INI-CET 2025 — Ophthalmology

Q: A patient presented 2 weeks after cataract surgery with decreased vision. On examination, there were anterior chamber cells and flare with hazy vitreous. What is the most likely cause and organism?

Endophthalmitis with Propionibacterium. ***Endophthalmitis with Propionibacterium*** - ***Propionibacterium acnes*** (now ***Cutibacterium acnes***) is the classic organism responsible for **delayed-onset** or subacute endophthalmitis, which typically presents weeks to months following cataract surgery. - This indolent infection is characterized by low-grade inflammation, **vitritis**, and often subtle findings, making the 2-week history highly suggestive of this causative agent. ***Endophthalmitis with Staphylococcus*** - **Acute post-operative endophthalmitis**, most commonly caused by *Staphylococcus epidermidis*, typically presents much earlier, usually within **1 to 7 days** post-surgery, with rapid decline in vision. - *Staphylococcus aureus* causes a highly virulent, fulminant acute infection that would almost certainly present less than 2 weeks post-op. ***Sympathetic ophthalmia*** - This is a rare, bilateral, granulomatous **panuveitis** that occurs after a penetrating trauma or surgery to one eye. - While it can present weeks after surgery, it is an autoimmune condition and would not typically be caused by a specific pathogen like *Propionibacterium* or *Staphylococcus*. ***Toxic anterior segment syndrome*** - TASS is an acute, **sterile inflammatory** response to non-infectious toxic substances (like detergents or preservatives) introduced during surgery. - TASS presents very early (12–48 hours post-op), is confined mainly to the **anterior segment**, and does not involve significant **vitritis**. [Practice more Ophthalmology PYQs on OnCourse]

Q: Which of the following lasers is used in refractive surgery?

Excimer laser. ***Excimer laser*** - The **Excimer laser** is the gold standard for refractive procedures like **LASIK** (Laser-Assisted *in Situ* Keratomileusis) and **PRK** (Photorefractive Keratectomy). - It uses **photoablation** (non-thermal tissue removal) to precisely reshape the corneal stroma and correct refractive errors (myopia, hyperopia, astigmatism). *Nd:YAG* - The **Nd:YAG** (Neodymium-doped Yttrium Aluminum Garnet) laser is a **photodisruptive** laser commonly used in the posterior segment. - Its primary application is in treating **posterior capsular opacification** (YAG capsulotomy) and performing **peripheral iridotomy** for glaucoma. *Argon* - The Argon laser is a **photocoagulation** laser that produces thermal burns by heating pigmented tissue. - It is mainly used for treating proliferative **diabetic retinopathy** (**panretinal photocoagulation**) and managing **retinal vascular occlusions**. *Diode* - Diode lasers are versatile, typically employed for thermal procedures like **transscleral cyclophotocoagulation** (TSCPC) to reduce aqueous humor production in glaucoma. - They are also utilized for some forms of retinal photocoagulation due to their small size and cost-effectiveness, but not for corneal reshaping. [Practice more Ophthalmology PYQs on OnCourse]

Q: In optic neuritis, which is true?

Unilateral vision loss, pain on eye movement, and decreased color vision. ***Unilateral vision loss, pain on eye movement, and decreased color vision*** - This combination represents the **classic triad** of optic neuritis: sudden **unilateral vision loss**, **pain with eye movement** (present in >90% of cases), and **dyschromatopsia** (decreased color discrimination, especially red-green). - These three features together provide the most comprehensive and accurate clinical picture of typical **inflammatory optic neuritis**, often associated with **multiple sclerosis**. *Unilateral vision loss with decreased color vision* - While **unilateral presentation** and **dyschromatopsia** are indeed characteristic features of optic neuritis, this option omits the highly specific symptom of **pain on eye movement**. - **Pain with eye movement** is present in over 90% of optic neuritis cases and is a key differentiating feature from other causes of **acute vision loss**. *Pain on eye movement only* - Although **retrobulbar pain** with eye movement is highly characteristic and present in most cases, focusing solely on this symptom ignores the primary visual manifestations. - Optic neuritis by definition involves **optic nerve inflammation** causing **visual dysfunction**, including decreased acuity and **color vision deficits**. *Bilateral vision loss is common* - **Bilateral optic neuritis** is actually uncommon in typical cases and suggests **atypical forms** such as **Neuromyelitis Optica Spectrum Disorder (NMOSD)** or **autoimmune optic neuropathy**. - Classic optic neuritis associated with **multiple sclerosis** typically presents **unilaterally**, with the fellow eye remaining unaffected initially. [Practice more Ophthalmology PYQs on OnCourse]

Q: Which of the following investigations allows examination of all layers of the retina?

