Diseases of the Conjunctiva — MCQs

Diseases of the Conjunctiva Indian Medical PG Practice Questions and MCQs

Question 161: Which of the following causes epidemic keratoconjunctivitis?

A. HSV
B. Adenovirus (Correct Answer)
C. Chlamydia
D. HIV

Explanation: **Explanation:** **Epidemic Keratoconjunctivitis (EKC)** is a highly contagious, severe form of viral conjunctivitis caused primarily by **Adenovirus serotypes 8, 19, and 37**. It typically presents with sudden onset follicular conjunctivitis, preauricular lymphadenopathy, and characteristic subepithelial corneal infiltrates (which appear about 7–10 days after onset). **Analysis of Options:** * **Adenovirus (Correct):** It is the most common cause of viral conjunctivitis. While serotypes 3 and 7 cause Pharyngoconjunctival Fever (PCF), serotypes 8 and 19 are the classic culprits for EKC. * **HSV:** Herpes Simplex Virus typically causes unilateral follicular conjunctivitis or dendritic keratitis, but it does not occur in "epidemics." * **Chlamydia:** Causes Trachoma (Serotypes A-C) or Inclusion Conjunctivitis (Serotypes D-K). These are chronic conditions rather than acute epidemic outbreaks. * **HIV:** While HIV-infected patients are prone to opportunistic ocular infections (like CMV retinitis or Kaposi sarcoma), HIV itself does not cause epidemic keratoconjunctivitis. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 8s:** EKC is often associated with Adenovirus **8**, has an incubation period of about **8** days, and the first **8** days are the most infectious. * **Transmission:** Highly contagious via respiratory droplets or contaminated fingers and ophthalmic instruments (e.g., tonometers). * **Clinical Sign:** Presence of **pseudomembranes** and **subepithelial infiltrates** (immune-mediated) are hallmarks of EKC. * **Management:** Primarily supportive (cold compresses, artificial tears). Steroids are reserved for severe subepithelial infiltrates affecting vision but must be used cautiously.

Question 162: Horner Trantas nodules are seen in:

A. Blepharoconjunctivitis
B. Vernal conjunctivitis (Correct Answer)
C. Phlyctenular conjunctivitis
D. Herpetic keratitis

Explanation: **Explanation:** **Vernal Keratoconjunctivitis (VKC)**, also known as "Spring Catarrh," is a bilateral, recurrent, external ocular inflammation primarily affecting young males in hot, dry climates. It is a Type I and Type IV hypersensitivity reaction. **Why the correct answer is right:** **Horner-Trantas Nodules** are a hallmark clinical feature of the **Limbal variant** of VKC. These are small, white, elevated gelatinous dots found at the limbus. Pathologically, they consist of collections of **eosinophils and epithelial debris**. Their presence indicates active disease. In the Palpebral variant, the characteristic finding is "cobblestone" or giant papillae on the superior tarsal conjunctiva. **Why the incorrect options are wrong:** * **Blepharoconjunctivitis:** This involves inflammation of the eyelid margins and conjunctiva, typically presenting with crusting, redness, and telangiectasia, but does not feature limbal eosinophilic nodules. * **Phlyctenular conjunctivitis:** This is a Type IV hypersensitivity to endogenous antigens (like *M. tuberculosis* or *Staphylococcus*). It presents with a **Phlycten**—a small, pinkish-white nodule near the limbus that ulcerates—but it is not composed of eosinophils. * **Herpetic keratitis:** Caused by HSV, this typically presents with dendritic ulcers (epithelial) or disciform edema (stromal) and decreased corneal sensations, rather than allergic nodules. **High-Yield Clinical Pearls for NEET-PG:** * **Maxwell-Lyons Sign:** A ropey, tenacious discharge characteristic of VKC. * **Shield Ulcer:** A sterile, transverse oval ulcer in the upper cornea seen in severe VKC. * **Treatment:** Topical mast cell stabilizers (Olopatadine) are the mainstay; topical steroids are used for acute exacerbations. * **Histology:** Look for increased eosinophils, mast cells, and plasma cells in the conjunctiva.

Question 163: Arlt's line is seen in which of the following conditions?

A. Vernal keratoconjunctivitis
B. Pterygium
C. Ocular pemphigoid
D. Trachoma (Correct Answer)

Explanation: **Explanation:** **Arlt’s line** is a classic clinical sign of **Trachoma**, a chronic keratoconjunctivitis caused by *Chlamydia trachomatis* (serotypes A, B, Ba, and C). It represents a horizontal band of scar tissue (cicatrization) located in the palpebral conjunctiva, specifically at the junction of the anterior one-third and posterior two-thirds of the upper lid. This scarring occurs due to the healing of lymphoid follicles and chronic inflammation characteristic of the cicatricial stage of the disease. **Analysis of Options:** * **Vernal Keratoconjunctivitis (VKC):** Characterized by "cobblestone" papillae on the superior tarsal conjunctiva and Horner-Tranta’s dots at the limbus, not linear scarring. * **Pterygium:** A degenerative, wing-shaped fibrovascular proliferation of the conjunctiva onto the cornea. A key sign here is **Stocker’s line** (iron deposition). * **Ocular Pemphigoid:** An autoimmune condition leading to symblepharon (adhesion of palpebral to bulbar conjunctiva) and progressive conjunctival shrinkage, but it does not present with the specific horizontal Arlt’s line. **High-Yield Clinical Pearls for Trachoma:** * **Herbert’s Pits:** Small circular depressions at the limbus (scars of limbal follicles); pathognomonic for Trachoma. * **SAFE Strategy:** WHO-recommended management (Surgery, Antibiotics—Azithromycin, Facial cleanliness, Environmental improvement). * **Complications:** Trichiasis, entropion, and corneal scarring (leading cause of preventable blindness worldwide). * **Classification:** Uses the **FISTO** mnemonic (Follicular, Intense, Scarring, Trichiasis, Opacity).

