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Question 1
Incorrect
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A 27-year-old female visited the OPD with a complaint of visual disturbance, eye pain, pain in the knee and hands, and a rash on her face. On examination, the rash was the shape of a butterfly, and the joints were mildly swollen. The eyes of the patient were found to be red with irregular pupils. Where do you think the problem lies?
Your Answer: Sclera
Correct Answer: Iris
Explanation:The patient’s symptoms are suggestive of ankylosing spondylitis which is often accompanied by iritis, the cause of this patient’s red eye.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Correct
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A 45-year-old pharmacist with a history of rheumatoid arthritis presents with a two day history of a red right eye. There is no itch or pain. Pupils are 3mm, equal and reactive to light. Visual acuity is 6/5 in both eyes. What is the most likely diagnosis?
Your Answer: Episcleritis
Explanation:Ocular manifestations of rheumatoid arthritis are common, with 25% of patients having eye problems. These manifestations include keratoconjunctivitis sicca (most common), episcleritis (erythema), scleritis (erythema and pain), corneal ulceration, and keratitis.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Correct
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A patient shows reduced central vision upon visual acuity test. He is advised to undergo a fundoscopy, which turns out to be normal. Which drug could be responsible for his symptoms?
Your Answer: Corticosteroids
Explanation:Corticosteroids are well known for their ocular complications such as glaucoma and cataracts.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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An 84-year-old retired police officer presents to the neurology clinic with double vision and unsteadiness whilst walking. He has a past medical history of hypertension, hypercholesterolemia and type 2 diabetes. On examination, you notice a right partial ptosis and miosis. The patient also has notable right facial loss of pain and temperature sensation with left sided truncal sensory loss contralateral to the face. In the clinic, apraclonidine eye drops are added to the affected eye, which causes a dilatation, whilst in the opposite eye, a pupil constriction occurs. After the eye drops have been eliminated from the body, 1% hydroxyamphetamine eye drops are then instilled. One hour after instillation, both pupils dilate. Which order of neurons is most likely affected in the sympathetic pathway?
Your Answer: Third order
Correct Answer: First order
Explanation:Apraclonidine eye drops are initially used to confirm a Horner’s pupil. Apraclonidine stimulates both alpha-1 and alpha-2 receptors. When added to the affected eye, it causes pupil dilation by >2mm because of the relative super sensitivity of this pupil to alpha-1 receptor activity. In a normal pupil, however, it causes constriction due to the more potent activity at the alpha-2 receptor which triggers re-uptake of noradrenaline in the synaptic cleft.
Hydroxy amphetamine is then used to distinguish between first/second or third order neurones. In other words, it will distinguish either a lesion in the brainstem, cervical cord, chest or neck and one affecting above the superior cervical ganglion at the carotid bifurcation. In a normal pupil or a first/second order Horner’s, the pupil will dilate secondary to increased levels of noradrenaline released from the post-synaptic neurones. In a third order neurone, this will not occur. There is no fourth or fifth order neurone.
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This question is part of the following fields:
- Ophthalmology
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Question 5
Correct
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A 45-year-old male patient came to the OPD with a complaint of severe headache on the right side, with right-sided jaw pain, and additional blurred vision in the right eye. The headache was throbbing in character. Which investigation will you prefer next?
Your Answer: Erythrocyte sedimentation rate (ESR)
Explanation:Age of the patient, headache only on one side, and loss of vision on that side suggest temporal arteritis, also known as giant cell arteritis. The laboratory hallmark of this condition is a raised ESR.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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A 30-year-old lawyer presents with a one-day history of a painful, red left eye. She describes how her eye is continually streaming tears. On examination, she exhibits a degree of photophobia in the affected eye and application of fluorescein demonstrates a dendritic pattern of staining. Visual acuity is 6/6 in both eyes. What is the most appropriate management?