OCT. ***Optical Coherence Tomography (OCT)*** - **OCT provides high-resolution, cross-sectional images of the retina**, allowing visualization and precise measurement of **all retinal layers** from the **Internal Limiting Membrane (ILM)** to the **Retinal Pigment Epithelium (RPE)**. - It is the **gold standard** for detailed morphological analysis of retinal architecture. - Crucial for diagnosing and monitoring **macular edema**, **age-related macular degeneration (ARMD)**, **diabetic retinopathy**, and other macular pathologies. - Provides **in vivo histological imaging** of retinal layers with resolution approaching 3-5 microns. *B-scan ultrasonography* - Uses sound waves to image the eye, primarily utilized when **ocular media are opaque** (e.g., dense cataract, vitreous hemorrhage). - Provides a **general structural outline** of the posterior segment but **cannot resolve individual microscopic retinal layers**. - Useful for detecting retinal detachment, intraocular masses, and posterior segment pathology when direct visualization is not possible. *Perimetry* - **Visual field testing** that measures the **functional sensitivity** of vision across the visual field. - Assesses the **overall functional integrity** of the retina and visual pathway, correlating with retinal ganglion cell function. - Does **not provide anatomical imaging** or visualization of individual retinal layers. - Important for glaucoma assessment and neurological visual pathway disorders. *Fundus fluorescein angiography (FFA)* - Involves injecting fluorescent dye and capturing images to study the **circulation of the retina and choroid**. - Primarily evaluates **vascular leakage**, **non-perfusion areas**, **microaneurysms**, and **neovascularization**. - Provides **en face (surface) vascular imaging**, not cross-sectional layer visualization. - Does not display individual retinal layers in the manner that OCT does. [Practice more Ophthalmology PYQs on OnCourse]

10 Previous Year Questions with Answers & Explanations

Questions

Which of the following best defines blindness?

A patient presented 2 weeks after cataract surgery with decreased vision. On examination, there were anterior chamber cells and flare with hazy vitreous. What is the most likely cause and organism?

Which of the following lasers is used in refractive surgery?

In optic neuritis, which is true?

Which of the following investigations allows examination of all layers of the retina?

All of the following are done in the treatment of amblyopia, except:

Which of the following is seen in proliferative diabetic retinopathy?

Following a fungal corneal ulcer, a farmer underwent corneal transplant surgery. What is the preservative used for storing the donor corneal graft and the suture material used in the procedure?

Acute hemorrhagic conjunctivitis is caused by which of the following combinations?

Q10

Which of the following is the diagnosis based on the given eye movement abnormality image?

INI-CET 2025 - Ophthalmology INI-CET Practice Questions and MCQs

Question 1: Which of the following best defines blindness?

A. Visual acuity less than 3/60 in the better eye after best possible correction (Correct Answer)
B. Visual field less than 10 degrees from fixation in the better eye
C. Inability to perceive light in both eyes
D. Visual acuity less than 6/60 in the better eye

