Ocular Pathology — MCQs
A 45-year-old diabetic presents with sudden painless vision loss. Cotton wool spots and dot hemorrhages seen. HbA1c is 9.2. Most likely diagnosis?
In primary open-angle glaucoma (POAG), which of the following findings is NOT typically seen?
Recurrent anterior uveitis with increased intraocular tension is seen in which of the following conditions?
A 5 year old child who presented with proptosis of one of the eyes was found to have a desmin positive tumour. What is the probable diagnosis?
MC site of basal cell carcinoma of eyelid:
All are seen in non-proliferative diabetic retinopathy except which of the following?
A 76-year-old female presents with difficulty reading. Bilateral white opacifications consistent with cataract formation are observed. In which structure are these opacifications located?
A patient with cataract presents with pain and redness of eye. On examination he had deep anterior chamber. What is the diagnosis?
Consider the following causes of visual loss : 1. Obstruction of the central retinal artery 2. Vitreous and retinal haemorrhage 3. Cataract 4. Retinal detachment Which of the above causes are associated with acute visual loss in a patient?
What is the first-line treatment for acute angle closure glaucoma?
Ocular Pathology Indian Medical PG Practice Questions and MCQs
Question 1: A 45-year-old diabetic presents with sudden painless vision loss. Cotton wool spots and dot hemorrhages seen. HbA1c is 9.2. Most likely diagnosis?
- A. Hypertensive retinopathy
- B. CRAO
- C. Diabetic retinopathy (Correct Answer)
- D. CRVO
Explanation: ***Diabetic retinopathy*** - The presence of **cotton wool spots** and **dot hemorrhages** in a diabetic patient with poor glycemic control (HbA1c 9.2) are classic signs of **diabetic retinopathy**. - **Painless vision loss** is a common presentation, especially with macular edema or proliferative disease. *Hypertensive retinopathy* - While cotton wool spots can be seen, **dot hemorrhages are less characteristic** than flame-shaped hemorrhages. - The primary driver here is **diabetes** and poor glycemic control, not necessarily hypertension as the main cause. *CRAO* - **Central retinal artery occlusion** typically presents with **sudden, profound, painless monocular vision loss**. - Funduscopic examination would reveal a **cherry-red spot** and **pale retina**, not cotton wool spots and dot hemorrhages. *CRVO* - **Central retinal vein occlusion** is characterized by **extensive retinal hemorrhages** (often described as "blood and thunder" appearance), tortuous veins, and optic disc edema. - While it can cause painless vision loss and some hemorrhages, the specific combination of **cotton wool spots and dot hemorrhages** in a diabetic context points more strongly to diabetic retinopathy.
Question 2: In primary open-angle glaucoma (POAG), which of the following findings is NOT typically seen?
- A. Bayoneting sign (arteriovenous crossing changes)
- B. Peripapillary atrophy
- C. Horizontal cupping of the optic disc
- D. Macular edema (Correct Answer)
Explanation: ***Macular edema*** - **Macular edema** is characterized by fluid accumulation in the fovea or retina, causing blurry vision and metamorphopsia. - While it can occur in conditions like **diabetic retinopathy** or **uveitis**, it is **not a typical finding in POAG**, which primarily affects the optic nerve. *Horizontal cupping of the optic disc* - **Horizontal cupping** (or vertical elongation of the optic cup) is a common sign of **glaucomatous damage**, reflecting the loss of retinal ganglion cells. - This morphological change suggests the progression of optic nerve atrophy. *Bayoneting sign (arteriovenous crossing changes)* - The **bayoneting sign**, where blood vessels appear to dip below the optic disc margin and then sharply bend, is a feature of **advanced glaucomatous cupping**. - It indicates significant loss of optic nerve tissue and is often associated with deeply excavated optic discs. *Peripapillary atrophy* - **Peripapillary atrophy** (PPA) refers to areas of RPE and choroidal atrophy surrounding the optic disc, commonly seen in glaucoma. - While its presence and extent may correlate with **glaucoma severity**, it is a recognized clinical feature of the disease.