Your Answer: Perform a lumbar puncture
Correct Answer: Topical acyclovir
Explanation:This patient has a dendritic corneal ulcer. Herpes simplex keratitis most commonly presents with a dendritic corneal ulcer. Topical acyclovir and ophthalmology review is required. Giving a topical steroid in this situation could be disastrous as it may worsen the infection.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Correct
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A 70-year-old female presented to her ophthalmologist with a complaint of weakening eyesight despite continued use of her corrective glasses. She also had a history of mild headaches for a few weeks. On fundoscopy, the disc had blurred margins with mild cupping and a sickle shaped scotoma in both eyes. What is the most appropriate treatment in this case?
Your Answer: Pilocarpine eye drops
Explanation:Frequent change of eye glasses, scotoma, and mild cupping are suggestive of primary open angle glaucoma. This means that the anterior angle of the eye is normal but there is a problem in the trabecular meshwork, where the Schlemm’s Canal is not allowing the drainage of the aqueous humor. Pilocarpine should be given to the patient because it is a parasympathomimetic agent. It causes the ciliary muscle of the eye to contract, causing the trabecular meshwork to open up, allowing the aqueous humor to drain again.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Incorrect
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A 62 year old patient presents to the ophthalmology OPD with progressive deterioration of vision and dazzling of view in well lit environments. Which of the following is the most likely diagnosis leading to this presentation?
Your Answer: Cataracts
Correct Answer:
Explanation:Cataract is a condition characterized by clouding of the lens of the eye. This condition most frequently occurs due to age-related degenerative processes in the lens, but can also be associated with ocular trauma, metabolic disorders, side-effects of drugs, or congenital infections. The clouding causes distortion of light, as it passes through the lens, resulting in visual impairment and glare. Initially, a cataract presents discretely and may even go unnoticed, but the visual impairment worsens as the cataract grows larger.
Diagnosis is typically established on the basis of a thorough history and direct visualization of the cataract (by means of slit-lamp microscopy). Surgery is indicated with significant visual impairment and involves lens extraction and implantation of an artificial lens. Untreated cataracts eventually lead to complete blindness.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Correct
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Which of the following is associated with heterochromia in congenital disease?
Your Answer: Horner's syndrome
Explanation:Heterochromia (difference in iris colour) is seen in congenital Horner’s syndrome, as well as anhidrosis. Other features of non-congenital Horner’s include miosis, ptosis and enophthalmos.
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This question is part of the following fields:
- Ophthalmology
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Question 10
Incorrect
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A 62-year-old laboratory technician presents to the ophthalmology emergency department with sudden onset painless loss of vision in the right eye. He describes it as having a dense shadow over his vision, progressing from the periphery to the centre. He has no past medical history of note. Which of the following is the most likely diagnosis?
Your Answer: Central retinal artery occlusion
Correct Answer: Retinal detachment
Explanation:The most common causes of a sudden painless loss of vision are as follows:
– Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis)
– Occlusion of central retinal vein
– Occlusion of central retinal artery
– Vitreous haemorrhage
– Retinal detachmentRetinal detachment is a cause of sudden painless loss of vision. It is characterised by a dense shadow starting peripherally and progressing centrally.
Vitreous haemorrhage usually presents with dark spots.
Central retinal artery and central retinal vein occlusion do not usually present with progressing dense shadow.
This man’s lack of ischaemic risk factors makes ischaemic optic neuropathy less likely.
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This question is part of the following fields:
- Ophthalmology
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Question 11
Incorrect
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A 70-year-old retired software developer with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his right eye. On examination of the right eye, the optic disc is swollen with multiple flame-shaped and blot haemorrhages. Which of the following is the most likely diagnosis?
Your Answer: Diabetic retinopathy
Correct Answer: Occlusion of central retinal vein
Explanation:Central retinal vein occlusion includes features such as sudden painless loss of vision, but is distinguished from central retinal artery occlusion by the presence of severe retinal haemorrhages on fundoscopy examination.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Incorrect
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A 27-year-old consultant who has a family history of retinitis pigmentosa is reviewed in the ophthalmology clinic. He reports worsening vision over the past few months. During fundoscopy, which of the following findings would most support a diagnosis of retinitis pigmentosa?
Your Answer: Pigmented choroidal neovascularisation throughout the retina
Correct Answer: Black bone spicule-shaped pigmentation in the peripheral retina
Explanation:Retinitis pigmentosa is a genetic disorder primarily affecting the peripheral retina resulting in tunnel vision. Night blindness is often the initial sign. Fundoscopy exam reveals black bone spicule-shaped pigmentation in the peripheral retina, and mottling of the retinal pigment epithelium.
