduce BP too rapidly - cerebral autoregulation failure can cause blindness", "Differentials of disc oedema: papilloedema (bilateral), AION (unilateral, pale disc), malignant HTN", ]) story += section_block("Quick-Revision Memory Aids", [ "1-2-3-4: Arteriolar narrowing, AV nipping, CWS + haem, disc oedema", "Grade 4 = 4 things: grade3 features + disc oedema", "Macula STAR = hard exudates at fovea in star pattern = Grade 3/4", "IV labetolol/nitroprusside = malignant HTN management", "PKD: bilateral cystic kidneys + subarachnoid haemorrhage + liver cysts + mitral valve prolapse", ]) story.append(HR()) # ============================================================ # TOPIC 7: OPTIC NEURITIS & DEMYELINATING DISEASE # ============================================================ story += [H1("TOPIC 7: Optic Neuritis & Demyelinating Disease")] story.append(merged("Optic Neuritis, Multiple Sclerosis, Neuromyelitis Optica (NMO/Devic), Transverse Myelitis, Optic atrophy, Internuclear ophthalmoplegia")) story.append(qnums("Q9, Q15, Q34, Q38, Q48, Q53, Q54")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Young adult (20-40), female predominance", "Q9: 26yo, pain behind right eye INCREASED ON MOVEMENT, blur + colour vision loss, RAPD, VA 6/18", "Q15: 24yo, ataxic gait + vestibular dysfunction + vision loss over 18 months → MS (relapsing-remitting)", "Q34: Painful eye movements + colour desaturation + lower limb weakness + MRI 4 vertebral level enhancement → NMO", "Q38: 21yo, left eye pain on movement + blurring, 1-week history → optic neuritis", "Q48: 25yo, sudden severe RIGHT eye pain watching TV (at rest, NOT on movement) → consider other diagnosis", "Q53, Q54: Young woman, rapid colour vision + VA deterioration + ataxia → optic neuritis in MS", "CLASSIC: unilateral, painful (PAIN ON EYE MOVEMENT), loss of colour vision (red desaturation), central scotoma, RAPD", ]) story += section_block("Investigations (Key & Diagnostic)", [ "MRI brain + spine: periventricular white matter lesions (Dawson's fingers - perpendicular to ventricles)", "Visual evoked potentials (VEP): delayed P100 wave = demyelination (gold standard for optic neuritis)", "OCT: RNFL thinning after optic neuritis", "CSF: oligoclonal bands (OCBs) in MS (90%), mild pleocytosis", "NMO: aquaporin-4 antibody (AQP4-IgG) positive, MRI shows extensive spinal cord lesion (≥3 vertebral levels)", "MRI criteria: McDonald criteria for MS diagnosis", ]) story += section_block("Treatment & Management", [ "Optic neuritis: IV methylprednisolone 1g/day x3 days (speeds recovery, doesn't change final outcome)", "Long-term recovery: 90% recover vision in 6 months", "MS first presentation (CIS): disease-modifying therapy (interferon-beta, glatiramer acetate)", "Relapsing-remitting MS: natalizumab, fingolimod, alemtuzumab", "NMO (Q34): Avoid beta-interferon (can worsen); use azathioprine or rituximab", "Optic neuritis + normal MRI: low risk of MS; Optic neuritis + periventricular lesions: 60-70% develop MS", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Pain ON EYE MOVEMENT = optic neuritis (distinguishes from AION where pain absent)", "Red/colour desaturation = earliest symptom of optic neuritis", "RAPD (relative afferent pupillary defect) = Marcus Gunn pupil = optic nerve lesion", "Uhthoff's phenomenon: worsening symptoms with heat/exercise (MS-specific)", "Q34: 4-vertebral-level MRI enhancement = NMO (not MS - MS lesions are shorter)", "Internuclear ophthalmoplegia (INO) = bilateral = MS; unilateral = brainstem stroke", "LHON (Leber hereditary optic neuropathy): bilateral, painless, young male, maternal inheritance", ]) story += section_block("Quick-Revision Memory Aids", [ "Optic Neuritis: PAIN on movement + Red desaturation + RAPD + young female", "Dawson's fingers = MS lesions perpendicular to corpus callosum", "OCBs in CSF: 90-95% MS; also in neurosarcoid, neurosyphilis", "NMO: AQP4 positive + bilateral optic neuritis + transverse myelitis (long segment)", "McDonald criteria: dissemination in TIME and SPACE", "Swinging flashlight test → RAPD in optic neuritis", ]) story.append(HR()) # ============================================================ # TOPIC 8: PAPILLOEDEMA & IDIOPATHIC INTRACRANIAL HYPERTENSION (IIH) # ============================================================ story += [H1("TOPIC 8: Papilloedema & Idiopathic Intracranial Hypertension (IIH)")] story.append(merged("Papilloedema, Raised Intracranial Pressure, Idiopathic Intracranial Hypertension (IIH), Benign Intracranial Hypertension, Pseudotumour cerebri")) story.append(qnums("Q14, Q31")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q14: 35yo woman, worsening headaches 3 months, worse in morning/lying flat/coughing (positional), transient visual blurring, no PMH → IIH", "Q31: 27yo woman on OCP, morning headaches worse on straining, blurred vision / colour loss → IIH", "Classic IIH profile: obese young woman, OCP use, bilateral disc swelling, headache", "BILATERAL disc swelling = papilloedema (vs unilateral = AION, optic neuritis)", "Transient visual obscurations (TVOs): brief bilateral visual loss seconds on postural change", "Pulsatile tinnitus: classic IIH symptom", "Peripheral visual field constriction, enlarged blind spot", ]) story += section_block("Investigations (Key & Diagnostic)", [ "MRI/CT brain: FIRST to exclude space-occupying lesion/venous sinus thrombosis", "MRI findings of IIH: empty sella, flattened posterior globe, tortuous optic nerve sheaths", "Lumbar puncture: opening pressure >25 cmH2O (GOLD STANDARD for IIH)", "CSF: normal composition in IIH", "Cerebral venous sinus thrombosis: MRI venogram", "Visual field perimetry: serial monitoring to assess optic nerve damage", ]) story += section_block("Treatment & Management", [ "Weight loss: most effective treatment (10% body weight → significant improvement)", "Acetazolamide: 1st line pharmacotherapy (carbonic anhydrase inhibitor → reduces CSF production)", "Stop OCP if implicated", "Serial lumbar punctures (therapeutic - temporary relief)", "Topiramate: 2nd line (also aids weight loss)", "Optic nerve sheath fenestration: to protect vision if failing", "CSF shunting (LP shunt or VP shunt): for severe/refractory cases", ]) story += section_block("Specific Peculiarities & Red Flags", [ "IIH = bilateral disc swelling + raised ICP + normal CSF + normal brain imaging", "OCP is a known cause of IIH (Q31)", "Papilloedema is BILATERAL (vs unilateral disc swelling in AION, optic neuritis)", "Visual acuity initially preserved in papilloedema (unlike AION where lost early)", "Risk of permanent visual loss if untreated - optic atrophy", "TVOs = transient visual obscurations = classic papilloedema symptom", ]) story += section_block("Quick-Revision Memory Aids", [ "IIH = obese young woman + OCP + bilateral disc swelling + headache", "3Bs of IIH: Bilateral disc swelling, Bilateral headache, Bilateral TVOs", "Acetazolamide = Reduces CSF production = 1st line", "LP opening pressure >25 cmH2O = raised ICP diagnostic", "ALWAYS exclude SOL with MRI BEFORE LP", ]) story.append(HR()) # ============================================================ # TOPIC 9: HEREDITARY RETINAL DYSTROPHIES # ============================================================ story += [H1("TOPIC 9: Hereditary Retinal Dystrophies")] story.append(merged("Retinitis Pigmentosa (RP), Malattia Leventinese, Autosomal Dominant Drusen, Alport Syndrome, Cone-rod dystrophies, Inherited macular dystrophies")) story.append(qnums("Q10, Q25, Q27, Q32, Q36 (Trachoma - see Topic 13), Q7 (Alport)")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q10: 19yo woman, peripheral field loss noticed while driving (mother spotted), on OCP → Retinitis Pigmentosa", "Q25: 22yo man, night vision deterioration 6 months, family blind (mother, uncle, cousin) → Malattia Leventinese", "Q27: 18yo woman, central vision difficulty + night vision loss, father blind at 46 → Malattia Leventinese", "Q32: 23yo woman, decreased peripheral vision worse at night, 12 months, no FH → RP", "Classic RP: 'bone spicule' pigmentation fundus + attenuated vessels + disc pallor + night blindness (nyctalopia) + peripheral field loss", "RP: can be associated with deafness (Usher syndrome)", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Electroretinogram (ERG): reduced/absent signals in RP (most sensitive test)", "Visual field: ring scotoma (concentric peripheral field loss) in RP", "Fundoscopy: bone-spicule pigmentation, attenuated vessels, waxy disc pallor", "OCT: drusen (raised deposits under RPE) in malattia leventinese", "Genetic testing: mutations in PRPH2 gene (malattia leventinese/DHRD)", "Audiometry: if Usher syndrome suspected (RP + deafness)", ]) story += section_block("Treatment & Management", [ "Retinitis Pigmentosa: NO curative treatment", "Low-vision aids: magnifiers, dark adaptation aids, reading devices", "Vitamin A palmitate: modest slowing of RP progression (evidence limited)", "Malattia Leventinese/Drusen: NO proven treatment; low-vision aids", "Monitor for choroidal neovascularisation (wet AMD-like complication)", "Genetic counselling for family members", "Q25, Q27: most appropriate intervention = provision of low-vision aids", ]) story += section_block("Specific Peculiarities & Red Flags", [ "RP associations: Usher syndrome (RP + sensorineural deafness), Refsum disease (RP + cerebellar ataxia + neuropathy + phytanic acid), Lawrence-Moon-Biedl/Bardet-Biedl, Kearns-Sayre", "Malattia leventinese = AUTOSOMAL DOMINANT drusen = multiple drusen on fundus", "RP inheritance: X-linked recessive most severe, also AR and AD forms", "Q10: OCP use - differential was CRVO (correct answer: RP based on fundus features)", "Bone spicules = pathognomonic fundus sign for RP", "Night blindness (nyctalopia) = FIRST symptom of RP", "Alport syndrome (Q7): sensorineural deafness + haematuria + ESRD + anterior lenticonus", ]) story += section_block("Quick-Revision Memory Aids", [ "RP mnemonic: RAPS - Rod cells affected first, Attenuated vessels, Pigment (bone spicules), Scotoma (peripheral)", "Night blindness first → peripheral field loss → tunnel vision → blindness", "Malattia = Many drusen = autosomal DOMINANT = family history of blindness", "RP + Deafness = Usher; RP + Cerebellar = Refsum; RP + Obesity + Polydactyly = Bardet-Biedl", "ERG = most sensitive test for RP", ]) story.append(HR()) # ============================================================ # TOPIC 10: CATARACTS # ============================================================ story += [H1("TOPIC 10: Cataracts")] story.append(merged("Age-related cataracts, Cataracts in systemic disease, Hypoparathyroidism cataracts, Diabetic cataracts, Drug-induced cataracts, Nuclear sclerosis")) story.append(qnums("Q5 (nuclear sclerosis in DM), Q37 (hypoparathyroidism cataract)")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q37: 25yo woman, deteriorating vision + muscle weakness + tetany + post-partum thyroiditis (autoimmune) → Hypoparathyroidism → Cataract", "Q5: 65yo, VA improving with pinhole → nuclear sclerosis cataract", "Gradual painless visual loss; VA improves with PINHOLE (refractive element)", "Glare, reduced contrast, myopic shift (nuclear), monocular diplopia", "Hypoparathyroid cataract: radial/stellate pattern, subcapsular", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Slit-lamp: type and density of lens opacity", "Pinhole test: improvement = refractive/cataract (NOT macular disease)", "Q37: calcium (low), phosphate (high), PTH (low/inappropriately normal) = hypoparathyroidism", "Hypoparathyroid: post-parathyroid surgery, autoimmune (post-partum thyroiditis), DiGeorge", ]) story += section_block("Treatment & Management", [ "Cataract: surgical extraction (phacoemulsification) + IOL implantation", "Hypoparathyroid cataract (Q37): Calcium + Vitamin D (calcitrol or alfacalcidol)", "NOT calcitriol requires no renal activation vs cholecalciferol (requires 1α-hydroxylation)", "DM cataract: control blood sugar; surgical when symptomatic", "Steroid-induced cataracts: posterior subcapsular - occur even with topical steroids", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Hypoparathyroidism → cataract (radial pattern) due to hypocalcaemia + hyperphosphataemia", "Diabetic cataract: 'snowflake' cataract (young T1DM) or premature nuclear sclerosis", "Steroid cataracts: posterior subcapsular; associated with inhaled and topical steroids", "VA improving with pinhole = cataract/refractive error (NOT maculopathy which does NOT improve)", "Calcitrol/alfacalcidol for hypoparathyroid: bypasses renal 1α-hydroxylation step", "Myotonic dystrophy: Christmas tree cataracts + ptosis + frontal balding", ]) story += section_block("Quick-Revision Memory Aids", [ "Pinhole improves VA = CATARACT; Pinhole doesn't improve VA = RETINAL/MACULAR disease", "Hypoparathyroid: LOW Ca, HIGH Phosphate, LOW PTH → treat with Calcitrol (NOT plain vit D)", "Cataract causes: Age, DM, Steroid, Trauma, UV, Hypoparathyroid, Wilson's (sunflower), Myotonic dystrophy", "Post-partum thyroiditis → autoimmune hypoparathyroidism → cataract", ]) story.append(HR()) # ============================================================ # TOPIC 11: AGE-RELATED MACULAR DEGENERATION (AMD) # ============================================================ story += [H1("TOPIC 11: Age-Related Macular Degeneration (AMD)")] story.append(merged("Dry AMD, Wet AMD, Drusen, Geographic atrophy, Anti-VEGF therapy, Choroidal neovascularisation, Malattia leventinese (hereditary drusen AMD)")) story.append(qnums("Q45, Q49")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q45: 74yo man, poor VA, drusen + geographic atrophy on fundus, progressive distance + reading difficulty → Dry AMD", "Q49: 70yo man, seeing 'lines' in vision (metamorphopsia) getting worse 3 weeks, HTN + DM, drusen → Dry AMD", "Dry AMD: gradual central vision loss (scotomas), metamorphopsia, drusen", "Wet AMD: sudden/rapid central vision loss, metamorphopsia, subretinal fluid/haemorrhage", "Central vision loss, reading difficulty, straight lines appear wavy (Amsler grid)", ]) story += section_block("Investigations (Key & Diagnostic)", [ "OCT: GOLD STANDARD - detects drusen, geographic atrophy, subretinal fluid (wet AMD)", "Fundoscopy: drusen (yellow deposits under RPE), geographic atrophy", "Fluorescein angiography: choroidal neovascularisation in wet AMD", "Amsler grid: metamorphopsia screening (wavy lines = wet AMD)", "Q45: OCT = initial diagnosis + severity assessment", ]) story += section_block("Treatment & Management", [ "Dry AMD: NO effective treatment; AREDS supplements (vitamins C/E, zinc, lutein)", "Dry AMD (Q45, Q49): Low-vision aids (most appropriate intervention)", "Wet AMD: Anti-VEGF intravitreal injections (ranibizumab, bevacizumab, aflibercept) - monthly initially", "Wet AMD: Photodynamic therapy (verteporfin) - 2nd line", "Smoking cessation reduces progression", "Monitor fellow eye closely for conversion to wet AMD", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Drusen = hallmark of AMD; soft drusen = higher risk wet AMD conversion", "Metamorphopsia (wavy lines) = neovascularisation → urgent referral", "Geographic atrophy = advanced dry AMD = irreversible central vision loss", "Anti-VEGF injections transform wet AMD prognosis (previously untreatable)", "AREDS supplements: vitamin C, vitamin E, beta-carotene (NOT smokers - lung cancer risk), zinc", "Q45: drusen + geographic atrophy = DRY AMD (not wet - no haemorrhage, no urgency for anti-VEGF)", ]) story += section_block("Quick-Revision Memory Aids", [ "DRY AMD: Drusen, Gradual loss, Geographic atrophy - NO treatment", "WET AMD: Wavy lines + Rapid loss + anti-VEGF works", "Amsler grid: wavy = WET AMD", "Anti-VEGF: ranibizumab (MARINA trial), bevacizumab, aflibercept", "AREDS: vitamins for dry AMD (no beta-carotene in smokers)", ]) story.append(HR()) # ============================================================ # TOPIC 12: UVEITIS # ============================================================ story += [H1("TOPIC 12: Uveitis & Intraocular Inflammation")] story.append(merged("Anterior Uveitis (Iritis/Iridocyclitis), Posterior Uveitis, Toxoplasma Chorioretinitis, Reactive Arthritis, HLA-B27-associated uveitis, IBD uveitis")) story.append(qnums("Q16, Q29")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q16: 34yo man, RED eye, intense dull aching pain in eye + orbital area, blurred vision, VA 6/24, sore throat + bilateral swollen knees/ankles + shin rash (erythema nodosum) → Reactive arthritis → Anterior Uveitis", "Q29: 18yo man working in boarding kennels (cat/dog), right eye pain + hazy blurred vision weeks, fundus shows chorioretinitis + vitritis → Toxoplasma gondii", "Anterior uveitis: red eye, PHOTOPHOBIA, PAIN, circumcorneal flush, keratic precipitates, hypopyon", "Posterior uveitis: floaters, visual loss, minimal external signs", "Toxoplasmosis: focal 'headlight in fog' lesion with adjacent old scar", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Slit-lamp: anterior chamber cells + flare, keratic precipitates (KPs), posterior synechiae", "HLA-B27: positive in ankylosing spondylitis, Reiter's/reactive arthritis, IBD, psoriatic arthritis", "Toxoplasma IgG/IgM serology", "ACE level + CXR: sarcoidosis", "VDRL/TPHA: syphilis", "FTA-ABS, Lyme serology, TB Mantoux/IGRA: as appropriate", "Q16: first episode → investigate for underlying systemic disease", ]) story += section_block("Treatment & Management", [ "Anterior uveitis (Q16): Topical corticosteroids + mydriatic drops (cyclopentolate/atropine - prevent posterior synechiae)", "Urgent ophthalmology within 24 hours for slit-lamp diagnosis", "Recurrent uveitis with HLA-B27: treat underlying systemic disease", "Toxoplasmosis (Q29): Pyrimethamine + sulphadiazine + folinic acid (classic triple therapy)", "Alternatively: co-trimoxazole (trimethoprim/sulphamethoxazole) ± prednisolone", "Posterior uveitis: systemic/periocular/intravitreal steroids", "Sarcoid uveitis: systemic corticosteroids ± methotrexate", ]) story += section_block("Specific Peculiarities & Red Flags", [ "HLA-B27 associations: Ankylosing Spondylitis, Reactive Arthritis (Reiter), IBD, Psoriasis = 'SARA' (Spondyloarthropathies Associated with Reactive Arthritis)", "Toxocara vs Toxoplasma: Toxocara = white pupil (leukocoria) + retinal fibrosis in children; Toxoplasma = focal chorioretinitis + vitritis ('headlight in fog')", "Q16: reactive arthritis = urethritis + arthritis + conjunctivitis/uveitis (can't see, can't pee, can't climb a tree)", "Q29: animal handlers → Toxoplasma (from cat faeces), BUT also consider Toxocara from dog kennel", "Posterior synechiae = iris adherent to lens → irregular pupil → secondary glaucoma", "Keratic precipitates (KPs): mutton-fat KPs = granulomatous (sarcoid, TB, syphilis)", ]) story += section_block("Quick-Revision Memory Aids", [ "Uveitis + HLA-B27 = Spondyloarthropathy (AS, ReA, IBD, Psoriasis)", "Reactive Arthritis triad: Can't see (uveitis), Can't pee (urethritis), Can't climb a tree (arthritis)", "Toxoplasma: cat/farm exposure + focal chorioretinitis + 'headlight in fog'", "Anterior uveitis Rx: Steroid drops + Mydriatic (dilates pupil, prevents synechiae)", "Mutton-fat KPs = GRANULOMATOUS uveitis (sarcoid, TB)", ]) story.append(HR()) # ============================================================ # TOPIC 13: INFECTIONS & EXTERNAL EYE # ============================================================ story += [H1("TOPIC 13: Infections & External Eye Disease")] story.append(merged("Onchocerciasis (River Blindness), Trachoma (Chlamydia trachomatis), Toxoplasma chorioretinitis, Corneal arcus, Familial hypercholesterolaemia")) story.append(qnums("Q4, Q18, Q36, Q46")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q4: 45yo man from Zimbabwe, visual impairment, on Ivermectin, dry thick depigmented skin (leopard skin), raised WCC + CRP, chest X-ray changes → Onchocerca volvulus", "Q18: 77yo woman, eye appearance (corneal arcus), no CVD history, normal lipids → Arcus senilis (age-related, NOT familial hypercholesterolaemia at age 77)", "Q36: 54yo woman from Iraq, progressive blindness + family history of blindness + son showing early signs → Trachoma (Chlamydia trachomatis)", "Q46: 26yo man, corneal arcus + family history of early death, tendon xanthomas → Familial Hypercholesterolaemia", "Trachoma: endemic Middle East/Africa; trichiasis → corneal opacification → blindness", "Onchocerciasis: simulium blackfly, nodules, skin changes, corneal opacities", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Onchocerciasis (Q4): skin snip biopsy → microfilariae (gold standard); Mazzotti test", "Trachoma: clinical diagnosis; Giemsa stain shows inclusion bodies; PCR for C. trachomatis", "Arcus senilis (Q18): lipid profile (to exclude FH); BUT at age >50 arcus is age-related", "FH (Q46): fasting lipids → total cholesterol >7.5 mmol/L (heterozygous FH); LDL-receptor gene mutation", "FH: Frank's sign (earlobe crease), tendon xanthomas (Achilles, extensor tendons), xanthelasma", ]) story += section_block("Treatment & Management", [ "Onchocerciasis: Ivermectin (macrolide antiparasitic, annual dose, kills microfilariae; NOT adult worms) - Q4 was already being treated", "Trachoma: azithromycin (SAFE protocol: Surgery, Antibiotics, Facial cleanliness, Environmental improvement)", "Trachoma surgery: eyelid surgery (trichiasis correction) before corneal scarring", "Arcus senilis: reassurance if age >50 with normal lipids (Q18)", "FH (Q46): high-intensity statin + dietary modification; consider PCSK9 inhibitors", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Onchocerciasis: 'river blindness' = Simulium blackfly near fast-flowing rivers in Africa/Yemen", "Ivermectin kills microfilariae but NOT adult worms (need doxycycline for wolbachia endosymbiont)", "Trachoma: from mother to child, lichenification → scarring → corneal opacification", "Arcus senilis