Question 3: Recurrent anterior uveitis with increased intraocular tension is seen in which of the following conditions?
- A. Posner-Schlossman syndrome (Correct Answer)
- B. Foster-Kennedy syndrome
- C. Vogt-Koyanagi-Harada syndrome
- D. Fuchs heterochromic iridocyclitis
Explanation: ***Posner-Schlossman syndrome*** - Characterized by **recurrent, unilateral, non-granulomatous anterior uveitis** associated with markedly **elevated intraocular pressure (IOP)**. - The condition is also known as **glaucomatocyclitic crisis**, highlighting the episodic inflammation and glaucoma. - Key features include **acute attacks** lasting hours to weeks with **dramatic IOP elevation** (often >40 mmHg). *Foster-Kennedy syndrome* - This syndrome is defined by ipsilateral **optic atrophy**, contralateral **papilledema**, and often **anosmia**, typically due to a frontal lobe tumor. - It does not involve anterior uveitis or primary elevated intraocular tension. - This is a neuro-ophthalmologic syndrome, not an inflammatory ocular condition. *Vogt-Koyanagi-Harada syndrome* - An autoimmune disorder affecting pigmented tissues, leading to **bilateral granulomatous panuveitis**, often with hearing loss, vitiligo, poliosis, and neurological symptoms. - While it involves uveitis, it is typically **bilateral and panuveitis**, not recurrent unilateral anterior uveitis. - IOP may be elevated but not the defining feature with dramatic episodic rises. *Fuchs heterochromic iridocyclitis* - A chronic, **unilateral, low-grade anterior uveitis** with characteristic iris heterochromia. - May have mild IOP elevation but **not recurrent episodic attacks** with marked pressure spikes. - Inflammation is typically **quiet and chronic** rather than acute and recurrent.
Question 4: A 5 year old child who presented with proptosis of one of the eyes was found to have a desmin positive tumour. What is the probable diagnosis?
- A. Neuroblastoma
- B. Retinoblastoma
- C. Rhabdomyosarcoma (Correct Answer)
- D. Ewing's sarcoma
Explanation: ***Rhabdomyosarcoma*** - **Desmin positivity** is a characteristic immunohistochemical feature of **rhabdomyosarcoma**, as desmin is an intermediate filament found in muscle cells [1]. - In a 5-year-old child presenting with **proptosis**, rhabdomyosarcoma of the orbit is a highly probable diagnosis, as it is the most common primary malignant orbital tumor in childhood [3]. *Neuroblastoma* - Neuroblastoma is typically a tumor of neural crest origin, with classic immunohistochemical markers being **neuron-specific enolase (NSE)** and **chromogranin**, not desmin [2]. - While it can manifest with orbital metastases leading to proptosis, the desmin positivity rules it out as the primary diagnosis [3]. *Retinoblastoma* - Retinoblastoma is a malignant tumor of the retina, presenting with **leukocoria** (white pupillary reflex) and occasionally proptosis in advanced stages [4]. - It arises from neuroectodermal cells, and its characteristic markers include **synaptophysin** and **neuron-specific enolase (NSE)**, not desmin [4]. *Ewing's sarcoma* - Ewing's sarcoma is a primary malignant small round blue cell tumor of bone and soft tissue, typically marked by expression of **CD99** and a characteristic **t(11;22) translocation**. - While it can occur in the orbit, it is not desmin positive, making rhabdomyosarcoma a more likely diagnosis given the immunohistochemical findings. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1224-1225. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 211-212. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1323-1324. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 737-738.