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This question is part of the following fields:
- Ophthalmology
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Question 13
Incorrect
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An 87-year-old woman presents with 'funny spots' affecting her vision. Over the past week she has noticed a number of flashes and floaters in the visual field of the right eye. Which of the following is the most likely diagnosis?
Your Answer: Optic neuritis
Correct Answer: Posterior vitreous detachment
Explanation:Posterior vitreous detachment is thought to occur in up to 50-75% of the population over 65 years and is the most likely diagnosis here. Patients should be reviewed by an ophthalmologist to assess the risk of progressing to retinal detachment. Flashes of light (photopsia) occur in the peripheral field of vision while floaters often occur on the temporal side of the central vision.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Correct
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A 8 year old boy presented with pain and swelling around the right eye. On examination there was no proptosis or ophthalmoplegia. Which of the following is the most probable diagnosis?
Your Answer: Peri orbital cellulitis
Explanation:Infections of the superficial skin around the eyes are called periorbital, or preseptal, cellulitis. It is predominantly a paediatric disease. Erysipelas is a bacterial skin infection involving the upper dermis which extends into the superficial cutaneous lymphatics. Sinusitis is in sinuses. Orbital infections and conjunctivitis are within the eye.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Incorrect
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A 39-year-old professor presents with visual problems. He has had very poor vision in the dark for a long time but is now worried as he is developing 'tunnel vision'. He states his grandfather had a similar problem and went blind in his 50's. Which of the following is the most likely diagnosis?
Your Answer: Primary open angle glaucoma
Correct Answer: Retinitis pigmentosa
Explanation:Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision. Night blindness is often the initial sign. Tunnel vision occurs due to loss of the peripheral retina (occasionally referred to as funnel vision).
Fundoscopy exam reveals black bone spicule-shaped pigmentation in the peripheral retina, and mottling of the retinal pigment epithelium. -
This question is part of the following fields:
- Ophthalmology
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Question 16
Incorrect
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A 45-year-old patient presents with a red, watering eye, complaining of a severe left sided headache and vision distortion with coloured haloes. What would be the next best step in management of this patient?
Your Answer: CT Scan
Correct Answer: Measure Intraocular pressure
Explanation:Acute angle closure glaucoma can manifests itself with severe headache, nausea or vomiting, very blurry or hazy vision, seeing rainbows or halos around lights and redness in the white part of the affected eye. It is caused by a rapid or sudden increase in pressure inside the eye – intraocular pressure (IOP). In order to establish the diagnosis and start treatment immediately, IOP should first be measured.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Correct
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A 30-year-old female diagnosed with rapidly progressive glomerulonephritis complains of pain and redness in the right eye. Which part of the eye is causing these symptoms in this case?
Your Answer: Sclera
Explanation:Rheumatoid Scleritis is a painful inflammatory condition of the sclera in patients with rheumatoid arthritis. It might be diffuse, nodular, or necrotizing in nature. This occurs mostly in the sixth decade of life and mostly when the rheumatoid disease is in remission. Sclera is the first ocular manifestation in a patient of rheumatoid arthritis. This inflammation might later spread to the adjacent ocular structures like the cornea, causing keratitis, the uveal tract causing uveitis and the lens causing cataracts.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Incorrect
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A 65-year-old complains of fatigue, headache and blurred vision in the left eye. Moreover, she is unable to comb her hair. What is the most probable diagnosis?
Your Answer: Amaurosis fugax
Correct Answer: Temporal arteritis
Explanation:The patient is in a suitable age for developing temporal arteritis and the fact that she’s unable to comb her hair indicates scalp tenderness or proximal muscle weakness. A high ESR together with increased CRP supports the diagnosis. Temporal artery biopsy is also useful to establish the diagnosis.
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This question is part of the following fields:
- Ophthalmology
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Question 19
Incorrect
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A 55 year old man experiences sudden loss of vision preceded by the perception of something he describes as jagged lines or 'heat waves'. He's known to be myopic. What is the best treatment?