vs corneal arcus: same thing; significance depends on AGE - <50 → screen for FH", "FH: corneal arcus + xanthelasma + tendon xanthoma + premature CVD (Frank's sign = earlobe crease)", "Trachoma: leading cause of PREVENTABLE blindness WORLDWIDE", ]) story += section_block("Quick-Revision Memory Aids", [ "Onchocerciasis = Africa + river + black fly + skin nodules + corneal opacity → Ivermectin", "Trachoma = SAFE strategy; Azithromycin; Middle East/Africa endemic", "Arcus senilis <50 = screen for FH; >50 = normal ageing", "FH: Frank's sign + Tendon Xanthomas + Corneal Arcus = Familial Hypercholesterolaemia", "Trachoma stages: Follicles → Scarring → Entropion/Trichiasis → Corneal blindness", ]) story.append(HR()) # ============================================================ # TOPIC 14: SYSTEMIC & METABOLIC EYE MANIFESTATIONS # ============================================================ story += [H1("TOPIC 14: Systemic & Metabolic Eye Manifestations")] story.append(merged("Alport Syndrome, Homocystinuria, Hypoparathyroidism, Polycystic Kidney Disease, Charles Bonnet Syndrome, Sarcoidosis eye manifestations")) story.append(qnums("Q7, Q33, Q37 (see Topic 10), Q39")) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q7: 30yo man, haematuria + sensorineural deafness → ESRD (Alport syndrome) - ocular: anterior lenticonus, RP (rare), macular changes", "Q33: 72yo man, bilateral glaucoma, visual hallucinations (colours, patterns, birds, buildings) → Charles Bonnet Syndrome", "Q39: 25yo, marfanoid habitus, learning disability, tall/thin, kyphoscoliosis, arm fracture → Homocystinuria", "Charles Bonnet: elderly patient with POOR VISION → well-formed visual hallucinations (NOT psychosis)", "Homocystinuria: downward lens dislocation, marfanoid, intellectual disability, DVT risk, osteoporosis", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Alport: X-linked dominant; gene mutation COL4A3/4/5 (type IV collagen); electron microscopy glomerular basement membrane", "Homocystinuria (Q39): elevated plasma homocysteine, cystathionine beta-synthase deficiency, autosomal recessive", "Charles Bonnet: clinical diagnosis - rule out psychosis, ensure no primary psychiatric disorder", "Glaucoma check: IOP, optic disc, visual fields", ]) story += section_block("Treatment & Management", [ "Alport: ACE inhibitors/ARBs to slow renal progression; renal transplant for ESRD", "Homocystinuria: high-dose pyridoxine (B6) in responsive cases; dietary methionine restriction + cysteine supplementation; anticoagulation for thrombotic risk", "Charles Bonnet (Q33): reassurance - explain hallucinations due to visual deprivation; treat underlying visual impairment if possible; rarely: SSRIs, cholinesterase inhibitors", "Hypoparathyroidism: calcium + calcitrol/alfacalcidol (see Topic 10)", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Alport: X-linked dominant (most common), autosomal recessive; anterior lenticonus = pathognomonic (oil droplet appearance)", "Homocystinuria lens dislocation: INFERIOR/NASAL (vs Marfan: SUPERIOR/TEMPORAL)", "Homocystinuria: DVT + PE risk → anticoagulation if surgery", "Charles Bonnet: NOT psychosis - patient KNOWS hallucinations are NOT REAL (insight preserved)", "Charles Bonnet trigger: any cause of significant visual loss (AMD, glaucoma, cataract, RP)", "Cystathionine beta-synthase deficiency = homocystinuria (methionine → homocysteine blocked)", ]) story += section_block("Quick-Revision Memory Aids", [ "Alport = 3As: collagen type IV (A3/A4/A5), sensorineural Auditory loss, Anterior lenticonus", "Homocystinuria vs Marfan: 'DOWN in Homocystinuria, UP in Marfan' (lens dislocation direction)", "Charles Bonnet: 'BEAUTIFUL hallucinations in the BLIND' - insight preserved", "Pyridoxine (B6) responsive homocystinuria = treat with high-dose B6", "Homocystinuria: recurrent DVT + marfanoid + learning difficulties + ectopia lentis downward", ]) story.append(HR()) # ============================================================ # TOPIC 15: DRUGS & EYE TOXICITY # ============================================================ story += [H1("TOPIC 15: Drugs Causing Ocular Toxicity")] story.append(merged("Drug-induced eye changes, Ethambutol, Hydroxychloroquine/Chloroquine, Amiodarone, Steroids, Tamoxifen, Vigabatrin, Sildenafil")) story.append(qnums("(Embedded throughout - Q24 anti-VEGF, Q37 steroid cataract, Q24 triamcinolone)")) story.append(SP()) story.append(mini_table( ['Drug', 'Ocular Toxicity', 'Monitoring/Notes'], [ ['Hydroxychloroquine', 'Bull\'s eye maculopathy → irreversible vision loss', 'Annual VF + OCT; safe dose <5mg/kg/day'], ['Chloroquine', 'Bull\'s eye maculopathy (earlier than HCQ)', 'Annual monitoring; avoid if renal impairment'], ['Ethambutol', 'Optic neuropathy → colour vision loss → VA loss', 'Baseline VEP; monthly VF; stop if colour changes'], ['Amiodarone', 'Corneal microdeposits (vortex keratopathy), optic neuropathy', 'Usually benign; rarely vision-threatening'], ['Steroids', 'Posterior subcapsular cataract, raised IOP/glaucoma', 'Even inhaled/topical; monitor IOP'], ['Vigabatrin', 'Irreversible peripheral visual field loss', 'Baseline + 6-monthly VF; irreversible'], ['Tamoxifen', 'Retinopathy, macular oedema, crystalline deposits', 'Baseline retinal exam; OCT monitoring'], ['Sildenafil (PDE5i)', 'Transient blue-green colour vision changes, NAION (rare)', 'Avoid in NAION; blue tinge at high doses'], ['Isotretinoin', 'Night blindness, dry eyes, corneal opacities', 'Monitor; reversible on stopping'], ['Quinine', 'Toxic retinopathy (overdose), ERG changes', 'Therapeutic doses generally safe'], ], col_widths=[3.8*cm, 7*cm, 6.9*cm] )) story.append(SP()) story += section_block("Quick-Revision Memory Aids", [ "Bull's eye maculopathy = Chloroquine/Hydroxychloroquine", "Vortex keratopathy = Amiodarone (whorl pattern corneal deposits)", "Ethambutol = STOP if colour vision changes (early warning sign)", "Vigabatrin = irreversible peripheral VF loss (don't miss baseline VF)", "Posterior subcapsular cataract = Steroids (even topical/inhaled)", ]) story.append(HR()) # ============================================================ # MOST IMPORTANT TOPICS SUMMARY # ============================================================ story += [H1("MOST IMPORTANT TOPICS - Summary (Top 15 by MCQ Frequency)")] story.append(SP()) story.append(mini_table( ['Rank', 'Topic', 'Q Count', 'Question Numbers'], [ ['1', 'Diabetic Retinopathy & Eye Disease', '7', 'Q5, Q6, Q11, Q24, Q26, Q56, Q58'], ['2', 'Glaucoma (AACG + POAG)', '7', 'Q8, Q12, Q13, Q28, Q30, Q39, Q57'], ['3', 'Retinal Vascular Occlusions', '7', 'Q3, Q43, Q47, Q50, Q51, Q52, Q55'], ['4', 'Optic Neuritis & Demyelination', '7', 'Q9, Q15, Q34, Q38, Q48, Q53, Q54'], ['5', 'Hypertensive Retinopathy', '4', 'Q17, Q21, Q22, Q35'], ['6', 'Hereditary Retinal Dystrophies (RP)', '4', 'Q10, Q25, Q27, Q32'], ['7', 'Episcleritis & Scleritis', '3', 'Q1, Q19, Q20'], ['8', 'Uveitis & Intraocular Inflammation', '2', 'Q16, Q29'], ['9', 'Giant Cell Arteritis & AION', '2', 'Q2, Q44'], ['10', 'Papilloedema & IIH', '2', 'Q14, Q31'], ['11', 'AMD (Dry & Wet)', '2', 'Q45, Q49'], ['12', 'Cataracts (Systemic Causes)', '2', 'Q5, Q37'], ['13', 'Infections (Trachoma, Onchocerciasis)', '3', 'Q4, Q36, Q29'], ['14', 'Systemic Manifestations (Alport, CBH, Homocystinuria)', '3', 'Q7, Q33, Q39'], ['15', 'Corneal Arcus & Familial Hypercholesterolaemia', '2', 'Q18, Q46'], ], col_widths=[1.2*cm, 7.5*cm, 1.8*cm, 7.2*cm] )) story.append(HR()) # ============================================================ # MCQ TO TOPIC MAPPING TABLE # ============================================================ story += [H1("MCQ Number to Topic Mapping Table")] story.append(body("Every MCQ number mapped to its topic section for quick cross-reference.")) story.append(SP(0.15)) story.append(mini_table( ['MCQ No.', 'Topic Section & Subtopic'], [ ['Q1', 'Topic 1: Episcleritis & Scleritis - Episcleritis in IBD, topical corticosteroids'], ['Q2', 'Topic 2: GCA & AION - Polymyalgia rheumatica + GCA + AION'], ['Q3', 'Topic 3: Retinal Vascular Occlusions - CRVO (DM + HTN)'], ['Q4', 'Topic 13: Infections - Onchocerciasis (river blindness, Ivermectin)'], ['Q5', 'Topic 5: Diabetic Retinopathy - Pre-proliferative DR + nuclear sclerosis (pinhole)'], ['Q6', 'Topic 5: Diabetic Retinopathy - Diabetic maculopathy (poor compliance)'], ['Q7', 'Topic 14: Systemic - Alport Syndrome (haematuria + deafness + ESRD)'], ['Q8', 'Topic 4: Glaucoma - Acute Angle Closure (Chinese woman, surgical ward)'], ['Q9', 'Topic 7: Optic Neuritis - Optic neuritis (pain on movement, RAPD)'], ['Q10', 'Topic 9: Hereditary Retinal Dystrophies - Retinitis Pigmentosa (peripheral field loss)'], ['Q11', 'Topic 5: Diabetic Retinopathy - Diabetic maculopathy (difficulty reading)'], ['Q12', 'Topic 4: Glaucoma - Acute Angle Closure (severe eye pain, coloured halos)'], ['Q13', 'Topic 4: Glaucoma - Subacute AACG (evening pain, halos, resolves in bed)'], ['Q14', 'Topic 8: Papilloedema & IIH - IIH (young woman, morning headaches)'], ['Q15', 'Topic 7: Optic Neuritis - Multiple sclerosis (ataxia + deafness + vision loss)'], ['Q16', 'Topic 12: Uveitis - Anterior uveitis in reactive arthritis (HLA-B27)'], ['Q17', 'Topic 6: Hypertensive Retinopathy - Grade 4 (APD, disc oedema, fundus photo)'], ['Q18', 'Topic 13: Infections/Corneal - Arcus senilis (77yo, normal lipids)'], ['Q19', 'Topic 1: Episcleritis - Episcleritis in IBD inpatient'], ['Q20', 'Topic 1: Episcleritis - Episcleritis acute red eye in IBD'], ['Q21', 'Topic 6: Hypertensive Retinopathy - Grade 4 + PKD (bilateral renal masses)'], ['Q22', 'Topic 6: Hypertensive Retinopathy - Grade 4, malignant HTN management (IV)'], ['Q24', 'Topic 5: Diabetic Retinopathy - Proliferative DR + macular oedema (anti-VEGF + PRP)'], ['Q25', 'Topic 9: Hereditary Retinal Dystrophies - Malattia leventinese (AD drusen, low vision aids)'], ['Q26', 'Topic 5: Diabetic Retinopathy - T1DM 40yr, blurring, HbA1c 69'], ['Q27', 'Topic 9: Hereditary Retinal Dystrophies - Malattia leventinese (18yo, central + night vision)'], ['Q28', 'Topic 4: Glaucoma - Acute Angle Closure (Asian woman, cinema, fixed dilated pupil)'], ['Q29', 'Topic 12: Uveitis - Toxoplasma chorioretinitis (animal handler, focal chorioretinitis)'], ['Q30', 'Topic 4: Glaucoma - Acute Angle Closure (dark tunnel trigger)'], ['Q31', 'Topic 8: Papilloedema & IIH - IIH (young woman, OCP)'], ['Q32', 'Topic 9: Hereditary Retinal Dystrophies - Retinitis Pigmentosa (peripheral night vision loss)'], ['Q33', 'Topic 14: Systemic - Charles Bonnet Syndrome (glaucoma + visual hallucinations)'], ['Q34', 'Topic 7: Optic Neuritis - Neuromyelitis optica / optic neuritis + transverse myelitis'], ['Q35', 'Topic 6: Hypertensive Retinopathy - Grade 4 (next step = BP measurement)'], ['Q36', 'Topic 13: Infections - Trachoma (Chlamydia trachomatis, Iraq, maternal transmission)'], ['Q37', 'Topic 10: Cataracts - Hypoparathyroidism cataract (Ca+VitD = calcitrol)'], ['Q38', 'Topic 