UKMLA Ophthalmology & ENT: High-Yield Guide

Ophthalmology and ENT are the "small specialties" that keep turning up in the UKMLA out of all proportion to teaching time in medical school. Both produce sharp, time-critical emergencies — sudden painless vision loss from a CRAO, acute angle-closure glaucoma, orbital cellulitis, epistaxis with airway compromise, a quinsy drooling in the corner of the ward — where the right five-minute decision saves sight, hearing, or life. The AKT loves them because the recognition patterns are discrete, and the CPSA tests the communication around sight-threatening or hearing-threatening diagnoses.

This pillar combines the two specialties on a single SEO page because the UKMLA exam pattern is the same: rapid differential, rapid next-best action, and heavy overlap with emergency medicine. We cover the red-eye differential, acute angle-closure glaucoma, every cause of sudden painless vision loss (CRAO, CRVO, vitreous haemorrhage, retinal detachment), giant cell arteritis, diabetic retinopathy screening, orbital vs pre-septal cellulitis, lid lesions, acute otitis media, otitis externa, epistaxis, tonsillitis and quinsy (Centor/FeverPAIN), Bell's palsy, vertigo (BPPV, Ménière's, vestibular neuritis), and ENT/ophthalmic foreign bodies.

Use this alongside our emergency presentations masterclass for the sight- and airway-threatening overlap, our neurology high-yield guide for GCA and Bell's palsy in context, the endocrinology guide for diabetic retinopathy, and NICE guidelines high-yield for the stewardship-aligned management of otitis media and acute sore throat.

1. Why Ophthalmology and ENT Punch Above Their Weight

There are two structural reasons these specialties appear so often:

Sharp differentials. A red eye has five or six discrete causes, and a well-written SBA stem can separate them in thirty seconds — one stem can cover anatomy, pathophysiology, investigation, and management in four options. Examiners love this density.

Time-critical emergencies. Both specialties include "blind in hours / airway in minutes" conditions — acute angle-closure glaucoma, CRAO, orbital cellulitis, epiglottitis, posterior epistaxis. The UKMLA tests whether a foundation-year doctor will recognise these and act correctly before the specialist arrives.

Three habits raise your score here: (1) triage the red eye in the first sentence — painful/painless, vision/no vision, discharge/no discharge — the rest falls out; (2) default to "refer to specialist" quickly when sight or airway is threatened — it is almost always the correct answer; (3) know the small number of UK-specific empirical antibiotic choices for otitis and tonsillitis under NICE guidelines.

2. Red Eye Differential: Conjunctivitis vs Uveitis vs Glaucoma vs Keratitis

The red-eye SBA is essentially a matrix question. Tease out the key features and the diagnosis drops out.

Conjunctivitis management:

• Viral (commonest, adenovirus, often bilateral, watery discharge, preceded by URTI): self-limiting in 1–2 weeks, cold compresses, high contagion — handwashing, separate towels.
• Bacterial (unilateral, mucopurulent discharge, lids stuck together): usually self-limiting; NICE recommends delayed/no antibiotic first-line. If severe, chloramphenicol drops. Gonococcal or chlamydial (hyperpurulent) → specialist.
• Allergic (itchy, bilateral, watery, often with atopy): topical antihistamine or mast-cell stabiliser.
• Neonatal (<30 days): ophthalmia neonatorum — chlamydia or gonococcus → urgent ophthalmology, systemic antibiotics (oral erythromycin for chlamydia; IV/IM ceftriaxone for gonococcus).

Anterior uveitis (iritis):

• Urgent ophthalmology referral (same day).
• Topical steroids + mydriatics (cyclopentolate) to prevent adhesions (posterior synechiae).
• Screen for underlying cause (ankylosing spondylitis, IBD, sarcoid, Behçet's, HSV — see MSK guide).

UKMLA trap: unilateral red eye + photophobia + small irregular pupil + known ankylosing spondylitis → anterior uveitis → urgent ophthalmology (same day).

3. Acute Angle-Closure Glaucoma — Triage and Management

Acute angle-closure glaucoma (AACG) is a sight-threatening emergency. Sudden closure of the iridocorneal angle → rapid IOP rise → optic nerve ischaemia → irreversible damage in hours.