Your Answer: Peripheral iridectomy
Correct Answer: Scleral buckling
Explanation:The clinical picture is characteristic of retinal detachment, which should be treated immediately to prevent permanent loss of vision. Scleral buckling is a surgical procedure used to repair a retinal detachment, where the surgeon attaches a piece of silicone or a sponge onto the white of the eye at the spot of a retinal tear pushing the sclera toward the retinal tear or break, promoting repair. Signs of detachment include an increase in the number of eye floaters, flashes of light in the field of vision, and reduced peripheral vision.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Correct
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A 40-year-old male has a 6-year history of hypertension. For two days, he has been having extreme difficulty in seeing things clearly and now complains of cloudy vision. On fundoscopy, flame-shaped haemorrhages are found in the patient's right eye. Margins of the optic disc were also found to be blurred. Which of the following conditions is this patient most likely suffering from?
Your Answer: CRV thrombosis
Explanation:Fundoscopy reveals flame-shaped haemorrhages which are specific to central retinal vein occlusion (CRVO). In CRA thrombosis, fundoscopy would show a cherry-red spot. A patient with retinal detachment would give a characteristic history of seeing flashes of light and floaters. Background retinopathy is associated with diabetes.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Correct
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A 40-year-old male patient, who is otherwise healthy and without a significant family history, presents with a history of early morning headache and visual field defects, When asked, he said that he has been having these complaints for three months now. What is the most possible diagnosis?
Your Answer: Pituitary tumour
Explanation:The most possible diagnosis is a pituitary tumour. Pituitary tumours compress the optic chiasm inferiorly and can cause visual field defects (bitemporal hemianopia or quadrantanopia). Temporal arteritis usually develops in older people and acute glaucoma usually requires a family history. Amaurosis fugax is classed as a stroke and usually leads to reversible unilateral vision loss. A subconjunctival haemorrhage does not typically produce the symptoms described.
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This question is part of the following fields:
- Ophthalmology
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Question 22
Incorrect
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A 27 year old female has been taken to A&E from a cinema after complaining of sudden severe pain in the eyes. This is followed by seeing coloured halos and vomiting. She has a history of reoccurring headaches which used to resolve themselves. She is examined and is found to have a fixed, dilated ovoid pupil. Choose the most appropriate first investigation from the list.
Your Answer: CT head
Correct Answer: Applanation tonometry
Explanation:The darkness of the cinema room will have caused halfway dilation of the pupil. This can cause an acute attack of angle closure glaucoma. The appropriate test to diagnose this is applanation tonometry.
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This question is part of the following fields:
- Ophthalmology
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Question 23
Correct
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A 20-year-old man presents with a history of sticky greenish discharge, accompanied by redness of the eyes, and difficulty opening his eyes in the morning. What is the single most likely cause of these symptoms?
Your Answer: Conjunctivitis
Explanation:Redness of the eyes can present in all of the conditions. However, the green sticky discharge that causes the eyelids to stick together overnight is characteristic of bacterial conjunctivitis. Bacterial conjunctivitis is an inflammatory condition of the conjunctiva in which bacteria commonly Staphylococcus Aureus invade the conjunctiva. The person experiences a foreign body feeling in the eye and mucopurulent or purulent discharge.
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This question is part of the following fields:
- Ophthalmology
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Question 24
Correct
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A 29-year-old accountant presents to the emergency department complaining of left eye pain. He has not been able to wear his contact lenses for the past 24 hours due to the pain. He describes the pain as severe and wonders whether he has 'got something stuck in his eye'. On examination, there is diffuse hyperaemia of the left eye. The left cornea appears hazy and pupillary reaction is normal. Visual acuity is reduced on the left side and a degree of photophobia is noted. A hypopyon is also seen. Which of the following is the most likely diagnosis?
Your Answer: Keratitis
Explanation:Hypopyon can be seen in anterior uveitis, however the combination of a normal pupillary reaction and contact lens use make a diagnosis of keratitis more likely. Keratitis describes inflammation of the cornea, and features include red eye with pain and erythema, photophobia, and foreign body/gritty sensation.