7: Optic Neuritis - Optic neuritis (left eye pain on movement, blurring)'], ['Q39', 'Topic 4: Glaucoma / Topic 14: Systemic - Homocystinuria (marfanoid + lens dislocation)'], ['Q43', 'Topic 3: Retinal Vascular Occlusions - CRAO (AF + sudden monocular loss, cherry-red spot)'], ['Q44', 'Topic 2: GCA - Branch retinal artery occlusion in GCA (temporal headaches, ESR)'], ['Q45', 'Topic 11: AMD - Dry AMD (drusen + geographic atrophy, low vision aids)'], ['Q46', 'Topic 13: Systemic/Cornea - Familial hypercholesterolaemia (corneal arcus + FH)'], ['Q47', 'Topic 3: Retinal Vascular Occlusions - BRVO + thrombophilia (DVT hx, warfarin)'], ['Q48', 'Topic 7: Optic Neuritis - Optic neuritis (sudden eye pain at rest)'], ['Q49', 'Topic 11: AMD - Dry AMD (metamorphopsia/lines, drusen)'], ['Q50', 'Topic 3: Retinal Vascular Occlusions - CRAO (glaucoma + DM, sudden painless loss)'], ['Q51', 'Topic 3: Retinal Vascular Occlusions - CRVO + APS/thrombophilia (recurrent miscarriages)'], ['Q52', 'Topic 3: Retinal Vascular Occlusions - CRVO (HTN, widespread haemorrhages)'], ['Q53', 'Topic 7: Optic Neuritis - Optic neuritis + MS (rapid VA deterioration + colour loss)'], ['Q54', 'Topic 7: Optic Neuritis - Optic neuritis in MS (colour vision + ataxia)'], ['Q55', 'Topic 3: Retinal Vascular Occlusions - BRVO + thrombophilia (DVT, upper field loss)'], ['Q56', 'Topic 5: Diabetic Retinopathy - Diabetic maculopathy (T2DM, difficulty reading)'], ['Q57', 'Topic 4: Glaucoma - Glaucoma management in CCU (drug interactions)'], ['Q58', 'Topic 5: Diabetic Retinopathy - Diabetic eye screening (T1DM annual review)'], ], col_widths=[1.8*cm, 15.9*cm] )) doc.build(story) print("PDF generated successfully!") PYEOF echo "Script written. Running..." python3 /home/daytona/workspace/gen_ophthal_notes.py

ls -lh /home/daytona/workspace/Ophthalmology_Revision_Notes.pdf && python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/Ophthalmology_Revision_Notes.pdf') print(f'Pages: {len(r.pages)}') print('First page preview:') print(r.pages[0].extract_text()[:500]) "

python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/Ophthalmology_Revision_Notes.pdf') print(f'Total pages: {len(r.pages)}') # Check last page print('\\n--- LAST PAGE ---') print(r.pages[-1].extract_text()[:800]) print('\\n--- PAGE 10 ---') print(r.pages[9].extract_text()[:600]) "

python3 -c " from reportlab.lib.pagesizes import A4 from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Table, TableStyle from reportlab.lib import colors from reportlab.platypus import Paragraph from reportlab.lib.styles import ParagraphStyle # Test: does reportlab wrap text in table cells automatically? # The issue is plain strings don't wrap - need Paragraph objects inside cells print('Testing fix: use Paragraph inside Table cells for word-wrap') print('This is the standard fix for overlapping table content in reportlab') "

cat > /home/daytona/workspace/gen_ophthal_notes_v2.py << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib.styles import ParagraphStyle from reportlab.lib.units import cm from reportlab.lib import colors from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable) from reportlab.lib.enums import TA_LEFT, TA_CENTER PAGE_W, PAGE_H = A4 CONTENT_W = PAGE_W - 2.4*cm # usable width between margins BLK = colors.black WHT = colors.white # ── style factory ────────────────────────────────────────── def sty(name, size, bold=False, italic=False, spaceB=2, spaceA=1, indent=0, leading=None): fn = 'Helvetica' if bold and italic: fn = 'Helvetica-BoldOblique' elif bold: fn = 'Helvetica-Bold' elif italic: fn = 'Helvetica-Oblique' return ParagraphStyle(name, fontSize=size, fontName=fn, spaceBefore=spaceB, spaceAfter=spaceA, leftIndent=indent, textColor=BLK, leading=leading or (size * 1.25)) T_MAIN = sty('tmain', 15, bold=True, spaceB=6, spaceA=2) T_HEAD = sty('thead', 11, bold=True, spaceB=5, spaceA=1) T_SEC = sty('tsec', 9, bold=True, spaceB=3, spaceA=1) T_MERGE = sty('tmerge', 7.5, italic=True, spaceB=1, spaceA=1) T_BODY = sty('tbody', 8.2, spaceB=0, spaceA=0, leading=10.5) T_BULL = sty('tbull', 8.2, spaceB=0, spaceA=0, indent=10, leading=10.5) T_CTR = sty('tctr', 13, bold=True, spaceB=4, spaceA=2) T_CTR.alignment = TA_CENTER T_SUB = sty('tsub', 10, spaceB=2, spaceA=4) T_SUB.alignment = TA_CENTER T_SUB2 = sty('tsub2', 8.5, italic=True, spaceB=2, spaceA=2) T_SUB2.alignment = TA_CENTER # ── table cell style (wrapping paragraphs) ───────────────── T_TH = sty('tth', 7.5, bold=True, spaceB=1, spaceA=1) # header cell T_TD = sty('ttd', 7.5, spaceB=1, spaceA=1) # body cell def cell(txt, header=False): """Return a Paragraph that wraps inside a table cell.""" return Paragraph(str(txt), T_TH if header else T_TD) # ── helper flowables ──────────────────────────────────────── def HR(): return HRFlowable(width="100%", thickness=0.5, color=BLK, spaceAfter=2, spaceBefore=2) def SP(h=0.08): return Spacer(1, h*cm) def H1(txt): return Paragraph(txt, T_MAIN) def H2(txt): return Paragraph(txt, T_HEAD) def H3(txt): return Paragraph(txt, T_SEC) def merged(txt): return Paragraph(f"<i>Merged Topics: {txt}</i>", T_MERGE) def qnums(txt): return Paragraph(f"<b>Questions:</b> {txt}", T_MERGE) def body(txt): return Paragraph(txt, T_BODY) def bull(txt): return Paragraph(f"• {txt}", T_BULL) def bullb(txt): return Paragraph(f"• <b>{txt}</b>", T_BULL) def section_block(label, bullets): items = [H3(label)] for b in bullets: items.append(bull(b)) return items # ── table builder (uses Paragraph cells → auto-wraps) ────── BASE_TS = TableStyle([ ('FONTNAME', (0,0), (-1, 0), 'Helvetica-Bold'), ('FONTNAME', (0,1), (-1,-1), 'Helvetica'), ('FONTSIZE', (0,0), (-1,-1), 7.5), ('TEXTCOLOR', (0,0), (-1,-1), BLK), ('BACKGROUND', (0,0), (-1,-1), WHT), ('GRID', (0,0), (-1,-1), 0.3, BLK), ('TOPPADDING', (0,0), (-1,-1), 2), ('BOTTOMPADDING',(0,0), (-1,-1), 2), ('LEFTPADDING', (0,0), (-1,-1), 3), ('RIGHTPADDING', (0,0), (-1,-1), 3), ('VALIGN', (0,0), (-1,-1), 'TOP'), ]) def make_table(headers, rows, col_widths): # Convert every cell to a wrapping Paragraph para_headers = [cell(h, header=True) for h in headers] para_rows = [[cell(c) for c in row] for row in rows] t = Table([para_headers] + para_rows, colWidths=col_widths, repeatRows=1) # repeat header row on page break t.setStyle(BASE_TS) return t # ── document ──────────────────────────────────────────────── doc = SimpleDocTemplate( '/home/daytona/workspace/Ophthalmology_Revision_Notes.pdf', pagesize=A4, rightMargin=1.2*cm, leftMargin=1.2*cm, topMargin=1.2*cm, bottomMargin=1.2*cm, title="Ophthalmology MRCP II - High-Yield Revision Notes" ) story = [] # ════════════════════════════════════════════════════════════ # COVER # ════════════════════════════════════════════════════════════ story += [SP(0.5), Paragraph("<b>OPHTHALMOLOGY</b>", T_CTR), Paragraph("MRCP II Pastest 2023 - Topic-wise High-Yield Revision Notes", T_SUB), Paragraph("54 MCQs | 15 Merged Topics | Exam-Oriented | Print-Ready", T_SUB2), HR()] # ════════════════════════════════════════════════════════════ # TOPIC 1: EPISCLERITIS & SCLERITIS # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 1: Episcleritis & Scleritis"), merged("Episcleritis, Scleritis, Red Eye in IBD, Inflammatory Bowel Disease ocular manifestations"), qnums("Q1, Q19, Q20"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Young adult, bilateral/unilateral RED EYE, NO purulent discharge", "History of IBD (Crohn's/UC), psoriatic arthritis, RA, ankylosing spondylitis", "Pain + grittiness; previous episode resolved with artificial tears", "Scleritis: SEVERE boring/aching pain, worse at night, scleral nodules, reduced VA", "Episcleritis: milder, self-limiting, NO vision loss, superficial redness", "Classic: 'recurrent bilateral red eye in IBD patient - no discharge'", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Clinical diagnosis - slit-lamp examination key", "Phenylephrine test: episcleritis blanches (vessels), scleritis does NOT blanch", "Investigations for underlying cause: ANA, ANCA, RF, ESR, CRP, urate", "Scleritis: USS B-scan to assess posterior scleritis", ]) story += section_block("Treatment & Management", [ "Episcleritis 1st episode: artificial tears / topical NSAIDs", "Recurrent/resistant episcleritis: topical corticosteroids (preferred in IBD over oral NSAIDs)", "Resistant episcleritis: oral NSAIDs (naproxen) - avoid if IBD (GI risk)", "Severe/resistant: oral prednisolone", "Scleritis: systemic NSAIDs → systemic steroids → immunosuppressants (methotrexate)", "Treat underlying systemic disease", ]) story += section_block("Specific Peculiarities & Red Flags", [ "IBD → episcleritis (NOT scleritis usually); activity may parallel gut disease", "In IBD: prefer TOPICAL therapy over oral NSAIDs", "Episcleritis vs Conjunctivitis: no discharge, no follicles, sectoral redness", "Necrotising scleritis = most severe; associated with RA, Wegener's (GPA)", "KEY: No antibiotic needed (topical chloramphenicol is WRONG here)", ]) story += section_block("Quick-Revision Memory Aids", [ "IBD eye: Episcleritis, Uveitis (anterior), Scleritis", "SCLERITIS = Severe, deep pain, Systemic treatment", "Numbers: episcleritis 30% IBD patients; scleritis 33% have systemic disease", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 2: GCA & AION # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 2: Giant Cell Arteritis (GCA) & Ischaemic Optic Neuropathy"), merged("GCA, Temporal Arteritis, AION, Polymyalgia Rheumatica, Branch Retinal Artery Occlusion (GCA-related)"), qnums("Q2, Q44"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Age >50 (almost exclusively), female > male (3:1)", "PMR history + incomplete headache control on low-dose steroids", "Sudden unilateral vision loss on waking, NO pain, chalky white disc swelling", "Temporal headache, jaw claudication, scalp tenderness, tender temporal artery", "Q2: PMR on prednisolone 2.5mg → left eye VA 6/36, pale fundus, disc swelling → AION", "Q44: Age 75, temporal headaches, tender temporal arteries, upper field loss → Branch RAO from GCA", "AION fundus: pale oedematous (chalky white) optic disc, NO cherry-red spot", ]) story += section_block("Investigations (Key & Diagnostic)", [ "ESR >50 mm/hr (KEY investigation - Q44), CRP elevated", "Temporal artery biopsy: GOLD STANDARD - skip lesions; do NOT delay treatment for biopsy", "FBC: normocytic anaemia, raised platelets", "Age >50 with BRAO + temporal headaches → ESR is first-line investigation (NOT thrombophilia screen)", "PET-CT: for large vessel vasculitis assessment", ]) story += section_block("Treatment & Management", [ "START STEROIDS IMMEDIATELY - do not wait for biopsy result", "AION/Visual loss: IV methylprednisolone 500mg-1g/day x3 days → oral prednisolone 1mg/kg", "No visual symptoms: oral prednisolone 40-60mg/day", "Biopsy within 2 weeks (skip lesions mean negative biopsy doesn't exclude GCA)", "Long-term: slow steroid taper over 1-2 years; add PPI + bisphosphonate", "Aspirin 75mg: added to prevent