Risk factors:

• Older women (shallow anterior chamber).
• Hypermetropes (short eye).
• Asian and Inuit heritage.
• Precipitants: pupil dilation in dark environments, anticholinergics (antihistamines, tricyclics, oxybutynin, atropine drops), sympathomimetics (adrenaline, topical decongestants).

Clinical features:

• Severe unilateral eye pain, headache, nausea, vomiting.
• Haloes around lights (corneal oedema).
• Reduced vision.
• Red eye with circumcorneal injection.
• Mid-dilated, fixed, oval pupil.
• Hazy cornea.
• Rock-hard globe on gentle palpation.
• IOP typically >40 mmHg (normal 10–21).

Immediate management (pre-ophthalmology):

• Emergency ophthalmology referral.
• Lie patient flat (may ease anterior chamber).
• Pilocarpine 2–4% drops (miotic — constricts pupil, pulls iris away from angle).
• Timolol 0.5% drops (β-blocker — reduces aqueous production).
• Acetazolamide 500 mg IV or oral (carbonic anhydrase inhibitor — reduces aqueous production).
• Systemic analgesia and antiemetic.
• Specialist: hyperosmotic agents (mannitol), laser peripheral iridotomy — definitive treatment; offered bilaterally as prophylaxis.

UKMLA trap: elderly woman with acute headache + nausea + haloes around lights + red eye with mid-dilated pupil → AACG → pilocarpine + timolol + acetazolamide + immediate ophthalmology. Do not give atropine/cyclopentolate — dilating drops precipitate the attack.

4. Sudden Painless Vision Loss

The painless/painful distinction immediately halves the differential. Painless = vascular or retinal until proven otherwise.

Central retinal artery occlusion (CRAO):

• Sudden, painless, complete monocular vision loss (seconds).
• RAPD (relative afferent pupillary defect).
• Fundus: pale retina + cherry-red spot at macula.
• Cause: embolic (carotid plaque, cardiac, GCA) or thrombotic.
• Management: immediate ocular massage, paper-bag rebreathing, IV acetazolamide, anterior chamber paracentesis (specialist) — time window very narrow (<90 minutes). Thrombolysis in specialist centres within 4.5 hours for selected patients.
• Workup: GCA screen (ESR, temporal artery biopsy), carotid Doppler, echo, ECG, BP, lipids, glucose — treat the cause (stroke-equivalent).

Central retinal vein occlusion (CRVO):

• Sudden painless monocular vision loss, moderate to severe.
• Fundus: "blood and thunder" — widespread retinal haemorrhages, dilated tortuous veins, cotton-wool spots, disc swelling.
• Risk: HTN, hyperviscosity, glaucoma, diabetes.
• Management: urgent ophthalmology referral. Treatments: intravitreal anti-VEGF (ranibizumab, aflibercept) for macular oedema; laser for neovascularisation; treat systemic risk factors.

Vitreous haemorrhage:

• Sudden painless loss of vision, often with "floaters" or "cobwebs".
• Causes: diabetic retinopathy (neovascularisation), retinal tear/detachment, trauma, posterior vitreous detachment.
• Red reflex reduced or absent.
• Management: urgent ophthalmology referral — B-scan ultrasound, treat underlying cause.

Retinal detachment:

• "Flashes, floaters, shadow/curtain over vision".
• Painless, progressive.
• Risk factors: myopia, trauma, previous cataract surgery, diabetic traction detachment.
• Management: urgent ophthalmology referral (same day) — retinal detachment requires surgery (scleral buckle, vitrectomy) for best visual outcome.
• Small tears without detachment may be laser-treated.

Retinal vein / artery branch occlusions: sector vision loss, less dramatic, treat as above.

Other: ischaemic optic neuropathy (GCA — see below), optic neuritis (painful, not painless — MS), migrainous aura (transient, bilateral, positive phenomena), amaurosis fugax (transient monocular — carotid or GCA, treat as TIA — see neurology guide).

UKMLA traps:

• Cherry-red spot → CRAO → ocular massage + GCA screen.
• Blood and thunder fundus → CRVO → urgent ophthalmology + anti-VEGF.
• Flashes, floaters, curtain → retinal detachment → urgent ophthalmology.
• Temporal headache + vision loss + jaw claudication → GCA → 60 mg prednisolone immediately.