Explanation: ***Visual acuity less than 3/60 in the better eye after best possible correction*** - This defines **blindness** according to the **WHO/ICD-11 classification** (Category 3 and 4). - VA < 3/60 to 1/60 is **Category 3 blindness**, and VA < 1/60 to light perception is **Category 4 blindness**. - This is the internationally accepted standard definition of blindness. *Visual acuity less than 6/60 in the better eye* - In **India**, the National Programme for Control of Blindness and Visual Impairment (NPCB&VI) defines blindness as VA < 6/60 in the better eye with best correction. - However, the **WHO international standard** uses the more stringent criterion of < 3/60. - For global standardization and comparison, the **WHO definition (< 3/60)** is considered the primary reference. *Visual field less than 10 degrees from fixation in the better eye* - This is an **alternative criterion** for defining blindness according to WHO guidelines. - A person with VF < 10° (or < 20° in some definitions) is considered legally blind even if VA is better than 3/60. - Both VA and VF criteria are valid, but the question asks for the "best" single definition, where the **VA criterion** is most commonly cited. *Inability to perceive light in both eyes* - This represents **No Light Perception (NLP)** or **total blindness** (WHO Category 5). - This is the most severe form of blindness but is too restrictive as a general definition, as it excludes individuals with light perception or minimal vision who are still legally and functionally blind.

Question 2: A patient presented 2 weeks after cataract surgery with decreased vision. On examination, there were anterior chamber cells and flare with hazy vitreous. What is the most likely cause and organism?

A. Endophthalmitis with Staphylococcus
B. Endophthalmitis with Propionibacterium (Correct Answer)
C. Sympathetic ophthalmia
D. Toxic anterior segment syndrome

Explanation: ***Endophthalmitis with Propionibacterium*** - ***Propionibacterium acnes*** (now ***Cutibacterium acnes***) is the classic organism responsible for **delayed-onset** or subacute endophthalmitis, which typically presents weeks to months following cataract surgery. - This indolent infection is characterized by low-grade inflammation, **vitritis**, and often subtle findings, making the 2-week history highly suggestive of this causative agent. ***Endophthalmitis with Staphylococcus*** - **Acute post-operative endophthalmitis**, most commonly caused by *Staphylococcus epidermidis*, typically presents much earlier, usually within **1 to 7 days** post-surgery, with rapid decline in vision. - *Staphylococcus aureus* causes a highly virulent, fulminant acute infection that would almost certainly present less than 2 weeks post-op. ***Sympathetic ophthalmia*** - This is a rare, bilateral, granulomatous **panuveitis** that occurs after a penetrating trauma or surgery to one eye. - While it can present weeks after surgery, it is an autoimmune condition and would not typically be caused by a specific pathogen like *Propionibacterium* or *Staphylococcus*. ***Toxic anterior segment syndrome*** - TASS is an acute, **sterile inflammatory** response to non-infectious toxic substances (like detergents or preservatives) introduced during surgery. - TASS presents very early (12–48 hours post-op), is confined mainly to the **anterior segment**, and does not involve significant **vitritis**.

Question 3: Which of the following lasers is used in refractive surgery?

A. Argon
B. Diode
C. Nd:YAG
D. Excimer laser (Correct Answer)

Explanation: ***Excimer laser*** - The **Excimer laser** is the gold standard for refractive procedures like **LASIK** (Laser-Assisted *in Situ* Keratomileusis) and **PRK** (Photorefractive Keratectomy). - It uses **photoablation** (non-thermal tissue removal) to precisely reshape the corneal stroma and correct refractive errors (myopia, hyperopia, astigmatism). *Nd:YAG* - The **Nd:YAG** (Neodymium-doped Yttrium Aluminum Garnet) laser is a **photodisruptive** laser commonly used in the posterior segment. - Its primary application is in treating **posterior capsular opacification** (YAG capsulotomy) and performing **peripheral iridotomy** for glaucoma. *Argon* - The Argon laser is a **photocoagulation** laser that produces thermal burns by heating pigmented tissue. - It is mainly used for treating proliferative **diabetic retinopathy** (**panretinal photocoagulation**) and managing **retinal vascular occlusions**. *Diode* - Diode lasers are versatile, typically employed for thermal procedures like **transscleral cyclophotocoagulation** (TSCPC) to reduce aqueous humor production in glaucoma. - They are also utilized for some forms of retinal photocoagulation due to their small size and cost-effectiveness, but not for corneal reshaping.

Question 4: In optic neuritis, which is true?

