INI-CET 2017 — Ophthalmology

Q: Identify the instrument used: (AIIMS Nov 2017)

Episiotomy scissors. ***Episiotomy scissors*** - These scissors are characterized by their **blunt, angled tip** on one blade, which is designed to protect the fetal head during an episiotomy. - The image clearly shows this specific design, making them ideal for cutting soft tissues in a controlled manner without puncturing underlying structures. *Dissection scissors* - Dissection scissors typically have **sharp tips**, either straight or curved, and are used for cutting and separating tissues with precision. - They lack the blunt, angled tip characteristic of episiotomy scissors. *Mayo scissors* - **Mayo scissors** are heavy-duty scissors, typically used for cutting **fascia, sutures, and dense tissues**. - They often have straight or slightly curved blades without the protective blunt tip seen in episiotomy scissors. *Metzenbaum scissors* - **Metzenbaum scissors** are known for their **long handles and relatively short, delicate blades**, designed for cutting and dissecting fine, delicate tissues. - Their blades are typically slender and do not feature the angled, blunt tip of episiotomy scissors. [Practice more Ophthalmology PYQs on OnCourse]

Q: Identify the FFA picture:

NPDR. ***NPDR*** - The image shows areas of **capillary non-perfusion** (dark areas without visible blood flow) and **microaneurysms** (small bright dots due to damaged capillaries). These are characteristic findings of **Non-Proliferative Diabetic Retinopathy (NPDR)** on fluorescein angiography. - There is no evidence of neovascularization, which is the hallmark of proliferative diabetic retinopathy. *PDR* - **Proliferative Diabetic Retinopathy (PDR)** is characterized by the presence of **neovascularization** (new, abnormal blood vessel growth) on the retina or optic disc. - This image does not show any signs of neovascularization, which would appear as brightly fluorescing, tangled vessels. *Familial dominant drusen* - **Familial dominant drusen** are typically seen as yellow-white deposits under the retinal pigment epithelium and would manifest on FFA as **hyperfluorescent spots**, but usually with a different distribution and appearance than the microaneurysms seen here. - This image reflects widespread microvascular damage consistent with a retinal vascular disease, not primarily drusen. *Birdshot choroidopathy* - **Birdshot choroidopathy** is a chronic, bilateral posterior uveitis characterized by multiple, depigmented choroidal lesions (birdshot lesions). - On FFA, these lesions would typically show **hypofluorescence** in the early phases due to blocked choroidal fluorescence and possible late staining, which is not depicted in this image. [Practice more Ophthalmology PYQs on OnCourse]

Q: Identify the refractive error shown in the image:

Astigmatism. ***Astigmatism*** - The image shows that light rays from a single point source are **not focused at a single point** on the retina, but rather spread across multiple focal points or a line. This pattern is characteristic of **astigmatism**, where the eye's cornea or lens has an irregular curvature. - Specifically, rays 1 and 2 converge at one point, while rays 3 and 4 converge at a different point, indicating that the eye has different refractive powers along different meridians, which defines **astigmatism**. *Myopia* - In **myopia (nearsightedness)**, light rays from a distant object focus **in front of the retina**, not at multiple planes or lines as depicted. - Myopia would show all rays converging to a single point before reaching the retina, resulting in a blurry image. *Hypermetropia* - In **hypermetropia (farsightedness)**, light rays from a distant object focus **behind the retina**, assuming the eye is unaccommodated. - This condition would show the rays converging to a single point beyond the retinal plane, not divergent focal points within the eye. *Presbyopia* - **Presbyopia** is an age-related condition where the eye's **lens loses its flexibility**, making it difficult to focus on nearby objects. - It primarily affects near vision and does not typically involve the multiple focal points for distant vision as shown in the image. [Practice more Ophthalmology PYQs on OnCourse]

Q: A patient has the following presentation. After administration of an intravenous drug to the patient, in 6 minutes his symptoms have resolved. The diagnosis of the patient is:

Myasthenia gravis. The question refers to an accompanying image (not provided in the text, but essential for context) showing a patient with **ptosis** (drooping eyelid) and possibly other ocular muscle weakness. The key information is that symptoms resolve within 6 minutes after administration of an intravenous drug. This rapid and complete resolution of symptoms following drug administration is highly characteristic of a specific condition and a specific diagnostic test. ***Myasthenia gravis*** - The rapid resolution of symptoms (ptosis and possibly other ocular muscle weakness) within 6 minutes after intravenous drug administration is the hallmark of a positive **Tensilon test**. - The **Tensilon test** involves injecting **edrophonium**, a short-acting acetylcholinesterase inhibitor, which temporarily increases acetylcholine at the neuromuscular junction, improving muscle strength in patients with **myasthenia gravis**. *Sixth nerve palsy* - Sixth nerve palsy (abducens nerve palsy) causes **diplopia** (double vision) and an inability to abduct the affected eye. - While symptoms may fluctuate or improve with treatment, they would not resolve completely in 6 minutes with a diagnostic agent like edrophonium. *Third nerve palsy* - Third nerve palsy (oculomotor nerve palsy) can cause **ptosis**, **diplopia**, and impairment of eye movements (inability to adduct, elevate, or depress the eye). - Nerve palsies are structural or neurological deficits that do not rapidly reverse with a cholinergic agonist like edrophonium. *Tolosa-Hunt syndrome* - Tolosa-Hunt syndrome is a rare inflammatory disorder characterized by **painful ophthalmoplegia** (paralysis of eye muscles), often affecting the third, fourth, and/or sixth cranial nerves. - It typically responds to corticosteroids, but symptoms would not resolve in 6 minutes with an intravenous drug, and the diagnostic approach is different. [Practice more Ophthalmology PYQs on OnCourse]

Q: What is the diagnosis?

Third nerve palsy. ***Third nerve palsy*** - The image shows **ptosis** (drooping of the eyelid) and **pupil dilation** with the eye deviated **down and out**, which are classic signs of a complete third nerve palsy. - The **oculomotor nerve (CN III)** innervates most extraocular muscles (**superior, medial, inferior recti, and inferior oblique**), the **levator palpebrae superioris**, and the **parasympathetic fibers to the pupillary constrictor muscle**. *Sixth nerve palsy* - A sixth nerve palsy (**abducens nerve**) would cause an inability to **abduct the eye** (move it outwards) leading to an **esotropia** (eye turned inward at rest) and **horizontal diplopia**, which is not depicted. - Symptoms primarily affect the **lateral rectus muscle**. *Myasthenia gravis* - Myasthenia gravis can cause **ptosis** and **diplopia**, but typically presents with **variable and fluctuating weakness** that worsens with fatigue. - It does not usually cause the fixed, specific pattern of strabismus and pupillary involvement seen in a severe third nerve palsy. *Tolosa-Hunt syndrome* - Tolosa-Hunt syndrome is a **painful ophthalmoplegia** caused by **non-specific inflammation** in the cavernous sinus or orbital apex. - While it can affect cranial nerves III, IV, V1, and VI, leading to **ophthalmoplegia** and **ptosis**, the defining feature is often **severe orbital pain**, which cannot be assessed from the image alone, and the specific constellation of symptoms in the image points more directly to a third nerve lesion rather than an inflammatory syndrome. [Practice more Ophthalmology PYQs on OnCourse]

7 Previous Year Questions with Answers & Explanations

Questions

Identify the instrument used: (AIIMS Nov 2017)

Identify the FFA picture:

Identify the refractive error shown in the image:

A patient has the following presentation. After administration of an intravenous drug to the patient, in 6 minutes his symptoms have resolved. The diagnosis of the patient is:

What is the diagnosis?

A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

INI-CET 2017 - Ophthalmology INI-CET Practice Questions and MCQs

Question 1: Identify the instrument used: (AIIMS Nov 2017)

A. Episiotomy scissors (Correct Answer)
B. Dissection scissors
C. Mayo scissors
D. Metzenbaum scissors

Explanation: ***Episiotomy scissors*** - These scissors are characterized by their **blunt, angled tip** on one blade, which is designed to protect the fetal head during an episiotomy. - The image clearly shows this specific design, making them ideal for cutting soft tissues in a controlled manner without puncturing underlying structures. *Dissection scissors* - Dissection scissors typically have **sharp tips**, either straight or curved, and are used for cutting and separating tissues with precision. - They lack the blunt, angled tip characteristic of episiotomy scissors. *Mayo scissors* - **Mayo scissors** are heavy-duty scissors, typically used for cutting **fascia, sutures, and dense tissues**. - They often have straight or slightly curved blades without the protective blunt tip seen in episiotomy scissors. *Metzenbaum scissors* - **Metzenbaum scissors** are known for their **long handles and relatively short, delicate blades**, designed for cutting and dissecting fine, delicate tissues. - Their blades are typically slender and do not feature the angled, blunt tip of episiotomy scissors.