5. Giant Cell Arteritis — ESR, High-Dose Steroids, Biopsy

GCA is large-vessel vasculitis of age >50. Temporal artery involvement → jaw claudication, scalp tenderness, temporal headache, amaurosis fugax progressing to permanent blindness if untreated.

Features:

• Age >50 (almost universal).
• New temporal headache.
• Jaw claudication (chewing-induced pain — highly specific).
• Scalp tenderness (brushing hair hurts).
• Visual disturbance: diplopia, amaurosis fugax, anterior ischaemic optic neuropathy (AION) — sudden painless monocular vision loss.
• Polymyalgia rheumatica features (bilateral shoulder/pelvic girdle stiffness).
• Systemic: fever, weight loss, fatigue.

Investigation:

• ESR almost always >50, often >100.
• CRP elevated.
• FBC: normocytic anaemia, thrombocytosis.
• Temporal artery biopsy within 7 days of starting steroids (skip lesions common — a single negative biopsy does not exclude GCA).
• Temporal artery ultrasound (hypoechoic halo sign) — now used as first-line imaging in many UK centres (BSR guidelines).

Management (British Society for Rheumatology):

• Visual symptoms present: IV methylprednisolone 500–1000 mg OD for 3 days, then oral prednisolone 60 mg OD. Ophthalmology review urgently.
• No visual symptoms: oral prednisolone 40–60 mg OD immediately (do NOT wait for biopsy).
• Aspirin 75 mg (stroke risk reduction).
• Bone protection (calcium, vitamin D, bisphosphonate — Frax-assessed).
• PPI (gastroprotection).
• Tocilizumab (IL-6 receptor) steroid-sparing NICE-approved for relapsing or refractory disease.
• Taper prednisolone over 18–24 months based on symptoms and ESR/CRP.

UKMLA trap: 72-year-old with temporal headache, ESR 95, jaw pain on chewing → immediately 60 mg prednisolone → then arrange biopsy within 7 days. Do not delay steroids for biopsy result.

6. Diabetic Retinopathy Screening

Diabetic retinopathy (DR) is the leading cause of blindness in working-age adults in the UK. Screening is universal for diagnosed diabetes.

NHS Diabetic Eye Screening Programme:

• Annual fundus photography from age 12 for everyone with type 1 or type 2 diabetes.
• Grade: R0 (no retinopathy) / R1 (background — microaneurysms, dot-and-blot haemorrhages) / R2 (pre-proliferative — cotton wool spots, venous beading, IRMAs) / R3 (proliferative — neovascularisation) ± M0/M1 (no / with maculopathy).

Management:

• R1 / M0: annual screening; optimise glycaemic and BP control.
• R2 or M1: referral to ophthalmology for monitoring.
• R3 (proliferative): pan-retinal photocoagulation (PRP) ± intravitreal anti-VEGF (ranibizumab, aflibercept) to prevent neovascular complications.
• Macular oedema with vision threat: intravitreal anti-VEGF first-line (macular laser second).

Complications of proliferative DR:

• Vitreous haemorrhage.
• Tractional retinal detachment.
• Neovascular glaucoma (secondary angle closure — sight-threatening).

UKMLA trap: newly diagnosed type 2 diabetic at first screening with R3 changes → urgent ophthalmology referral for PRP. Tight glycaemic control + BP optimisation.

7. Orbital vs Pre-septal Cellulitis

The distinction is sight- and life-critical.

Pre-septal (periorbital) cellulitis:

• Infection anterior to orbital septum (eyelid and surrounding skin).
• Features: erythematous, swollen, tender eyelid. No proptosis, no ophthalmoplegia, no visual disturbance.
• Commonly follows local trauma, insect bite, stye, sinusitis (but confined).
• Management: oral co-amoxiclav, close monitoring, review 24–48 hours.

Orbital (post-septal) cellulitis:

• Infection posterior to orbital septum, involving orbital contents.
• Proptosis, restricted/painful eye movements (ophthalmoplegia), diplopia, reduced visual acuity, RAPD.
• Systemic: fever, malaise.
• Usually spreads from ethmoid sinusitis in children.
• Complications: optic nerve compression (vision loss), cavernous sinus thrombosis, intracranial spread (abscess, meningitis).
• Management: admit, IV broad-spectrum antibiotics (e.g. ceftriaxone + metronidazole, or local protocol), urgent CT orbits + sinuses, ENT/ophthalmology review, surgical drainage if abscess.