A. Unilateral vision loss with decreased color vision
B. Pain on eye movement only
C. Bilateral vision loss is common
D. Unilateral vision loss, pain on eye movement, and decreased color vision (Correct Answer)

Explanation: ***Unilateral vision loss, pain on eye movement, and decreased color vision*** - This combination represents the **classic triad** of optic neuritis: sudden **unilateral vision loss**, **pain with eye movement** (present in >90% of cases), and **dyschromatopsia** (decreased color discrimination, especially red-green). - These three features together provide the most comprehensive and accurate clinical picture of typical **inflammatory optic neuritis**, often associated with **multiple sclerosis**. *Unilateral vision loss with decreased color vision* - While **unilateral presentation** and **dyschromatopsia** are indeed characteristic features of optic neuritis, this option omits the highly specific symptom of **pain on eye movement**. - **Pain with eye movement** is present in over 90% of optic neuritis cases and is a key differentiating feature from other causes of **acute vision loss**. *Pain on eye movement only* - Although **retrobulbar pain** with eye movement is highly characteristic and present in most cases, focusing solely on this symptom ignores the primary visual manifestations. - Optic neuritis by definition involves **optic nerve inflammation** causing **visual dysfunction**, including decreased acuity and **color vision deficits**. *Bilateral vision loss is common* - **Bilateral optic neuritis** is actually uncommon in typical cases and suggests **atypical forms** such as **Neuromyelitis Optica Spectrum Disorder (NMOSD)** or **autoimmune optic neuropathy**. - Classic optic neuritis associated with **multiple sclerosis** typically presents **unilaterally**, with the fellow eye remaining unaffected initially.

Question 5: Which of the following investigations allows examination of all layers of the retina?

A. OCT (Correct Answer)
B. B-scan ultrasonography
C. Perimetry
D. Fundus fluorescein angiography

Explanation: ***Optical Coherence Tomography (OCT)*** - **OCT provides high-resolution, cross-sectional images of the retina**, allowing visualization and precise measurement of **all retinal layers** from the **Internal Limiting Membrane (ILM)** to the **Retinal Pigment Epithelium (RPE)**. - It is the **gold standard** for detailed morphological analysis of retinal architecture. - Crucial for diagnosing and monitoring **macular edema**, **age-related macular degeneration (ARMD)**, **diabetic retinopathy**, and other macular pathologies. - Provides **in vivo histological imaging** of retinal layers with resolution approaching 3-5 microns. *B-scan ultrasonography* - Uses sound waves to image the eye, primarily utilized when **ocular media are opaque** (e.g., dense cataract, vitreous hemorrhage). - Provides a **general structural outline** of the posterior segment but **cannot resolve individual microscopic retinal layers**. - Useful for detecting retinal detachment, intraocular masses, and posterior segment pathology when direct visualization is not possible. *Perimetry* - **Visual field testing** that measures the **functional sensitivity** of vision across the visual field. - Assesses the **overall functional integrity** of the retina and visual pathway, correlating with retinal ganglion cell function. - Does **not provide anatomical imaging** or visualization of individual retinal layers. - Important for glaucoma assessment and neurological visual pathway disorders. *Fundus fluorescein angiography (FFA)* - Involves injecting fluorescent dye and capturing images to study the **circulation of the retina and choroid**. - Primarily evaluates **vascular leakage**, **non-perfusion areas**, **microaneurysms**, and **neovascularization**. - Provides **en face (surface) vascular imaging**, not cross-sectional layer visualization. - Does not display individual retinal layers in the manner that OCT does.