stroke/MI", "Tocilizumab (IL-6 inhibitor): steroid-sparing agent in GCA", ]) story += section_block("Specific Peculiarities & Red Flags", [ "50% of GCA patients develop visual symptoms; AION is commonest cause of visual loss in GCA", "GCA-AION: chalky white disc (posterior ciliary artery ischaemia) - NO cherry red spot", "CRAO: pale retina + CHERRY RED SPOT at macula", "BRAO in >50 + headache: think GCA → ESR first; in <50: think thrombophilia → thrombophilia screen", "Bilateral blindness can occur within days if untreated", ]) story += section_block("Quick-Revision Memory Aids", [ "GCA TRIAD: Temporal headache + Jaw claudication + Visual loss", "JAW claudication = pathognomonic buzzword for GCA in MCQs", "ESR in GCA: typically >50, often >100 mm/hr", "PMR + eye symptoms = GCA until proven otherwise", "Biopsy: 'treat first, biopsy later' - steroids don't affect biopsy for 2 weeks", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 3: RETINAL VASCULAR OCCLUSIONS # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 3: Retinal Vascular Occlusions"), merged("CRVO, BRVO, CRAO, BRAO, Thrombophilia-related ocular events, Anti-phospholipid syndrome"), qnums("Q3, Q43, Q47, Q50, Q51, Q52, Q55"), SP()] story += [H3("Comparison Table")] story.append(make_table( ['Feature', 'CRVO', 'BRVO', 'CRAO', 'BRAO'], [ ['Pain', 'No', 'No', 'No', 'No'], ['Visual loss','Sudden severe central','Sectoral upper/lower field','Sudden TOTAL monocular','Sectoral field loss'], ['Fundus', '4-quadrant flame haemorrhages, disc swelling, CWS, macular oedema', 'Sectoral flame haemorrhages', 'Pale retina + cherry-red spot at macula', 'Pale wedge of retina (arterial territory)'], ['APD', 'May be present','Absent/mild','Present','Absent/mild'], ['Risk factors','HTN, DM, thrombophilia','HTN, DM, thrombophilia','AF, carotid emboli, GCA (>50)','Emboli, GCA (>50), thrombophilia (<50)'], ['Treatment', 'Anti-VEGF intravitreal; laser; treat HTN','Anti-VEGF/laser if macula involved','No proven Rx; ocular massage; carbogen','Treat cause; ESR if >50 yrs'], ], col_widths=[2.5*cm, 3.8*cm, 3.2*cm, 3.5*cm, 3.2*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q3: DM + HTN, sudden upper field loss, 4-quadrant haemorrhages, disc swelling → CRVO", "Q43: AF + HTN, sudden monocular vision loss, cherry-red spot → CRAO", "Q47/Q55: Young woman, previous DVT, upper field loss → BRVO + thrombophilia → Warfarin", "Q51: Sudden painless VA loss, extensive flame haemorrhages, recurrent miscarriages → CRVO + APS", "Q52: HTN, progressive visual loss, widespread haemorrhages all 4 quadrants → CRVO", "Q50: Glaucoma + DM, sudden painless visual loss → CRAO", ]) story += section_block("Investigations (Key & Diagnostic)", [ "FBC, ESR, CRP, lipids, glucose, HbA1c, BP measurement", "Thrombophilia screen (young patients): Factor V Leiden, Protein C/S, Antithrombin III, APS antibodies, homocysteine", "CRVO: Fluorescein angiography - gold standard to classify ischaemic vs non-ischaemic", "CRAO: Urgent carotid Doppler (emboli), Echo (cardiac source), ECG (AF)", "OCT: assess macular oedema in CRVO/BRVO", "Age >50 + BRAO + headache: ESR (GCA); Age <50: thrombophilia screen", ]) story += section_block("Treatment & Management", [ "CRVO: Anti-VEGF intravitreal injections (ranibizumab, bevacizumab) for macular oedema", "CRVO: Laser photocoagulation for neovascularisation", "CRAO (Q43, Q50): No proven treatment; ocular massage, anterior chamber paracentesis, carbogen (95% O2 + 5% CO2)", "BRVO + thrombophilia (Q47, Q55): Warfarin long-term (antiplatelet drugs ineffective for venous thrombosis)", "CRVO + APS (Q51): Thrombophilia screen → anticoagulation if positive", "Treat underlying HTN, DM, hyperlipidaemia", ]) story += section_block("Specific Peculiarities & Red Flags", [ "CRVO fundus: 'blood and thunder' - all 4 quadrants haemorrhages", "CRAO: cherry-red spot = fovea appears red against pale ischaemic retina (fovea has no inner layers)", "CRAO + AF → cardiac emboli; CRAO + age >50 + headache → GCA", "Young + venous occlusion = thrombophilia until proven otherwise", "APS: recurrent miscarriages + DVT + ocular venous occlusion", "BRVO = sectoral (one quadrant); CRVO = all 4 quadrants", "Triamcinolone: treats macular oedema but NOT future thrombosis", ]) story += section_block("Quick-Revision Memory Aids", [ "CRVO = 4-quadrant storm haemorrhages", "CRAO = Cherry Red spot; Artery = Atheroembolism", "DVT + young + ocular venous occlusion = thrombophilia → Warfarin", "AF + sudden monocular loss = CRAO (embolic)", "Anti-VEGF for CRVO macular oedema; Warfarin for thrombophilia-BRVO", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 4: GLAUCOMA # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 4: Glaucoma"), merged("Acute Angle Closure Glaucoma (AACG), Primary Open Angle Glaucoma (POAG), Normal Tension Glaucoma, Secondary Glaucoma, Homocystinuria"), qnums("Q8, Q12, Q13, Q28, Q30, Q39, Q57"), SP()] story += [H3("AACG vs POAG Comparison")] story.append(make_table( ['Feature', 'Acute Angle Closure (AACG)', 'Primary Open Angle (POAG)'], [ ['Onset', 'Acute, dramatic', 'Chronic, insidious'], ['Pain', 'SEVERE - headache, nausea, vomiting', 'None'], ['IOP', '>21 mmHg (often >50)', '>21 mmHg (gradual rise)'], ['Pupil', 'Fixed, mid-dilated, oval', 'Normal initially'], ['Cornea', 'Cloudy/steamy', 'Normal'], ['Visual fields', 'Sudden loss', 'Peripheral loss first (arcuate scotoma)'], ['Risk factors', 'Hypermetropia, Asian/female, dark rooms, mydriatics', 'Myopia, FH, Black race, age, DM, steroid use'], ['Treatment', 'Pilocarpine + IV acetazolamide + laser iridotomy', 'Prostaglandin analogues (latanoprost) 1st line'], ], col_widths=[3.0*cm, 8.0*cm, 6.7*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q8: Chinese woman, severe nausea/vomiting under surgical team, progressive right eye visual loss at night → AACG masquerading as GI emergency", "Q12: Severe right eye pain 3h, coloured halos around lights, headache, unilateral → AACG", "Q13: Right orbital pain evenings while reading, halos, resolves in bed → Subacute AACG", "Q28: Asian woman, sudden headache leaving cinema (dark→light change), vomiting, fixed dilated pupil → AACG", "Q30: Eye pain + vision loss driving through DARK TUNNEL → AACG triggered by mydriasis", "Q39: Tall thin young man, learning disability, marfanoid, fracture → Homocystinuria → lens dislocation → secondary glaucoma", "Q57: Elderly CCU patient with glaucoma + DM → drug interaction/management", "COLOURED HALOS around lights = pathognomonic buzzword for AACG", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Tonometry: IOP (normal <21 mmHg; AACG often >50 mmHg)", "Gonioscopy: GOLD STANDARD to classify open vs closed angle", "Slit-lamp: corneal oedema, shallow anterior chamber", "Visual field testing (Humphrey): arcuate scotoma, nasal step in POAG", "OCT: RNFL thinning in POAG", "Optic disc: cup:disc ratio >0.6 suspicious; disc haemorrhages, notching of neuroretinal rim", ]) story += section_block("Treatment & Management", [ "AACG Emergency: Pilocarpine 4% (miotic - opens drainage angle) + IV/oral acetazolamide + topical beta-blocker (timolol) + IV mannitol", "Definitive AACG: Laser peripheral iridotomy (bilateral - prevents fellow eye AACG)", "POAG 1st line: Prostaglandin analogues (latanoprost, bimatoprost - once daily at night)", "POAG alternatives: beta-blockers (timolol), CAIs (dorzolamide), alpha-2 agonists (brimonidine)", "Surgical: Trabeculectomy for uncontrolled POAG", ]) story += section_block("Specific Peculiarities & Red Flags", [ "AACG precipitants: DARK rooms, emotional stress, mydriatic drops, anticholinergic/TCA drugs", "AACG misdiagnosed as: migraine, acute abdomen (nausea/vomiting), meningitis", "Q8: Surgeons thought bowel obstruction - classic AACG masquerade", "Homocystinuria: lens dislocates DOWNWARD/NASAL (vs Marfan: lens dislocates UP/TEMPORAL)", "Normal tension glaucoma: IOP normal (<21) but optic nerve damage occurs", "Charles Bonnet syndrome (Q33): well-formed visual hallucinations with poor vision - NOT psychosis", ]) story += section_block("Quick-Revision Memory Aids", [ "AACG = Acute, Asian, Acute pain, halos Around lights", "Pilocarpine = Pupil constriction = opens angle drainage", "AACG trigger: 'left the cinema (dark)' - classic MCQ phrase", "Latanoprost = 1st line POAG = once daily night = brown iris pigmentation (SE)", "Lens dislocation: DOWN = Homocystinuria; UP = Marfan/Weill-Marchesani", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 5: DIABETIC RETINOPATHY # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 5: Diabetic Retinopathy & Diabetic Eye Disease"), merged("Background DR, Pre-proliferative DR, Proliferative DR, Diabetic Maculopathy, Cataract in DM, Vitreous haemorrhage, Rubeosis iridis"), qnums("Q5, Q6, Q11, Q24, Q26, Q56, Q58"), SP()] story += [H3("Staging of Diabetic Retinopathy")] story.append(make_table( ['Stage', 'Features', 'Action'], [ ['Background (mild NPDR)', 'Microaneurysms, dot haemorrhages', 'Annual review'], ['Moderate NPDR', 'Blot haemorrhages, hard exudates, CWS', '6-monthly review'], ['Pre-proliferative (severe NPDR)', 'CWS, IRMA, venous beading/looping, large blot haemorrhages', 'Urgent ophthalmology referral'], ['Proliferative DR (PDR)', 'New vessels at disc (NVD) or elsewhere (NVE), vitreous haem, TRD', 'URGENT: Pan-retinal photocoagulation (PRP)'], ['Maculopathy', 'Hard exudates/oedema/ischaemia at macula; central VA loss', 'Anti-VEGF intravitreal injections'], ], col_widths=[3.5*cm, 8.5*cm, 5.7*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q5: 65yo Asian woman, DM, VA improves with PINHOLE (lens/refractive) + nuclear sclerosis + pre-proliferative features on fundus", "Q6: Poor DM compliance, HbA1c 65 mmol/mol, sudden worsening VA → DM maculopathy", "Q11: 54yo T2DM 11yr, difficulty reading, gradual onset → DM maculopathy", "Q24: Poorly controlled DM, floaters + decreased vision, PDR + macular oedema + extensive new vessels", "Q26: T1DM 40yr, HbA1c 69, BP 155/90, blurring right eye → proliferative DR", "Q56: T2DM 11yr, difficulty reading → maculopathy", "Q58: T1DM 8yr, insulin-dependent, annual review → screening", "VA improving with pinhole = refractive/lens opacity (cataract), NOT maculopathy", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Fundal photography: UK screening method (optometrist-based)", "Fluorescein angiography: GOLD STANDARD for DR staging; shows microaneurysms, capillary non-perfusion", "OCT: measures macular oedema precisely", "HbA1c, BP, lipids, renal function (systemic risk assessment)", "Pinhole test: VA improvement with pinhole → refractive error/cataract (NOT macular)", ]) story += section_block("Treatment & Management", [ "Pre-proliferative: Urgent ophthalmology referral; optimise glycaemic + BP control", "PDR (Q24): Pan-retinal photocoagulation (PRP) - laser ablation of peripheral retina", "PDR + macular oedema (Q24): Anti-VEGF intravitreal (ranibizumab, bevacizumab, aflibercept)", "Maculopathy 1st