Question 2: Identify the FFA picture:

A. NPDR (Correct Answer)
B. PDR
C. Familial dominant drusen
D. Birdshot choroidopathy

Explanation: ***NPDR*** - The image shows areas of **capillary non-perfusion** (dark areas without visible blood flow) and **microaneurysms** (small bright dots due to damaged capillaries). These are characteristic findings of **Non-Proliferative Diabetic Retinopathy (NPDR)** on fluorescein angiography. - There is no evidence of neovascularization, which is the hallmark of proliferative diabetic retinopathy. *PDR* - **Proliferative Diabetic Retinopathy (PDR)** is characterized by the presence of **neovascularization** (new, abnormal blood vessel growth) on the retina or optic disc. - This image does not show any signs of neovascularization, which would appear as brightly fluorescing, tangled vessels. *Familial dominant drusen* - **Familial dominant drusen** are typically seen as yellow-white deposits under the retinal pigment epithelium and would manifest on FFA as **hyperfluorescent spots**, but usually with a different distribution and appearance than the microaneurysms seen here. - This image reflects widespread microvascular damage consistent with a retinal vascular disease, not primarily drusen. *Birdshot choroidopathy* - **Birdshot choroidopathy** is a chronic, bilateral posterior uveitis characterized by multiple, depigmented choroidal lesions (birdshot lesions). - On FFA, these lesions would typically show **hypofluorescence** in the early phases due to blocked choroidal fluorescence and possible late staining, which is not depicted in this image.

Question 3: Identify the refractive error shown in the image:

A. Myopia
B. Hypermetropia
C. Astigmatism (Correct Answer)
D. Presbyopia

Explanation: ***Astigmatism*** - The image shows that light rays from a single point source are **not focused at a single point** on the retina, but rather spread across multiple focal points or a line. This pattern is characteristic of **astigmatism**, where the eye's cornea or lens has an irregular curvature. - Specifically, rays 1 and 2 converge at one point, while rays 3 and 4 converge at a different point, indicating that the eye has different refractive powers along different meridians, which defines **astigmatism**. *Myopia* - In **myopia (nearsightedness)**, light rays from a distant object focus **in front of the retina**, not at multiple planes or lines as depicted. - Myopia would show all rays converging to a single point before reaching the retina, resulting in a blurry image. *Hypermetropia* - In **hypermetropia (farsightedness)**, light rays from a distant object focus **behind the retina**, assuming the eye is unaccommodated. - This condition would show the rays converging to a single point beyond the retinal plane, not divergent focal points within the eye. *Presbyopia* - **Presbyopia** is an age-related condition where the eye's **lens loses its flexibility**, making it difficult to focus on nearby objects. - It primarily affects near vision and does not typically involve the multiple focal points for distant vision as shown in the image.

Question 4: A patient has the following presentation. After administration of an intravenous drug to the patient, in 6 minutes his symptoms have resolved. The diagnosis of the patient is:

A. Myasthenia gravis (Correct Answer)
B. Sixth nerve palsy
C. Third nerve palsy
D. Tolosa-Hunt syndrome

Explanation: The question refers to an accompanying image (not provided in the text, but essential for context) showing a patient with **ptosis** (drooping eyelid) and possibly other ocular muscle weakness. The key information is that symptoms resolve within 6 minutes after administration of an intravenous drug. This rapid and complete resolution of symptoms following drug administration is highly characteristic of a specific condition and a specific diagnostic test. ***Myasthenia gravis*** - The rapid resolution of symptoms (ptosis and possibly other ocular muscle weakness) within 6 minutes after intravenous drug administration is the hallmark of a positive **Tensilon test**. - The **Tensilon test** involves injecting **edrophonium**, a short-acting acetylcholinesterase inhibitor, which temporarily increases acetylcholine at the neuromuscular junction, improving muscle strength in patients with **myasthenia gravis**. *Sixth nerve palsy* - Sixth nerve palsy (abducens nerve palsy) causes **diplopia** (double vision) and an inability to abduct the affected eye. - While symptoms may fluctuate or improve with treatment, they would not resolve completely in 6 minutes with a diagnostic agent like edrophonium. *Third nerve palsy* - Third nerve palsy (oculomotor nerve palsy) can cause **ptosis**, **diplopia**, and impairment of eye movements (inability to adduct, elevate, or depress the eye). - Nerve palsies are structural or neurological deficits that do not rapidly reverse with a cholinergic agonist like edrophonium. *Tolosa-Hunt syndrome* - Tolosa-Hunt syndrome is a rare inflammatory disorder characterized by **painful ophthalmoplegia** (paralysis of eye muscles), often affecting the third, fourth, and/or sixth cranial nerves. - It typically responds to corticosteroids, but symptoms would not resolve in 6 minutes with an intravenous drug, and the diagnostic approach is different.