Question 6: All of the following are done in the treatment of amblyopia, except:

A. Refractive error correction
B. Strabismus surgery (Correct Answer)
C. Video game therapy
D. Patching (occlusion therapy)

Explanation: ***Strabismus surgery*** - Strabismus surgery is primarily performed to **correct ocular misalignment** (deviation) in strabismic amblyopia, improving cosmesis and binocular potential. - However, **surgery alone does NOT treat amblyopia** – it addresses the anatomical deviation but not the visual deficit itself. - Amblyopia treatment (patching, penalization, or vision therapy) must be performed **before and/or after surgery** to improve visual acuity in the amblyopic eye. - This makes it the exception as it's not a direct treatment modality for the amblyopic visual deficit. *Incorrect: Refractive error correction* - **Correcting refractive errors** with spectacles or contact lenses is the **absolute first step** in all amblyopia treatment. - This is especially crucial in **refractive amblyopia** (anisometropic or isoametropic). - Often, correction alone can lead to significant visual improvement in mild cases. *Incorrect: Video game therapy* - **Dichoptic video game therapy** (e.g., Luminopia) is an **emerging, evidence-based treatment** for amblyopia. - FDA-approved therapies use binocular games to promote visual development in the amblyopic eye. - Used as primary therapy or adjunct to patching, particularly in older children or cases with poor compliance. *Incorrect: Patching (occlusion therapy)* - **Occlusion therapy** (patching the better eye) is the **gold standard treatment** for amblyopia. - Forces the brain to use the amblyopic eye, promoting visual development. - Duration and regimen depend on severity and age, with part-time or full-time patching protocols.

Question 7: Which of the following is seen in proliferative diabetic retinopathy?

A. Tractional retinal detachment (Correct Answer)
B. No retinal detachment
C. Exudative retinal detachment
D. Rhegmatogenous retinal detachment

Explanation: ***Tractional retinal detachment*** - This is the hallmark complication of **Proliferative Diabetic Retinopathy (PDR)**, caused by the contraction of **fibrovascular tissue** growing on the retinal surface. - The pulling force separates the sensory retina from the **retinal pigment epithelium (RPE)**, often leading to slow, progressive vision loss. *Rhegmatogenous retinal detachment* - This results from a **full-thickness retinal break** that allows fluid vitreous to pass into the subretinal space. - Pure rhegmatogenous detachment is less common in PDR; diabetic detachments are typically **tractional** or occasionally mixed **tractional-rhegmatogenous**. *Exudative retinal detachment* - This type is caused by fluid accumulation due to leakage through intact vessels, often associated with conditions like **posterior scleritis** or choroidal tumors. - It is characterized by highly mobile subretinal fluid that shifts with changes in head position, a finding not typical of PDR's primary mechanism. *No retinal detachment* - Although not all patients with PDR develop detachment, the condition is defined by the high risk of severe complications, including **tractional retinal detachment** and **vitreous hemorrhage**. - PDR is the stage where extensive **neovascularization** occurs, structurally predisposing the eye to retinal separation.

Question 8: Following a fungal corneal ulcer, a farmer underwent corneal transplant surgery. What is the preservative used for storing the donor corneal graft and the suture material used in the procedure?

A. Polyethylene glycol, Nylon
B. Moist chamber, Vicryl
C. Ethanol, Silk
D. McCarey-Kaufman, Nylon (Correct Answer)

Explanation: ***McCarey-Kaufman, Nylon*** - **McCarey-Kaufman (MK) medium** is the classic short-term preservation medium (effective for up to 4 days) traditionally used for storing donor corneal grafts, ensuring the vitality of the essential **endothelial cells**. *Note: Modern practice now primarily uses Optisol-GS, Cornisol, or Eusol-C for longer storage (14+ days), but MK medium remains the standard textbook answer.* - The procedure employs fine, non-absorbable **10-0 Nylon** monofilament sutures, which is the standard material for penetrating keratoplasty and maintains long-term structural integrity and precise corneal curvature. *Incorrect: Polyethylene glycol, Nylon* - **Polyethylene glycol (PEG)** is an osmotic agent and lubricant but is not utilized as the primary, formulated storage medium for whole donor corneal grafts required for transplantation. - While **Nylon** is the correct suture material, the incorrect association with PEG as the storage medium makes this option unsuitable. *Incorrect: Ethanol, Silk* - **Ethanol** is highly damaging and denaturing to living tissues, particularly the delicate **corneal endothelium**, rendering the graft non-viable upon exposure. - **Silk** sutures are generally avoided in penetrating keratoplasty because they are braided, have high tissue reactivity, and carry a risk of introducing infection or generating excessive inflammation. *Incorrect: Moist chamber, Vicryl* - Storage in a **moist chamber** offers minimal nutritional support and is only suitable for very short-term storage (<24 hours), often resulting in significant **endothelial cell loss** for longer storage periods. - **Vicryl** (Polyglactin 910) is an **absorbable suture** that breaks down rapidly, making it inappropriate for penetrating keratoplasty where non-absorbable material is needed to maintain tectonic support and corneal shape for extended periods.