The single discriminator: ability to move the eye. If the eye can move fully and vision is normal → pre-septal. If any restriction, pain on movement, or visual change → orbital until proven otherwise.

UKMLA trap: child with sinusitis + swollen eyelid + painful eye movements + fever → orbital cellulitis → admit, IV antibiotics, CT.

8. Chalazion vs Stye

Stye (hordeolum):

• Acute, painful, red lump on the eyelid margin.
• Infection of eyelash follicle (external) or Meibomian gland (internal).
• Self-limiting — warm compresses, lid hygiene; antibiotic drops if secondary infection.

Chalazion (Meibomian cyst):

• Painless (or only mildly tender), firm, rubbery lump in the eyelid body.
• Chronic blockage of Meibomian gland; no active infection.
• Management: warm compresses, lid massage; refer for incision and curettage if persistent or large.

9. Acute Otitis Media — NICE Management in Children

Acute otitis media (AOM) is very common in young children and usually viral. NICE NG91 (updated) keeps antibiotic stewardship front and centre.

Features:

• Ear pain, fever, irritability, reduced feeding.
• On examination: red bulging tympanic membrane, loss of light reflex, air-fluid level, occasionally perforation with otorrhoea.

Management (NICE NG91):

• Paracetamol and/or ibuprofen for pain.
• Most resolve within 3 days without antibiotics.
• Consider immediate antibiotic if:
  • Systemically very unwell, signs of serious illness.
  • Bilateral AOM in a child under 2.
  • AOM with otorrhoea (perforation).
  • Symptoms lasting >4 days with no improvement.
• First-line antibiotic: amoxicillin 5 days (clarithromycin if penicillin-allergic).
• Safety-net advice for parents — return if worsening, signs of serious illness, lasting >3 days.
• Referral: recurrent AOM, hearing concerns, complications (mastoiditis).

Complications:

• Tympanic membrane perforation — usually heals spontaneously.
• Mastoiditis — post-auricular swelling/erythema + displaced pinna → emergency admission, IV antibiotics, possible mastoidectomy.
• Facial nerve palsy.
• Meningitis, intracranial abscess (rare).
• Chronic suppurative otitis media.
• Cholesteatoma (pearly white mass in attic; requires surgical removal).

Otitis media with effusion (glue ear):

• Common in under-5s post-AOM. Dull TM, air-fluid level, hearing loss.
• Watchful waiting 6–12 weeks; most resolve.
• Persistent → audiology ± ENT; grommets for bilateral effusion with ≥25 dB hearing loss persistent for 3 months.

10. Otitis Externa — Management Ladder

Otitis externa (OE) is inflammation of the ear canal — infection (bacterial, fungal), dermatitis, or both.

Risk factors: swimming, humidity, cerumen impaction, aggressive cleaning (cotton buds), dermatoses, diabetes, immunosuppression.

Features:

• Ear pain (classically severe with tragus tenderness on palpation).
• Itch.
• Discharge.
• Erythematous oedematous canal ± debris; tympanic membrane normal (may be obscured).

Management (NICE CKS):

• Mild: keep dry; topical acetic acid 2% (EarCalm) spray.
• Moderate: aural toileting + topical antibiotic–steroid combo drops (Otomize, Locorten-Vioform, Sofradex).
• Severe/fungal: aural toileting, topical clotrimazole (fungal), referral to ENT.
• Oral antibiotics (flucloxacillin) only if cellulitis spreading beyond canal, systemic symptoms, diabetic/immunocompromised.
• Avoid aminoglycoside drops if known TM perforation (ototoxicity risk).

Malignant (necrotising) otitis externa:

• Usually diabetic or immunocompromised.
• Pseudomonas aeruginosa infection extending to skull base.
• Severe pain out of proportion, granulation tissue in canal, cranial nerve palsies (VII most common).
• Emergency: admit, IV ciprofloxacin, urgent ENT referral, imaging (CT/MRI, bone scan).

11. Epistaxis — Anterior vs Posterior, First-Aid and Procedures

Anterior epistaxis (90%):

• Bleed from Kiesselbach's plexus (Little's area) on anterior septum.
• Causes: digital trauma (nose-picking), dry air, URI, cocaine use, HHT (hereditary haemorrhagic telangiectasia), anticoagulants, antiplatelets.