Question 5: What is the diagnosis?

A. Sixth nerve palsy
B. Myasthenia gravis
C. Third nerve palsy (Correct Answer)
D. Tolosa-Hunt syndrome

Explanation: ***Third nerve palsy*** - The image shows **ptosis** (drooping of the eyelid) and **pupil dilation** with the eye deviated **down and out**, which are classic signs of a complete third nerve palsy. - The **oculomotor nerve (CN III)** innervates most extraocular muscles (**superior, medial, inferior recti, and inferior oblique**), the **levator palpebrae superioris**, and the **parasympathetic fibers to the pupillary constrictor muscle**. *Sixth nerve palsy* - A sixth nerve palsy (**abducens nerve**) would cause an inability to **abduct the eye** (move it outwards) leading to an **esotropia** (eye turned inward at rest) and **horizontal diplopia**, which is not depicted. - Symptoms primarily affect the **lateral rectus muscle**. *Myasthenia gravis* - Myasthenia gravis can cause **ptosis** and **diplopia**, but typically presents with **variable and fluctuating weakness** that worsens with fatigue. - It does not usually cause the fixed, specific pattern of strabismus and pupillary involvement seen in a severe third nerve palsy. *Tolosa-Hunt syndrome* - Tolosa-Hunt syndrome is a **painful ophthalmoplegia** caused by **non-specific inflammation** in the cavernous sinus or orbital apex. - While it can affect cranial nerves III, IV, V1, and VI, leading to **ophthalmoplegia** and **ptosis**, the defining feature is often **severe orbital pain**, which cannot be assessed from the image alone, and the specific constellation of symptoms in the image points more directly to a third nerve lesion rather than an inflammatory syndrome.

Question 6: A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

A. 2nd nerve palsy
B. 3rd nerve palsy
C. 4th nerve palsy
D. 6th nerve palsy (Correct Answer)

Explanation: ***6th nerve palsy*** - The image shows the **right eye** is unable to **abduct** (move outwards) when looking to the right, and is **adducted** (turned inwards) when looking straight ahead, which is characteristic of a **sixth cranial nerve (abducens) palsy**. - The abducens nerve innervates the **lateral rectus muscle**, which is responsible for abduction of the eye. Its paralysis causes the affected eye to deviate medially due to the unopposed action of the medial rectus muscle. *2nd nerve palsy* - **Second nerve (optic nerve) palsy** would primarily present with **vision loss** or field defects, not with abnormal eye movements. - The optic nerve transmits visual information from the eye to the brain and does not control ocular motility. *3rd nerve palsy* - **Third nerve (oculomotor) palsy** typically presents with **ptosis**, **dilated pupil**, and the eye positioned **down and out**. - This is because the oculomotor nerve innervates most extraocular muscles (medial, superior, inferior rectus, inferior oblique) and the levator palpebrae superioris, as well as pupillary constrictors. *4th nerve palsy* - **Fourth nerve (trochlear) palsy** affects the **superior oblique muscle**, leading to **vertical diplopia** and the eye being unable to move down and in. - Patients often compensate by **tilting their head** to the opposite shoulder.

Question 7: A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

A. Irvine-Gass syndrome
B. After cataract (Correct Answer)
C. UGH syndrome
D. Endophthalmitis

Explanation: ***After cataract*** - The image depicts a **thickening and opacification of the posterior capsule** behind an intraocular lens, which is characteristic of after cataract (also known as **posterior capsular opacification** or PCO). - PCO is a common complication following cataract surgery, leading to **diminished vision** months to years after the initial procedure, consistent with the patient's presentation. *Irvine-Gass syndrome* - Irvine-Gass syndrome refers to **pseudophakic cystoid macular edema**, which causes diminished vision after cataract surgery due to fluid accumulation in the macula. - While it can cause vision loss post-cataract surgery, it is a retinal condition and does not present with the **posterior capsule opacification** seen in the image. *UGH syndrome* - UGH (Uveitis-Glaucoma-Hyphema) syndrome is a complication typically associated with poorly designed or positioned **intraocular lenses (IOLs)** that rub against uveal tissue. - It presents with **intraocular inflammation, elevated intraocular pressure, and recurrent hyphema**, none of which are directly suggested by the provided image or clinical details. *Endophthalmitis* - Endophthalmitis is a severe **intraocular infection** that typically occurs days to weeks after cataract surgery, presenting acutely with significant **pain, redness, and severe vision loss**. - The patient's presentation of diminished vision one year after surgery and the image showing a **fibrotic posterior capsule** are not consistent with the acute, infectious nature of endophthalmitis.