line: Anti-VEGF injections", "Vitreous haemorrhage: vitrectomy", "Systemic: HbA1c <53 mmol/mol, BP <130/80, statin, ACEI/ARB", "Screening: Annual retinal photos for ALL diabetics", ]) story += section_block("Specific Peculiarities & Red Flags", [ "CWS (cotton wool spots) = retinal ischaemia = neovascularisation stimulus → proliferative", "Hard exudates near macula = REFER (maculopathy risk)", "Any VA loss in DM = maculopathy until proven otherwise", "IRMA = intraretinal microvascular abnormalities = pre-proliferative feature", "Rapid glycaemic improvement can WORSEN retinopathy short-term", "Rubeosis iridis (iris new vessels) → neovascular glaucoma", ]) story += section_block("Quick-Revision Memory Aids", [ "MICRO to MACRO: Microaneurysms → Haemorrhages → Exudates → CWS → New vessels", "PRP for PDR; Anti-VEGF for maculopathy", "4-2-1 rule (Pre-proliferative): >4 quadrant blot haem, >2 quadrant venous beading, >1 quadrant IRMA", "Pinhole improves VA = cataract/refractive; does NOT improve = maculopathy", "Floaters + DM = vitreous haemorrhage from new vessels → URGENT referral", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 6: HYPERTENSIVE RETINOPATHY # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 6: Hypertensive Retinopathy"), merged("Hypertensive Retinopathy grades 1-4, Keith-Wagener-Barker classification, Malignant hypertension, PKD, Macula star"), qnums("Q17, Q21, Q22, Q35"), SP()] story += [H3("Keith-Wagener-Barker Grading")] story.append(make_table( ['Grade', 'Features', 'Clinical significance'], [ ['1', 'Silver wiring of arterioles (thickened walls)', 'Hypertension, low risk'], ['2', 'AV nipping (arteriovenous compression)', 'Significant HTN'], ['3', 'CWS, flame haemorrhages, hard exudates, macula star', 'Severe HTN, end-organ damage'], ['4', 'Grade 3 features + DISC OEDEMA (papilloedema)', 'Malignant/accelerated hypertension - EMERGENCY'], ], col_widths=[1.8*cm, 9.5*cm, 6.4*cm] )) story.append(SP()) story += section_block("Stem Clues (High-Yield Presentation)", [ "Q17: Reduced vision noticed while taking photo, APD, disc oedema + CWS + A-V nipping + flame haemorrhages → Grade 4", "Q21: 32yo severe headache, BP 190/110, bilateral flank masses (PKD), Grade 4 retinal photo", "Q22: Severe frontal headache + N&V building over week, markedly raised BP → Grade 4, malignant HTN", "Q35: Same Grade 4 fundus picture → next step = BP MEASUREMENT", "Grade 4 = optic disc oedema = malignant hypertension = medical emergency", "Macula star = hard exudates radiating from fovea in spoke pattern", ]) story += section_block("Treatment & Management", [ "Grade 1-3: oral antihypertensives, treat gradually", "Grade 4/Malignant HTN (Q21, Q22): IV sodium nitroprusside OR labetalol (titratable)", "PKD + HTN (Q21): ACE inhibitors mainstay long-term; IV for acute malignant HTN", "Target: reduce diastolic gradually to ~100 mmHg over first hour (not too fast - stroke risk)", "Investigate for secondary causes of HTN", "Q35: Next investigation = BP measurement (not fluorescein angiography)", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Grade 4 = malignant HTN → IV antihypertensive URGENT", "Macula star = pathognomonic grade 3/4 hypertensive retinopathy", "Do NOT reduce BP too rapidly - cerebral autoregulation failure → blindness", "PKD: bilateral renal masses + family history of renal failure + HTN = ADPKD", "Differentials of disc oedema: papilloedema (bilateral), AION (unilateral, pale), malignant HTN", ]) story += section_block("Quick-Revision Memory Aids", [ "1-2-3-4: Arteriolar narrowing, AV nipping, CWS + haem, disc oedema", "Macula STAR = hard exudates at fovea in star/spoke pattern = Grade 3/4", "IV labetalol/nitroprusside = malignant HTN", "PKD: bilateral cystic kidneys + SAH risk + liver cysts + mitral valve prolapse", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 7: OPTIC NEURITIS & DEMYELINATION # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 7: Optic Neuritis & Demyelinating Disease"), merged("Optic Neuritis, Multiple Sclerosis, Neuromyelitis Optica (NMO/Devic), Transverse Myelitis, RAPD, Internuclear ophthalmoplegia"), qnums("Q9, Q15, Q34, Q38, Q48, Q53, Q54"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Young adult (20-40), female predominance", "Q9: 26yo, pain behind right eye INCREASED ON MOVEMENT, blur + colour vision loss, RAPD, VA 6/18", "Q15: 24yo, ataxic gait + vestibular dysfunction + vision loss over 18 months → MS (relapsing-remitting)", "Q34: Painful eye movements + colour desaturation + lower limb weakness + MRI 4 vertebral level enhancement → NMO", "Q38: 21yo, left eye pain on movement + blurring, 1-week history → optic neuritis", "Q53, Q54: Young woman, rapid colour vision + VA deterioration + ataxia → optic neuritis in MS", "CLASSIC: unilateral, painful (PAIN ON EYE MOVEMENT), colour/red desaturation, central scotoma, RAPD", ]) story += section_block("Investigations (Key & Diagnostic)", [ "MRI brain + spine: periventricular white matter lesions (Dawson's fingers - perpendicular to ventricles)", "Visual evoked potentials (VEP): delayed P100 wave = demyelination (gold standard for optic neuritis)", "CSF: oligoclonal bands (OCBs) in MS (90%), mild pleocytosis", "NMO: aquaporin-4 antibody (AQP4-IgG) positive; MRI spine extensive lesion (≥3 vertebral levels)", "MRI criteria: McDonald criteria for MS diagnosis (dissemination in time and space)", ]) story += section_block("Treatment & Management", [ "Optic neuritis: IV methylprednisolone 1g/day x3 days (speeds recovery; does NOT change final outcome)", "90% recover vision within 6 months", "MS first presentation (CIS): disease-modifying therapy (interferon-beta, glatiramer acetate)", "Relapsing-remitting MS: natalizumab, fingolimod, alemtuzumab", "NMO (Q34): Avoid beta-interferon (can worsen NMO); use azathioprine or rituximab", "Optic neuritis + periventricular lesions → 60-70% develop MS", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Pain ON EYE MOVEMENT = optic neuritis (distinguishes from AION where pain is absent)", "Red/colour desaturation = earliest symptom of optic neuritis", "RAPD (relative afferent pupillary defect) = Marcus Gunn pupil = optic nerve lesion", "Uhthoff's phenomenon: worsening symptoms with heat/exercise (MS-specific)", "Q34: 4-vertebral-level MRI enhancement = NMO (MS lesions are shorter <3 segments)", "Internuclear ophthalmoplegia (INO): bilateral = MS; unilateral = brainstem stroke", ]) story += section_block("Quick-Revision Memory Aids", [ "Optic Neuritis: PAIN on movement + Red desaturation + RAPD + young female", "Dawson's fingers = MS lesions perpendicular to corpus callosum on MRI", "NMO: AQP4 positive + bilateral optic neuritis + long transverse myelitis", "McDonald criteria: dissemination in TIME and SPACE", "Swinging flashlight test → RAPD in optic neuritis", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 8: PAPILLOEDEMA & IIH # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 8: Papilloedema & Idiopathic Intracranial Hypertension (IIH)"), merged("Papilloedema, Raised ICP, IIH, Benign Intracranial Hypertension, Pseudotumour cerebri, OCP-related IIH"), qnums("Q14, Q31"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Q14: 35yo woman, worsening headaches 3 months, worse in morning/lying flat/coughing, transient visual blurring, no PMH → IIH", "Q31: 27yo woman on OCP, morning headaches worse on straining, blurred vision/colour loss → IIH", "Classic IIH profile: obese young woman, OCP use, bilateral disc swelling, headache", "BILATERAL disc swelling = papilloedema (unilateral = AION or optic neuritis)", "Transient visual obscurations (TVOs): brief bilateral visual loss on postural change", "Pulsatile tinnitus + enlarged blind spot on visual field", ]) story += section_block("Investigations (Key & Diagnostic)", [ "MRI/CT brain: FIRST - exclude space-occupying lesion / venous sinus thrombosis", "MRI findings of IIH: empty sella, flattened posterior globe, tortuous optic nerve sheaths", "Lumbar puncture: opening pressure >25 cmH2O = GOLD STANDARD for IIH; CSF normal composition", "Cerebral venous sinus thrombosis: MRI venogram", "Visual field perimetry: serial monitoring to assess optic nerve damage", ]) story += section_block("Treatment & Management", [ "Weight loss: most effective treatment (10% body weight → significant improvement)", "Acetazolamide: 1st line pharmacotherapy (reduces CSF production)", "Stop OCP if implicated", "Topiramate: 2nd line (also aids weight loss)", "Optic nerve sheath fenestration: protect vision if failing", "CSF shunting (LP shunt or VP shunt): severe/refractory cases", ]) story += section_block("Specific Peculiarities & Red Flags", [ "IIH = bilateral disc swelling + raised ICP + normal CSF + normal brain imaging", "OCP is a known precipitant of IIH (Q31)", "Visual acuity initially PRESERVED in papilloedema (unlike AION where lost early)", "Risk of permanent visual loss if untreated (optic atrophy)", "ALWAYS exclude SOL with MRI BEFORE LP", ]) story += section_block("Quick-Revision Memory Aids", [ "IIH = obese young woman + OCP + bilateral disc swelling + headache", "Acetazolamide = Reduces CSF production = 1st line drug", "LP opening pressure >25 cmH2O = raised ICP", "TVOs = transient visual obscurations = classic papilloedema symptom", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 9: HEREDITARY RETINAL DYSTROPHIES # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 9: Hereditary Retinal Dystrophies"), merged("Retinitis Pigmentosa (RP), Malattia Leventinese, Autosomal Dominant Drusen, Cone-rod dystrophies, Usher syndrome, Refsum disease"), qnums("Q10, Q25, Q27, Q32"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Q10: 19yo woman, peripheral field loss noticed while driving, mother spotted it, on OCP → RP", "Q25: 22yo man, night vision deterioration 6 months, multiple blind family members → Malattia Leventinese", "Q27: 18yo woman, central vision difficulty + night vision loss, father blind at 46 → Malattia Leventinese", "Q32: 23yo woman, decreased peripheral vision worse at night, 12 months, no FH → RP", "Classic RP: 'bone spicule' pigmentation + attenuated vessels + disc pallor + nyctalopia + peripheral field loss", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Electroretinogram (ERG): reduced/absent signals in RP (most sensitive test)", "Visual field: ring scotoma (concentric peripheral field loss) in RP", "Fundoscopy: bone-spicule pigmentation, attenuated vessels, waxy disc pallor", "OCT: drusen (raised deposits under RPE) in malattia leventinese", "Genetic testing: PRPH2 gene (malattia leventinese), multiple genes for RP", ]) story += section_block("Treatment & Management", [ "RP: NO curative treatment; low-vision aids (Q10, Q25, Q27, Q32)", "Malattia Leventinese/Drusen: NO proven treatment; low-vision aids (Q25, Q27)", "Vitamin A palmitate: modest slowing of RP progression (limited evidence)", "Monitor for choroidal neovascularisation", "Genetic counselling for