Question 9: Acute hemorrhagic conjunctivitis is caused by which of the following combinations?

A. Coxsackie A and Enterovirus 70 (Correct Answer)
B. Coxsackie B and Enterovirus 70
C. Coxsackie A, Coxsackie B and Enterovirus 70
D. Coxsackie A and Coxsackie B

Explanation: ***Coxsackie A and Enterovirus 70 (Correct Answer)*** - **Enterovirus 70 (EV70)** is one of the two main causative agents historically responsible for rapid, widespread, and explosive epidemics of Acute Hemorrhagic Conjunctivitis (AHC) worldwide. - **Coxsackievirus A24 variant (CA24v)** is the other significant cause of AHC, often causing large outbreaks that are clinically indistinguishable from those caused by EV70. - This combination represents the **established etiology** of epidemic acute hemorrhagic conjunctivitis. *Coxsackie B and Enterovirus 70* - While **Enterovirus 70** is correct, **Coxsackievirus B** is primarily associated with systemic illnesses like **myocarditis**, pericarditis, and pleurodynia, rather than AHC. - The critical combination responsible for AHC epidemics involves a specific variant of **Coxsackievirus A (A24v)**, not B, alongside EV70. *Coxsackie A, Coxsackie B and Enterovirus 70* - This option is inaccurate because the inclusion of **Coxsackievirus B** (associated with diseases other than AHC) makes the combination incorrect as a primary etiology. - AHC etiology relies specifically on **Enterovirus 70** and the pathogenic strain **Coxsackievirus A24 variant (CA24v)**. *Coxsackie A and Coxsackie B* - This combination is incomplete because it omits **Enterovirus 70 (EV70)**, which is arguably the most important etiological agent known for causing severe, hemorrhagic, epidemic conjunctivitis. - **Coxsackievirus B** is not a typical agent of AHC, further making this combination incorrect for the clinical syndrome described.

Question 10: Which of the following is the diagnosis based on the given eye movement abnormality image?

A. 3rd nerve palsy
B. Internuclear ophthalmoplegia (Correct Answer)
C. 6th nerve palsy
D. Horizontal gaze palsy

Explanation: **Internuclear ophthalmoplegia** - This diagnosis is indicated by the failure of the right eye to **adduct** (move inwards) when looking to the left, which is a hallmark sign. This specific defect is caused by a lesion in the **Medial Longitudinal Fasciculus (MLF)** on the same side as the adduction failure. - Another key feature shown is **nystagmus** in the contralateral (left) eye during **abduction** (outward movement). This combination of ipsilateral adduction failure and contralateral abducting nystagmus is classic for INO. *3rd nerve palsy* - A 3rd nerve palsy would present with the affected eye positioned 'down and out' due to unopposed action of the superior oblique and lateral rectus muscles. It also typically involves **ptosis** and a **dilated pupil**. - In the given image, the vertical movements and pupillary function are not depicted as abnormal, and the primary issue is with horizontal conjugate gaze, not the multiple deficits seen in 3rd nerve palsy. *6th nerve palsy* - This condition results in the inability to **abduct** the eye (move it outwards) due to paralysis of the **lateral rectus muscle**. The patient would complain of horizontal diplopia, worse on gaze towards the affected side. - The image shows that both eyes are capable of abduction. The defect is clearly in adduction of the right eye. *Horizontal gaze palsy* - This involves the inability of **both eyes** to move in one horizontal direction. It is caused by a lesion in the pontine gaze center, the **Paramedian Pontine Reticular Formation (PPRF)**. - In this case, the left eye successfully moves to the left, and both eyes can move to the right, ruling out a complete gaze palsy to either side.