Posterior epistaxis (10%):

• Bleed from posterior branches of sphenopalatine artery.
• Usually older patients with HTN, anticoagulation.
• Heavier, more difficult to control, higher risk of airway compromise.

First aid (the "Trotter's maneuver" is sometimes called Trotter's position):

1. Sit upright, lean forward (prevents swallowing blood), mouth open to spit out blood.
2. Pinch the soft cartilaginous part of the nose (below the bony bridge) continuously for 10–20 minutes.
3. Ice pack on bridge of nose or back of neck.
4. Do not tip head back (blood swallowed, nausea, aspiration risk).

Escalation ladder:

• Failed pressure → topical vasoconstrictor-anaesthetic (co-phenylcaine or oxymetazoline).
• Visible anterior bleeding point → silver nitrate cautery (after anaesthesia).
• Failed → anterior nasal packing (Rapid Rhino, Merocel, or ribbon gauze with Vaseline).
• Ongoing → posterior packing (Foley catheter, posterior balloon) — admit, ENT review.
• Refractory → ENT procedures: endoscopic ligation of sphenopalatine artery, embolisation by IR.

Reversal of anticoagulation:

• Stop DOAC / warfarin.
• Reverse if major bleed: warfarin → IV vitamin K + PCC; dabigatran → idarucizumab; apixaban/rivaroxaban → PCC ± andexanet (see prescribing safety).

UKMLA trap: bleeding from posterior pharynx (visible) + haemodynamic instability + no visible anterior source → posterior epistaxis → posterior pack + ENT admission.

12. Tonsillitis vs Quinsy — Centor / FeverPAIN, Drainage

Acute tonsillitis:

• Sore throat, fever, cervical lymphadenopathy, exudate.
• Viral (majority) or bacterial (group A strep most common).

Scoring (NICE NG84 / Centor / FeverPAIN):

Centor (classic): tonsillar exudate / tender anterior cervical lymphadenopathy / fever >38°C / absence of cough. Each = 1 point. Score ≥3 suggests strep.

FeverPAIN (NICE-preferred): Fever in last 24 hours / Purulence / Attend rapidly (≤3 days) / severely Inflamed tonsils / No cough or coryza. Score ≥4 → antibiotic; 2–3 → delayed/no script; 0–1 → no antibiotic.

Management:

• Analgesia (paracetamol/ibuprofen), hydration.
• Antibiotics when indicated: phenoxymethylpenicillin (Penicillin V) 500 mg QDS for 10 days. Clarithromycin if allergy. Avoid amoxicillin — causes a morbilliform rash in EBV (glandular fever, which can mimic tonsillitis).
• Admission if severe (dehydration, airway compromise, immunocompromised, scarlet fever with complications, suspected quinsy).

Peritonsillar abscess (quinsy):

• Deep throat pain (often unilateral), trismus (difficulty opening mouth), muffled "hot potato" voice, uvular deviation away from the abscess, severe odynophagia, fever.
• Medical emergency — airway risk.
• Management: IV antibiotics (co-amoxiclav + metronidazole) + urgent ENT referral for drainage (needle aspiration or incision).

Complications:

• Rheumatic fever (post-strep, 2–3 weeks later) — carditis, polyarthritis, chorea.
• Post-streptococcal glomerulonephritis.
• Scarlet fever.
• Parapharyngeal / retropharyngeal abscess.

UKMLA trap: sore throat + trismus + muffled voice + uvular deviation → quinsy → IV antibiotics + ENT drainage. Do not trial oral amoxicillin.

Tonsillectomy (NICE/SIGN indications):

• ≥7 episodes/year for 1 year, OR
• ≥5 episodes/year for 2 years, OR
• ≥3 episodes/year for 3 years, each disabling.

13. Bell's Palsy — Steroids, Timing, Stroke Differential

Bell's palsy is idiopathic acute peripheral (lower motor neuron) facial nerve palsy — involves the forehead (distinguishes from stroke, where forehead is spared by bilateral UMN innervation of frontalis).

Features:

• Unilateral facial weakness (forehead, eye, mouth), onset over hours to days.
• Often preceded by aural pain or post-auricular pain.
• May have altered taste (anterior 2/3 tongue via chorda tympani), hyperacusis (stapedius), reduced tearing.