family members", ]) story += section_block("Specific Peculiarities & Red Flags", [ "RP associations: Usher (RP + deafness), Refsum (RP + cerebellar ataxia + neuropathy + phytanic acid), Bardet-Biedl (RP + obesity + polydactyly), Kearns-Sayre", "Malattia leventinese = AUTOSOMAL DOMINANT drusen = multiple drusen on fundus", "RP inheritance: X-linked recessive most severe; also AR and AD forms", "Night blindness (nyctalopia) = FIRST symptom of RP", "Bone spicules = pathognomonic fundus sign for RP", ]) story += section_block("Quick-Revision Memory Aids", [ "RP: RAPS - Rod cells first, Attenuated vessels, Pigment (bone spicules), Scotoma (peripheral)", "Night blindness → peripheral field loss → tunnel vision → blindness", "Malattia = Many drusen = autosomal DOMINANT = family history of blindness", "RP + Deafness = Usher; RP + Cerebellar = Refsum; RP + Obesity + Polydactyly = Bardet-Biedl", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 10: CATARACTS # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 10: Cataracts"), merged("Age-related cataract, Hypoparathyroidism cataract, Diabetic cataract, Drug-induced cataract, Nuclear sclerosis"), qnums("Q5 (nuclear sclerosis in DM), Q37 (hypoparathyroidism)"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Q37: 25yo woman, deteriorating vision + muscle weakness + tetany + post-partum thyroiditis (autoimmune) → Hypoparathyroidism → Cataract (radial/stellate pattern)", "Q5: 65yo, VA improving with pinhole → nuclear sclerosis (cataract) in DM", "Gradual painless VA loss; VA improves with PINHOLE", "Glare, reduced contrast, myopic shift (nuclear cataract), monocular diplopia", ]) story += section_block("Investigations & Treatment", [ "Slit-lamp: type and density of lens opacity", "Pinhole test: improvement → refractive/cataract (NOT macular disease)", "Q37 bloods: Ca low, PO4 high, PTH low/inappropriately normal = hypoparathyroidism", "Cataract treatment: surgical extraction (phacoemulsification) + IOL", "Hypoparathyroid cataract (Q37): Calcium + Vitamin D as calcitrol or alfacalcidol (bypasses renal 1α-hydroxylation step - NOT plain cholecalciferol)", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Calcitrol/alfacalcidol for hypoparathyroid: bypasses renal 1α-hydroxylation", "Steroid cataracts: posterior subcapsular; occur with inhaled and topical steroids", "Pinhole improves VA = CATARACT; does NOT improve = RETINAL/MACULAR disease", "Myotonic dystrophy: Christmas tree cataracts + ptosis + frontal balding", ]) story += section_block("Quick-Revision Memory Aids", [ "Cataract causes: Age, DM, Steroid, Trauma, UV, Hypoparathyroid, Wilson's (sunflower), Myotonic dystrophy", "Hypoparathyroid: LOW Ca + HIGH PO4 + LOW PTH → Calcitrol/Alfacalcidol", "Post-partum thyroiditis → autoimmune hypoparathyroidism → cataract", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 11: AMD # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 11: Age-Related Macular Degeneration (AMD)"), merged("Dry AMD, Wet AMD, Drusen, Geographic atrophy, Anti-VEGF, Choroidal neovascularisation, AREDS supplements"), qnums("Q45, Q49"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Q45: 74yo man, poor VA, drusen + geographic atrophy, progressive distance + reading difficulty → Dry AMD", "Q49: 70yo man, seeing 'lines' in vision (metamorphopsia) getting worse 3 weeks, HTN + DM, drusen → Dry AMD", "Dry AMD: gradual central vision loss (scotomas), drusen on fundus", "Wet AMD: sudden/rapid central vision loss, metamorphopsia, subretinal fluid/haemorrhage", "Amsler grid: straight lines appear wavy = metamorphopsia = wet AMD flag", ]) story += section_block("Investigations (Key & Diagnostic)", [ "OCT: GOLD STANDARD - detects drusen, geographic atrophy, subretinal fluid (wet AMD)", "Fundoscopy: drusen (yellow deposits under RPE), geographic atrophy (pigment loss patches)", "Fluorescein angiography: choroidal neovascularisation in wet AMD", "Q45: OCT used for initial diagnosis + severity assessment", ]) story += section_block("Treatment & Management", [ "Dry AMD (Q45, Q49): NO effective treatment; low-vision aids; AREDS supplements (vit C/E, zinc, lutein)", "Wet AMD: Anti-VEGF intravitreal injections (ranibizumab, bevacizumab, aflibercept)", "Wet AMD: Photodynamic therapy (verteporfin) - 2nd line", "Smoking cessation reduces progression", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Drusen = hallmark of AMD; soft large drusen = high risk for wet AMD conversion", "Metamorphopsia (wavy lines) = neovascularisation → urgent ophthalmology referral", "Geographic atrophy = advanced dry AMD = irreversible central vision loss", "AREDS supplements: NO beta-carotene in smokers (lung cancer risk)", ]) story += section_block("Quick-Revision Memory Aids", [ "DRY AMD: Drusen, Gradual loss, Geographic atrophy - no pharmacological treatment", "WET AMD: Wavy lines (metamorphopsia) + Rapid loss + anti-VEGF works", "Amsler grid: wavy = WET AMD", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 12: UVEITIS # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 12: Uveitis & Intraocular Inflammation"), merged("Anterior Uveitis (Iritis), Posterior Uveitis, Toxoplasma Chorioretinitis, HLA-B27-associated uveitis, Reactive Arthritis, IBD uveitis"), qnums("Q16, Q29"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Q16: 34yo man, red eye with INTENSE DULL ACHING pain in eye + orbital area, blurred vision, VA 6/24, sore throat + bilateral swollen joints + shin rash (erythema nodosum) → Reactive arthritis → Anterior Uveitis", "Q29: 18yo man working in boarding kennels (cats/dogs), right eye pain + hazy blurred vision weeks, fundus shows chorioretinitis + vitritis → Toxoplasma gondii", "Anterior uveitis: red eye, PHOTOPHOBIA, PAIN, circumcorneal flush, hypopyon", "Posterior uveitis: floaters, visual loss, minimal external signs", "Toxoplasma: focal 'headlight in fog' lesion with adjacent old pigmented scar", ]) story += section_block("Investigations (Key & Diagnostic)", [ "Slit-lamp: anterior chamber cells + flare, keratic precipitates (KPs), posterior synechiae", "HLA-B27: positive in AS, reactive arthritis, IBD, psoriatic arthritis", "Toxoplasma IgG/IgM serology", "ACE level + CXR: sarcoidosis", "VDRL/TPHA: syphilis; Lyme serology; TB Mantoux/IGRA", ]) story += section_block("Treatment & Management", [ "Anterior uveitis (Q16): Topical corticosteroids + mydriatic drops (cyclopentolate/atropine - prevent posterior synechiae)", "Urgent ophthalmology within 24 hours for slit-lamp diagnosis", "Toxoplasmosis (Q29): Pyrimethamine + sulphadiazine + folinic acid (classic triple therapy) OR co-trimoxazole +/- prednisolone", "Sarcoid uveitis: systemic corticosteroids +/- methotrexate", ]) story += section_block("Specific Peculiarities & Red Flags", [ "HLA-B27 associations: Ankylosing Spondylitis, Reactive Arthritis (Reiter), IBD, Psoriasis", "Toxocara vs Toxoplasma: Toxocara = white pupil (leukocoria) + retinal fibrosis in children; Toxoplasma = focal chorioretinitis + vitritis", "Reactive arthritis triad: can't see (uveitis), can't pee (urethritis), can't climb a tree (arthritis)", "Posterior synechiae = iris adherent to lens → irregular pupil → secondary glaucoma", "Mutton-fat KPs = granulomatous uveitis (sarcoid, TB)", ]) story += section_block("Quick-Revision Memory Aids", [ "Uveitis + HLA-B27 = spondyloarthropathy (AS, ReA, IBD, Psoriasis)", "Reactive arthritis: Can't see, Can't pee, Can't climb a tree", "Toxoplasma: cat/farm exposure + focal chorioretinitis + 'headlight in fog'", "Anterior uveitis Rx: Steroid drops + Mydriatic (dilates pupil, prevents synechiae)", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 13: INFECTIONS & EXTERNAL EYE # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 13: Infections & External Eye Disease"), merged("Onchocerciasis, Trachoma (Chlamydia trachomatis), Corneal arcus, Familial Hypercholesterolaemia, Frank's sign"), qnums("Q4, Q18, Q36, Q46"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Q4: 45yo man from Zimbabwe, visual impairment, on Ivermectin, dry thick depigmented skin (leopard skin), raised WCC + CRP → Onchocerca volvulus", "Q18: 77yo woman, corneal arcus on eye photograph, no CVD, normal lipids → Arcus senilis (age-related, NOT FH at age 77)", "Q36: 54yo woman from Iraq, progressive blindness, family history of blindness, son showing early signs → Trachoma (C. trachomatis)", "Q46: 26yo man, corneal arcus + family history of early cardiac death → Familial Hypercholesterolaemia", "Trachoma: endemic Middle East/North Africa; trichiasis → corneal opacification → blindness", ]) story += section_block("Investigations & Treatment", [ "Onchocerciasis (Q4): skin snip biopsy → microfilariae (gold standard); Ivermectin treatment (kills microfilariae, NOT adult worms)", "Trachoma: clinical diagnosis; Giemsa stain - inclusion bodies; PCR for C. trachomatis; SAFE strategy treatment", "Arcus senilis (Q18): fasting lipids; at age >50 arcus = age-related (no treatment needed if normal lipids)", "FH (Q46): fasting lipids (total cholesterol >7.5 mmol/L in heterozygous FH); Frank's sign (earlobe crease), tendon xanthomas", "FH treatment: high-intensity statin + dietary modification; PCSK9 inhibitors for severe cases", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Onchocerciasis: 'river blindness' = Simulium blackfly near fast-flowing rivers in Africa/Yemen", "Ivermectin kills microfilariae but NOT adult worms (need doxycycline for wolbachia endosymbiont)", "Trachoma = leading cause of PREVENTABLE INFECTIOUS BLINDNESS worldwide", "Arcus senilis: <50 years → screen for FH; >50 years = normal ageing", "FH: corneal arcus + xanthelasma + tendon xanthoma + premature CVD = clinical diagnosis", "Trachoma SAFE: Surgery (trichiasis), Antibiotics, Facial cleanliness, Environmental improvement", ]) story += section_block("Quick-Revision Memory Aids", [ "Onchocerciasis = Africa + river + black fly + leopard skin → Ivermectin", "Trachoma = SAFE strategy; Azithromycin; Middle East/Africa endemic", "Arcus senilis <50 = screen for FH; >50 = normal ageing (no action if normal lipids)", "FH: Frank's sign + Tendon Xanthomas + Corneal Arcus = Familial Hypercholesterolaemia", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 14: SYSTEMIC & METABOLIC EYE MANIFESTATIONS # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 14: Systemic & Metabolic Eye Manifestations"), merged("Alport Syndrome, Homocystinuria, Charles Bonnet Syndrome, Polycystic Kidney Disease"), qnums("Q7, Q33, Q39"), SP()] story += section_block("Stem Clues (High-Yield Presentation)", [ "Q7: 30yo man, microscopic haematuria + sensorineural deafness → ESRD (Alport syndrome); ocular: anterior lenticonus", "Q33: 72yo man, bilateral glaucoma, well-formed visual hallucinations (colours, patterns, birds, buildings) → Charles Bonnet Syndrome", "Q39: 25yo, marfanoid habitus, learning disability, tall/thin, kyphoscoliosis, arm fracture → Homocystinuria → lens dislocation