Question 5: MC site of basal cell carcinoma of eyelid:
- A. Medial canthus
- B. Lower eyelid (Correct Answer)
- C. Upper eyelid
- D. Outer canthus
Explanation: ***Lower eyelid*** - The **lower eyelid** is the most common site for basal cell carcinoma (BCC) of the eyelid, accounting for approximately **50-60%** of all eyelid BCCs. - This high frequency is due to increased exposure to **UV radiation**, which is the primary risk factor for BCC development. - BCC often presents as a **pearly nodule** with telangiectasias and central ulceration, frequently found on the lower lid margin. *Medial canthus* - The medial canthus is the **second most common site**, accounting for approximately **25-30%** of eyelid BCCs. - Tumors in this area can be **more aggressive** and challenging to treat due to proximity to the lacrimal system and orbital structures. - Medial canthal BCCs may require more extensive surgical reconstruction. *Upper eyelid* - The upper eyelid accounts for only **10-15%** of eyelid BCCs, making it significantly **less common** than the lower eyelid. - This is due to **less direct sun exposure** compared to the lower lid, as the upper lid is often shaded by the brow. *Outer canthus* - The outer (lateral) canthus is the **least common site**, accounting for only about **5%** of eyelid BCCs. - Tumors here may present with similar features but are much less frequently encountered than those on the lower lid or medial canthus.
Question 6: All are seen in non-proliferative diabetic retinopathy except which of the following?
- A. Microaneurysm
- B. Neovascularization (Correct Answer)
- C. Cotton wool spots
- D. Retinal hemorrhages
Explanation: ***Neovascularization*** - **Neovascularization** signifies the growth of new, fragile blood vessels and is a hallmark feature of **proliferative diabetic retinopathy**, not non-proliferative. - These new vessels can bleed, leading to vitreous hemorrhage and tractional retinal detachment, which are severe complications. *Microaneurysm* - **Microaneurysms** are the earliest clinical sign of diabetic retinopathy, visible as small, red dots on funduscopic examination due to capillary outpouchings. - They are characteristic findings in **non-proliferative diabetic retinopathy (NPDR)**. *Cotton wool spots* - **Cotton wool spots** are soft exudates resulting from microinfarcts in the retinal nerve fiber layer due to occluded precapillary arterioles. - They are findings commonly seen in **non-proliferative diabetic retinopathy (NPDR)**. *Retinal hemorrhages* - **Retinal hemorrhages** (dot-blot hemorrhages) occur when blood leaks from damaged capillaries in the retina. - They are a common occurrence in **non-proliferative diabetic retinopathy (NPDR)**.
Question 7: A 76-year-old female presents with difficulty reading. Bilateral white opacifications consistent with cataract formation are observed. In which structure are these opacifications located?
- A. Aqueous humor
- B. Cornea
- C. Lens (Correct Answer)
- D. Optic nerve
Explanation: ***Lens*** - **Cataracts** are defined by the **clouding of the natural lens** of the eye, which causes blurred vision and difficulty with activities like reading. - The condition is very common, especially among older adults, and affects the **bilateral vision** as described in the case. *Aqueous humor* - The **aqueous humor** is a clear fluid that fills the space between the cornea and the lens; it is not the structure that becomes opaque in cataracts. - Problems with aqueous humor are typically associated with glaucoma (due to increased intraocular pressure) rather than cataract formation. *Cornea* - The **cornea** is the transparent outer layer of the eye that helps focus light, but it does not develop cataracts. - Opacities in the cornea (e.g., from injuries or infections) would be described differently and produce different visual symptoms. *Optic nerve* - The **optic nerve** transmits visual information from the retina to the brain; it is a nerve, not a structure where light focuses or where cataracts develop. - Damage to the optic nerve typically leads to vision loss or blind spots, not blurred vision from opacification.
Question 8: A patient with cataract presents with pain and redness of eye. On examination he had deep anterior chamber. What is the diagnosis?