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This question is part of the following fields:
- Ophthalmology
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Question 25
Incorrect
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A 34-year-old woman has had progressive reduction of visual acuity over the past 3 years. She has now almost lost all of her vision. What is the diagnosis?
Your Answer: Cataract
Correct Answer: Retinitis pigmentosa
Explanation:Retinitis pigmentosa is a genetic disorder of the eyes that causes loss of vision. Symptoms include trouble seeing at night and decreased peripheral vision. Onset of symptoms is generally gradual.
– In keratitis, there will be pain, redness and photophobia but vision is not affected
– In macular degeneration, near blindness does not occur rather the inability to identify faces or read small print
– Cataracts are more common in elderly
– It is not angle closure glaucoma as angle closure glaucoma occurs usually after the age of 50; In open angle glaucoma visual loss is not gradual but rather occurs suddenly following progression -
This question is part of the following fields:
- Ophthalmology
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Question 26
Correct
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Which of the following statements regarding macular degeneration is true?
Your Answer: Wet macular degeneration carries the worst prognosis
Explanation:Traditionally two forms of macular degeneration are seen:
– Dry (geographic atrophy) macular degeneration is characterized by drusen – yellow round spots in Bruch’s membrane.
– Wet (exudative, neovascular) macular degeneration is characterized by choroidal neovascularization. Leakage of serous fluid and blood can subsequently result in a rapid loss of vision. This carries the worst prognosis. -
This question is part of the following fields:
- Ophthalmology
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Question 27
Incorrect
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A 75-year-old retired firefighter with a history of type 2 diabetes mellitus and hypertension presents due to the sensation of light flashes in his right eye. These symptoms have been present for the past 2 days and seem to occur more at the peripheral part of vision. There is no redness or pain in the affected eye. Corrected visual acuity is measured as 6/9 in both eyes. Which of the following is the most likely diagnosis?
Your Answer: Normal phenomenon in diabetic retinopathy
Correct Answer: Vitreous detachment
Explanation:Flashes and floaters are symptoms of vitreous detachment. The patient is at risk of retinal detachment and should be referred urgently to an ophthalmologist.
The most common causes of a sudden painless loss of vision are as follows:
– Ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis)
– Occlusion of central retinal vein
– Occlusion of central retinal artery
– Vitreous haemorrhage
– Retinal detachment -
This question is part of the following fields:
- Ophthalmology
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Question 28
Correct
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A 44-year-old physiotherapist with a history of rheumatoid arthritis presents with a painful, red left eye. Visual acuity is normal. Fundoscopy is also unremarkable. Which of the following is the most likely diagnosis?
Your Answer: Scleritis
Explanation:Scleritis, or inflammation of the sclera, is usually painful whereas episcleritis is not painful.
Keratoconjunctivitis sicca is usually bilateral and associated more with dryness, burning and itching.
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This question is part of the following fields:
- Ophthalmology
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Question 29
Correct
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A 49-year-old woman suddenly experienced complete loss of vision in her right eye. Fundoscopy results show a pale retina, and a cherry red spot on the macular region. She also experienced right sided headaches aggravated by chewing. What caused her vision loss?
Your Answer: CRAO
Explanation:Central retinal artery occlusion (CRAO) is a disease of the eye where the flow of blood through the central retinal artery is blocked (occluded). There are several different causes of this occlusion; the most common is carotid artery atherosclerosis. It causes sudden vision loss in one eye. Fundoscopic exam will show a red lesion, called a cherry red spot, with surrounding pale retina (the pale colour is caused by ischemia of the retina)
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This question is part of the following fields:
- Ophthalmology
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Question 30
Incorrect
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A 70 year old male complained of poor vision at night which has gradually worsened with time. He has changed his glasses several times but there has been no improvement. On examination his pupils and cornea were normal. Which of the following is the most probable diagnosis?
Your Answer:
Correct Answer: Cataract
Explanation:Senile cataract is an age-related, vision-impairing disease characterized by gradual progressive clouding and thickening of the lens of the eye. Patients with senile cataracts often present with a history of gradual progressive visual deterioration and disturbance in night and near vision.
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This question is part of the following fields:
- Ophthalmology
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