DOWNWARD", "Charles Bonnet: elderly with POOR VISION → well-formed visual hallucinations; INSIGHT PRESERVED (patient knows they are not real)", ]) story += section_block("Investigations & Treatment", [ "Alport: X-linked dominant; COL4A3/A4/A5 gene mutation; EM shows glomerular basement membrane thinning", "Homocystinuria (Q39): elevated plasma homocysteine; cystathionine beta-synthase deficiency; autosomal recessive", "Alport treatment: ACE inhibitors/ARBs; renal transplant for ESRD", "Homocystinuria treatment: high-dose pyridoxine (B6) if responsive; low-methionine diet + cysteine; anticoagulation for DVT risk", "Charles Bonnet (Q33): reassurance; treat underlying visual impairment if possible; rarely SSRIs/cholinesterase inhibitors", ]) story += section_block("Specific Peculiarities & Red Flags", [ "Alport: anterior lenticonus = pathognomonic (oil droplet appearance on slit-lamp)", "Homocystinuria lens dislocation: INFERIOR/NASAL (vs Marfan: SUPERIOR/TEMPORAL)", "Homocystinuria: DVT + PE risk → anticoagulation perioperatively", "Charles Bonnet: NOT psychosis - patient KNOWS hallucinations are NOT REAL", "Charles Bonnet trigger: any severe visual loss (AMD, glaucoma, RP, cataract)", ]) story += section_block("Quick-Revision Memory Aids", [ "Alport = 3As: collagen type IV (A3/A4/A5), sensorineural Auditory loss, Anterior lenticonus", "DOWN in Homocystinuria, UP in Marfan (lens dislocation direction)", "Charles Bonnet: 'BEAUTIFUL hallucinations in the BLIND' - insight preserved", "Pyridoxine (B6) responsive homocystinuria = treat with high-dose B6", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # TOPIC 15: DRUG-INDUCED OCULAR TOXICITY # ════════════════════════════════════════════════════════════ story += [H1("TOPIC 15: Drugs Causing Ocular Toxicity"), merged("Hydroxychloroquine, Ethambutol, Amiodarone, Steroids, Tamoxifen, Vigabatrin, Sildenafil"), Paragraph("(Embedded throughout: Q24 anti-VEGF, Q37 steroid cataract, Q24 triamcinolone)", T_MERGE), SP()] story.append(make_table( ['Drug', 'Ocular Toxicity', 'Monitoring / Notes'], [ ['Hydroxychloroquine', "Bull's eye maculopathy → irreversible vision loss", 'Annual VF + OCT; safe dose <5mg/kg/day'], ['Chloroquine', "Bull's eye maculopathy (earlier onset than HCQ)", 'Annual monitoring; avoid if renal impairment'], ['Ethambutol', 'Optic neuropathy → colour vision loss → VA loss', 'Baseline VEP; monthly VF; STOP immediately if colour vision changes'], ['Amiodarone', 'Corneal microdeposits (vortex keratopathy), optic neuropathy', 'Usually benign/asymptomatic; rarely vision-threatening'], ['Steroids', 'Posterior subcapsular cataract; raised IOP/glaucoma', 'Even inhaled/topical steroids; monitor IOP'], ['Vigabatrin', 'Irreversible peripheral visual field loss (BILAT)', 'Baseline + 6-monthly VF; changes are irreversible'], ['Tamoxifen', 'Retinopathy, macular oedema, crystalline deposits', 'Baseline retinal exam + OCT monitoring'], ['Sildenafil (PDE5i)', 'Transient blue-green colour vision changes; NAION (rare)', 'Avoid in NAION history; blue tinge at high doses'], ['Isotretinoin', 'Night blindness, dry eyes, corneal opacities', 'Monitor; usually reversible on stopping'], ['Quinine', 'Toxic retinopathy in overdose; ERG changes', 'Therapeutic doses generally safe'], ], col_widths=[3.5*cm, 6.5*cm, 7.7*cm] )) story.append(SP()) story += section_block("Quick-Revision Memory Aids", [ "Bull's eye maculopathy = Chloroquine / Hydroxychloroquine", "Vortex keratopathy (whorl-pattern corneal deposits) = Amiodarone", "Ethambutol = STOP if colour vision changes (earliest warning sign)", "Vigabatrin = irreversible peripheral VF loss (always do baseline VF before starting)", "Posterior subcapsular cataract = Steroids (even topical/inhaled)", ]) story.append(HR()) # ════════════════════════════════════════════════════════════ # MOST IMPORTANT TOPICS SUMMARY # ════════════════════════════════════════════════════════════ story += [H1("MOST IMPORTANT TOPICS - Summary (Ranked by MCQ Frequency)"), SP()] story.append(make_table( ['Rank', 'Topic', 'MCQ Count', 'Question Numbers'], [ ['1', 'Diabetic Retinopathy & Eye Disease', '7', 'Q5, Q6, Q11, Q24, Q26, Q56, Q58'], ['2', 'Glaucoma (AACG + POAG)', '7', 'Q8, Q12, Q13, Q28, Q30, Q39, Q57'], ['3', 'Retinal Vascular Occlusions (CRVO/BRVO/CRAO/BRAO)', '7', 'Q3, Q43, Q47, Q50, Q51, Q52, Q55'], ['4', 'Optic Neuritis & Demyelination (MS/NMO)', '7', 'Q9, Q15, Q34, Q38, Q48, Q53, Q54'], ['5', 'Hypertensive Retinopathy', '4', 'Q17, Q21, Q22, Q35'], ['6', 'Hereditary Retinal Dystrophies (RP, Malattia Leventinese)', '4', 'Q10, Q25, Q27, Q32'], ['7', 'Episcleritis & Scleritis', '3', 'Q1, Q19, Q20'], ['8', 'Infections (Onchocerciasis, Trachoma, Toxoplasma)', '3', 'Q4, Q29, Q36'], ['9', 'Systemic Manifestations (Alport, Homocystinuria, Charles Bonnet)', '3', 'Q7, Q33, Q39'], ['10', 'Uveitis & Intraocular Inflammation', '2', 'Q16, Q29'], ['11', 'Giant Cell Arteritis & AION', '2', 'Q2, Q44'], ['12', 'Papilloedema & IIH', '2', 'Q14, Q31'], ['13', 'Age-Related Macular Degeneration (AMD)', '2', 'Q45, Q49'], ['14', 'Cataracts (Systemic Causes)', '2', 'Q5, Q37'], ['15', 'Corneal Arcus & Familial Hypercholesterolaemia', '2', 'Q18, Q46'], ], col_widths=[1.2*cm, 8.0*cm, 2.0*cm, 6.5*cm] )) story.append(HR()) # ════════════════════════════════════════════════════════════ # MCQ → TOPIC MAPPING TABLE # ════════════════════════════════════════════════════════════ story += [H1("MCQ Number to Topic Mapping Table"), body("Every MCQ cross-referenced to its topic section."), SP(0.1)] story.append(make_table( ['MCQ No.', 'Topic & Subtopic'], [ ['Q1', 'Topic 1: Episcleritis - Episcleritis in IBD; topical corticosteroids'], ['Q2', 'Topic 2: GCA & AION - PMR + GCA + AION (chalky white disc)'], ['Q3', 'Topic 3: Retinal Vascular Occlusions - CRVO in DM + HTN'], ['Q4', 'Topic 13: Infections - Onchocerciasis (river blindness, Ivermectin)'], ['Q5', 'Topic 5: Diabetic Retinopathy - Pre-proliferative DR + nuclear sclerosis (pinhole)'], ['Q6', 'Topic 5: Diabetic Retinopathy - Maculopathy (poor compliance, rapid VA loss)'], ['Q7', 'Topic 14: Systemic - Alport Syndrome (haematuria + deafness + ESRD)'], ['Q8', 'Topic 4: Glaucoma - AACG (Chinese woman, surgical ward, night onset)'], ['Q9', 'Topic 7: Optic Neuritis - Pain on movement, RAPD, colour loss'], ['Q10', 'Topic 9: Hereditary Dystrophies - Retinitis Pigmentosa (peripheral field loss while driving)'], ['Q11', 'Topic 5: Diabetic Retinopathy - Maculopathy (difficulty reading, gradual onset)'], ['Q12', 'Topic 4: Glaucoma - AACG (severe eye pain, coloured halos around lights)'], ['Q13', 'Topic 4: Glaucoma - Subacute AACG (evening orbital pain, halos, resolves in bed)'], ['Q14', 'Topic 8: Papilloedema & IIH - IIH (young woman, positional morning headaches)'], ['Q15', 'Topic 7: Optic Neuritis - MS (ataxia + vestibular + vision loss, relapsing)'], ['Q16', 'Topic 12: Uveitis - Anterior uveitis in reactive arthritis (HLA-B27)'], ['Q17', 'Topic 6: Hypertensive Retinopathy - Grade 4 fundus (APD, disc oedema, photo)'], ['Q18', 'Topic 13: External Eye - Arcus senilis (age 77, normal lipids, no treatment)'], ['Q19', 'Topic 1: Episcleritis - Episcleritis in IBD inpatient (acute red eye)'], ['Q20', 'Topic 1: Episcleritis - Episcleritis acute red eye in IBD'], ['Q21', 'Topic 6: Hypertensive Retinopathy - Grade 4 + ADPKD (bilateral renal masses)'], ['Q22', 'Topic 6: Hypertensive Retinopathy - Grade 4, malignant HTN, IV management'], ['Q24', 'Topic 5: Diabetic Retinopathy - Proliferative DR + macular oedema (anti-VEGF + PRP)'], ['Q25', 'Topic 9: Hereditary Dystrophies - Malattia leventinese (AD drusen; low vision aids)'], ['Q26', 'Topic 5: Diabetic Retinopathy - T1DM 40yr, HbA1c 69, blurring right eye'], ['Q27', 'Topic 9: Hereditary Dystrophies - Malattia leventinese (18yo, central + night vision)'], ['Q28', 'Topic 4: Glaucoma - AACG (Asian woman, cinema, headache, fixed dilated pupil)'], ['Q29', 'Topic 12: Uveitis - Toxoplasma chorioretinitis (animal handler, vitritis)'], ['Q30', 'Topic 4: Glaucoma - AACG (dark tunnel trigger, eye pain + visual loss)'], ['Q31', 'Topic 8: Papilloedema & IIH - IIH (young woman on OCP, morning headaches)'], ['Q32', 'Topic 9: Hereditary Dystrophies - RP (decreased peripheral vision at night, 12 months)'], ['Q33', 'Topic 14: Systemic - Charles Bonnet Syndrome (glaucoma + well-formed hallucinations)'], ['Q34', 'Topic 7: Optic Neuritis - NMO/optic neuritis + 4-level transverse myelitis'], ['Q35', 'Topic 6: Hypertensive Retinopathy - Grade 4; next step = BP measurement'], ['Q36', 'Topic 13: Infections - Trachoma (C. trachomatis, Iraq, maternal transmission, blindness)'], ['Q37', 'Topic 10: Cataracts - Hypoparathyroidism cataract; treatment = calcitrol/alfacalcidol'], ['Q38', 'Topic 7: Optic Neuritis - Left eye pain on movement + blurring (1 week)'], ['Q39', 'Topics 4+14: Glaucoma/Systemic - Homocystinuria (marfanoid, downward lens dislocation)'], ['Q43', 'Topic 3: Retinal Vascular Occlusions - CRAO (AF, sudden monocular loss, cherry-red spot)'], ['Q44', 'Topic 2: GCA - BRAO in GCA (age 75, temporal headaches → ESR first investigation)'], ['Q45', 'Topic 11: AMD - Dry AMD (drusen + geographic atrophy; low vision aids)'], ['Q46', 'Topic 13: External Eye - Familial hypercholesterolaemia (corneal arcus + Frank\'s sign)'], ['Q47', 'Topic 3: Retinal Vascular Occlusions - BRVO + thrombophilia (DVT history → Warfarin)'], ['Q48', 'Topic 7: Optic Neuritis - Sudden eye pain at rest (optic neuritis variant)'], ['Q49', 'Topic 11: AMD - Dry AMD (metamorphopsia/lines in vision, drusen, HTN + DM)'], ['Q50', 'Topic 3: Retinal Vascular Occlusions - CRAO (glaucoma + DM, sudden painless loss)'], ['Q51', 'Topic 3: Retinal Vascular Occlusions - CRVO + APS/thrombophilia (recurrent miscarriages)'], ['Q52', 'Topic 3: Retinal Vascular Occlusions - CRVO (HTN, widespread 4-quadrant haemorrhages)'], ['Q53', 'Topic 7: Optic Neuritis - Rapid VA + colour deterioration + fatigue (MS)'], ['Q54', 'Topic 7: Optic Neuritis - Colour vision + ataxia refused investigations (MS)'], ['Q55', 'Topic 3: Retinal Vascular Occlusions - BRVO + thrombophilia (DVT at 18, upper field loss)'], ['Q56', 'Topic 5: Diabetic Retinopathy - Maculopathy (T2DM 11yr, difficulty reading)'], ['Q57', 'Topic 4: Glaucoma - Glaucoma management in CCU (co-existing conditions, drug interactions)'], ['Q58', 'Topic 5: Diabetic Retinopathy - Annual screening (T1DM 8yr, insulin-dependent)'], ], col_widths=[1.8*cm, 15.9*cm] )) # ── build ────────────────────────────────────────────────── doc.build(story) print("PDF generated successfully!") PYEOF echo "Running script..." python3 /home/daytona/workspace/gen_ophthal_notes_v2.py

python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/Ophthalmology_Revision_Notes.pdf') print(f'Total pages: {len(r.pages)}') # Check a few pages for content integrity for pg in [0, 3, 6, 9, len(r.pages)-1]: txt = r.pages[pg].extract_text() print(f'\\n--- Page {pg+1} (first 200 chars) ---') print(txt[:200]) "