- A. Acute phacolytic glaucoma (Correct Answer)
- B. Acute angle closure glaucoma
- C. Acute neovascular glaucoma
- D. Acute phacomorphic glaucoma
Explanation: ***Acute phacolytic glaucoma*** - This condition occurs when **lens proteins leak** from a mature or hypermature cataract into the aqueous humor, causing an inflammatory reaction and **trabecular meshwork obstruction**, leading to elevated intraocular pressure. - The presence of a **deep anterior chamber** distinguishes it from phacomorphic glaucoma, which is characterized by a shallow anterior chamber due to lens intumescence. *Acute angle closure glaucoma* - This typically presents with a **shallow anterior chamber** as the iris bows forward, blocking the trabecular meshwork. - While it causes pain and redness, the deep anterior chamber described in the patient makes this diagnosis unlikely. *Acute neovascular glaucoma* - This type of glaucoma results from the formation of **new blood vessels** on the iris and in the angle of the anterior chamber, often due to conditions like **diabetic retinopathy** or **retinal vein occlusion**. - There is no mention of such predisposing factors or visible neovascularization in the patient's presentation. *Acute phacomorphic glaucoma* - This condition is caused by the **intumescence (swelling) of a cataractous lens**, which pushes the iris forward, leading to a **shallow anterior chamber** and angle closure. - The patient's presentation of a **deep anterior chamber** rules out phacomorphic glaucoma.
Question 9: Consider the following causes of visual loss : 1. Obstruction of the central retinal artery 2. Vitreous and retinal haemorrhage 3. Cataract 4. Retinal detachment Which of the above causes are associated with acute visual loss in a patient?
- A. 1, 3 and 4
- B. 1, 2 and 3
- C. 2, 3 and 4
- D. 1, 2 and 4 (Correct Answer)
Explanation: ***1, 2 and 4*** - **Obstruction of the central retinal artery**, **vitreous and retinal haemorrhage**, and **retinal detachment** all present as sudden, acute vision loss. - **Central retinal artery occlusion** causes complete, sudden, painless monocular vision loss. **Vitreous hemorrhage** is acute, painless, and can present with floaters or red haze. **Retinal detachment** is acute, painless vision loss, often preceded by flashes and floaters, and can present as a "curtain" coming across the vision. *1, 3 and 4* - While **central retinal artery obstruction** and **retinal detachment** cause acute vision loss, **cataracts** typically cause gradual, progressive vision loss over months to years. - Cataracts primarily affect lens clarity, leading to blurry vision, glare, and dull colors rather than an abrupt onset of blindness. *1, 2 and 3* - **Central retinal artery obstruction** and **vitreous/retinal hemorrhage** lead to acute vision loss, but **cataracts** are a cause of *chronic* and *gradual* vision impairment. - The onset and progression of a **cataract** are distinctly different from the sudden nature of acute vision loss conditions. *2, 3 and 4* - **Vitreous and retinal haemorrhage** and **retinal detachment** are causes of acute vision loss, but a **cataract** is not. - The defining characteristic of acute vision loss is its rapid onset, which does not align with the slow development of a cataract.
Question 10: What is the first-line treatment for acute angle closure glaucoma?
- A. Pilocarpine
- B. Beta blocker eyedrops
- C. IV mannitol
- D. Acetazolamide (Correct Answer)
Explanation: **Acetazolamide** - **Acetazolamide** (oral or intravenous) is a carbonic anhydrase inhibitor that rapidly reduces intraocular pressure by decreasing aqueous humor production, making it the **first-line medical treatment** for acute angle-closure glaucoma. - While other agents are used, acetazolamide provides the quickest and most significant initial reduction in **intraocular pressure (IOP)**, which is crucial in preventing permanent vision loss. *IV mannitol* - **Intravenous mannitol** is an osmotic diuretic used to draw fluid from the vitreous humor to lower **IOP** significantly, but it is typically reserved for cases where **acetazolamide** alone is insufficient or for very high **IOPs**. - It is often considered a second-line or adjunctive agent rather than the initial first-line treatment. *Pilocarpine* - **Pilocarpine** is a miotic agent that constricts the pupil, which helps to pull the iris away from the trabecular meshwork and open the angle. - However, it should only be administered *after* the **intraocular pressure** has been significantly lowered (e.g., with acetazolamide), as it can worsen angle closure in an inflamed eye with very high **IOP**. *Beta blocker eyedrops* - **Topical beta-blockers** (e.g., timolol) reduce **IOP** by decreasing aqueous humor production and are a common treatment for various types of glaucoma. - While useful in acute angle-closure glaucoma, they act more slowly than **acetazolamide** and are typically used as an adjunct rather than the sole initial first-line treatment.
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