Differential (always exclude these before diagnosing Bell's):

• Stroke (UMN — forehead spared; other signs) — see neurology guide.
• Ramsay Hunt syndrome — VZV reactivation in geniculate ganglion: vesicles in ear canal / soft palate + facial palsy ± hearing loss/vertigo. Treat: aciclovir + prednisolone.
• Lyme disease (bilateral facial palsy in endemic areas).
• Cholesteatoma, parotid tumour — subacute progression.
• MS, Guillain-Barré (often bilateral).
• Otitis media, malignant otitis externa.
• Sarcoidosis (Heerfordt's syndrome).

Management (Bell's palsy):

• Prednisolone 50 mg OD for 10 days OR 60 mg OD for 5 days then taper — within 72 hours of onset (best evidence for improved outcome). NICE CKS aligned.
• Antivirals (aciclovir) not routinely recommended in Bell's (only in Ramsay Hunt or if pregnancy-related Bell's).
• Eye care — lubricants + tape eye shut at night (risk of exposure keratitis).
• ENT / ophthalmology if incomplete recovery at 3 weeks or signs of complications.
• Prognosis: 70–80% full recovery within 3–6 months. Incomplete recovery → physio, possibly plastic/ENT referral.

UKMLA trap: patient presents day 4 after onset of Bell's palsy → can still start prednisolone (benefit greatest in first 72 hours but reasonable up to 7 days per NICE CKS and Cochrane). Always examine ear for Ramsay Hunt vesicles — changes management.

14. BPPV vs Ménière's vs Vestibular Neuritis

Three common causes of vertigo with different mechanisms and management.

BPPV (benign paroxysmal positional vertigo):

• Otoconia in posterior semicircular canal.
• Brief (<60 seconds) vertigo triggered by head movement (rolling over in bed, looking up).
• No hearing loss or tinnitus.
• Dix-Hallpike test provokes nystagmus (torsional, upbeating, latency 2–20 seconds, fatigable).
• Epley manoeuvre — repositioning procedure; effective in 80% after 1–2 treatments.
• Self-help: Brandt-Daroff exercises.

Ménière's disease:

• Endolymphatic hydrops — increased endolymph pressure.
• Classic triad: vertigo (lasting 20 minutes to 24 hours) + fluctuating sensorineural hearing loss + tinnitus ± aural fullness.
• Recurrent attacks, progressive hearing loss over years.
• Management:
  • Acute: prochlorperazine, antihistamines (cinnarizine, cyclizine), bed rest.
  • Prophylaxis: betahistine, low-salt diet, caffeine reduction, avoid alcohol.
  • Intratympanic gentamicin, endolymphatic sac decompression for refractory cases.
• Audiology referral for hearing aids; driving advice (DVLA).

Vestibular neuritis / labyrinthitis:

• Viral inflammation of vestibular nerve (± cochlear = labyrinthitis).
• Single prolonged episode of vertigo (days), nausea, vomiting, unsteadiness.
• No hearing loss (neuritis) vs hearing loss (labyrinthitis).
• Often post-URTI.
• Management: prochlorperazine (short-term only, max 3 days — prolonged use delays central compensation), vestibular rehabilitation exercises.
• Most resolve in weeks.

Central causes to exclude:

• Stroke (posterior circulation — cerebellar stroke often presents with isolated vertigo; HINTS examination sensitive).
• MS (optic neuritis, relapsing-remitting pattern).
• Acoustic neuroma (progressive unilateral hearing loss + tinnitus + imbalance — MRI IAMs).

UKMLA traps:

• Brief spinning on turning in bed + positive Dix-Hallpike → BPPV → Epley.
• Recurrent prolonged vertigo + progressive hearing loss + tinnitus → Ménière's → betahistine + lifestyle.
• Single 5-day vertigo post-URTI, no hearing loss → vestibular neuritis → prochlorperazine short-term + vestibular rehab.
• Sudden vertigo + ataxia + cranial nerve signs → central (stroke) → CT/MRI, stroke pathway.

15. Common Foreign Bodies in ENT and Ophth

Eye:

• Conjunctival / corneal foreign body: fluorescein stain, topical anaesthetic, slit lamp examination. Remove with cotton bud or needle (experienced clinician). Topical antibiotic prophylaxis. Refer if embedded, metallic, near visual axis, or unable to remove.
• Chemical injury: irrigate immediately with saline or water for ≥30 minutes — do not delay for pH measurement. Alkali injuries (cement, bleach, ammonia) worse than acid. Urgent ophthalmology.
• High-velocity foreign body (grinding, hammering metal): suspect intraocular FB → X-ray orbits, urgent ophthalmology, no eye patching.

Ear:

• Children often insert beads, small toys, food. Adult FBs often insects (flush with olive oil or water to drown first).
• Do not attempt removal if live insect moving (risk of damage), or if deep/medial, or if lithium button battery (urgent ENT — corrosive damage within hours).
• Removal by irrigation, hooks, or alligator forceps by experienced clinician.

Nose:

• Children: peas, beads, peanuts, toys.
• "Mother's kiss" technique: occlude other nostril, parent blows gentle puff of air into mouth.
• Refer to ENT if posterior or failed.
• Button battery in the nose — emergency: bilateral perforation of nasal septum within hours. Urgent removal.

Throat / airway:

• Coin or small object lodged at cricopharyngeus (commonest site).
• Assess airway. Choking → back blows → abdominal thrusts (adult/child) / chest thrusts (infant).
• CXR (bone impacted at C6 level), AXR if swallowed further.
• Fish bone: tonsillar fossa or base of tongue; remove under direct vision.
• Button battery in oesophagus: emergency endoscopic removal — oesophageal perforation within 2 hours.

UKMLA trap: child with new-onset foul unilateral nasal discharge → nasal foreign body → examine and remove or refer. A button battery demands same-day ENT regardless of symptoms.

The UKMLA Ophth + ENT Pattern Library

Twelve stems worth owning:

1. Elderly woman, eye pain, vomiting, haloes, mid-dilated pupil → acute angle-closure glaucoma → pilocarpine + timolol + acetazolamide + ophthalmology.
2. Sudden painless monocular vision loss + cherry-red spot → CRAO → ocular massage + GCA workup + vascular workup.
3. Blood and thunder fundus → CRVO → urgent ophthalmology + anti-VEGF for macular oedema.
4. Flashes, floaters, curtain → retinal detachment → urgent ophthalmology.
5. 72 y/o with temporal headache + jaw claudication + ESR 95 → GCA → 60 mg prednisolone now + biopsy within 7 days.
6. Child with sinusitis + painful eye movements + proptosis → orbital cellulitis → IV antibiotics + CT + ENT/ophth.
7. Child with bilateral AOM <2, fever, bulging TMs → amoxicillin 5 days.
8. Diabetic with severe ear pain, granulation in canal, cranial nerve VII palsy → malignant otitis externa → IV ciprofloxacin + ENT.
9. Epistaxis not stopping with 20 minutes' pressure + visible bleed far posteriorly → posterior pack + ENT admission.
10. Sore throat + trismus + muffled voice + uvular deviation → quinsy → IV antibiotics + drainage.
11. Forehead-involved facial droop within 48 hours → Bell's palsy → prednisolone + eye care; examine for Ramsay Hunt vesicles.
12. Brief rotatory vertigo on turning in bed + positive Dix-Hallpike → BPPV → Epley manoeuvre.

Putting It All Together

Ophthalmology and ENT reward a three-question triage on every stem: (1) is it sight- or airway-threatening? (2) what is the single discriminator — pupil, fundus, eye movement, forehead involvement? (3) who needs to see them within an hour? Those three answers account for most of the marks.

Pair this pillar with our emergency presentations masterclass for sight-threatening pathology, the neurology high-yield guide for GCA, Bell's palsy, posterior circulation vertigo, and stroke differentials, the endocrinology guide for diabetic retinopathy screening and management, and NICE guidelines high-yield for antibiotic stewardship in AOM and sore throat.

If an ophthalmology stem is unclear, reach for the red-eye matrix and fill in the row. If an ENT stem is unclear, ask whether the airway is safe and whether hearing or facial-nerve function is at risk. The right answer will usually fall out in the next sentence. Ready to test yourself? Start with an MLA Prep ophthalmology + ENT mini-mock and see which of the twelve patterns you close on first read.