Question 164: Pinguecula is best characterized histologically by?

A. Fatty degeneration
B. Hyaline degeneration
C. Elastotic degeneration (Correct Answer)
D. Fibrinoid degeneration

Explanation: **Explanation:** **Pinguecula** is a common, non-cancerous degeneration of the conjunctival stroma, typically occurring in the interpalpebral fissure. **Why Elastotic Degeneration is Correct:** The hallmark histological feature of Pinguecula (and Pterygium) is **elastotic degeneration**. This process involves the breakdown of collagen fibers in the substantia propria, which are replaced by abnormal, thickened, and convoluted yellowish elastic-like fibers. It is important to note that these are not true elastic fibers, but rather degraded collagen that stains with elastic stains; hence the term "elastotic." This change is primarily triggered by chronic exposure to **ultraviolet (UV) radiation**, wind, and dust. **Analysis of Incorrect Options:** * **A. Fatty degeneration:** Despite the name "Pinguecula" (derived from *pinguis*, meaning fat) and its yellowish appearance, there is no actual fatty infiltration or lipid deposition involved. * **B. Hyaline degeneration:** While hyaline changes can occur in various chronic inflammations, it is not the primary pathological process in Pinguecula. * **D. Fibrinoid degeneration:** This is typically seen in vasculitis or immune-mediated injuries (like in Rheumatic nodules), involving the deposition of fibrin, which is not a feature of conjunctival degenerations. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Most commonly found on the **nasal side** within the palpebral aperture. * **Clinical Appearance:** A yellowish-white, triangular, or amorphous deposit near the limbus. * **Key Difference from Pterygium:** Unlike Pterygium, a Pinguecula **never** invades or crosses the cornea. * **Complication:** **Pingueculitis** occurs when the lesion becomes acutely inflamed and vascularized. * **Treatment:** Usually none required; lubricants or mild steroids are used for inflammation. Excision is only for cosmetic reasons.

Question 165: Which of the following is true about pterygium?

A. It is common on the nasal side
B. It is common with exposure to UV rays (Correct Answer)
C. It is a neoplastic condition
D. All pterygia require surgical intervention

Explanation: **Explanation:** A **pterygium** is a triangular, fibrovascular subepithelial ingrowth of degenerative bulbar conjunctiva onto the cornea. It typically occurs in the interpalpebral fissure. **1. Why Option B is correct:** The primary etiology of pterygium is chronic exposure to **Ultraviolet (UV) radiation** (specifically UV-B rays). This leads to the mutation of the **p53 tumor suppressor gene** in limbal basal cells and the elastotic degeneration of collagen. It is most common in people living in the "Pterygium Belt" (near the equator) and those with outdoor occupations. **2. Analysis of Incorrect Options:** * **Option A:** While pterygium is indeed **more common on the nasal side** due to the reflection of light from the nose onto the nasal limbus, Option B is considered the more fundamental "true" statement regarding its pathogenesis in many standardized exams. However, in many clinical contexts, both A and B are true. In the context of this specific question, UV exposure is the definitive causative factor. * **Option C:** Pterygium is a **degenerative condition**, not a neoplastic one. It involves elastotic degeneration and proliferation of vascularized granulation tissue. * **Option D:** Not all pterygia require surgery. Small, asymptomatic pterygia are managed conservatively with lubricants and UV protection (sunglasses). Surgery is indicated only if it threatens the visual axis, causes significant astigmatism, restricts ocular motility, or for cosmetic reasons. **High-Yield Clinical Pearls for NEET-PG:** * **Stocker’s Line:** An iron deposition line seen on the corneal epithelium at the leading edge (head) of the pterygium, indicating stability. * **Fuchs’ Flecks:** Small greyish-white opacities seen near the head. * **Surgical Gold Standard:** Excision with **Limbal Conjunctival Autograft (CAG)** is the treatment of choice to minimize recurrence. * **Recurrence:** The most common complication after surgery. Antimetabolites like **Mitomycin-C** or Thiotepa are sometimes used to prevent it.

Question 166: Spontaneous subconjunctival hemorrhage is considered:

A. A benign condition (Correct Answer)
B. A malignant condition
C. A medical emergency
D. None of the above

Explanation: **Explanation:** **Subconjunctival Hemorrhage (SCH)** is defined as the rupture of a small blood vessel (capillary) under the conjunctiva, leading to the accumulation of blood between the conjunctiva and the episclera. 1. **Why Option A is Correct:** Spontaneous SCH is almost always a **benign, self-limiting condition**. It typically occurs without a clear inciting event or may follow minor trauma, coughing, sneezing, or straining (Valsalva maneuver). Despite its alarming "bright red" appearance, it does not affect vision, is painless, and the blood is usually reabsorbed spontaneously within 1–2 weeks without any specific treatment. 2. **Why Other Options are Incorrect:** * **Option B (Malignant):** SCH is a vascular event, not a neoplastic process. It does not involve uncontrolled cell growth or metastasis. * **Option C (Medical Emergency):** Unlike conditions like acute congestive glaucoma or retinal detachment, SCH does not threaten vision. It requires reassurance rather than urgent intervention. **Clinical Pearls for NEET-PG:** * **Etiology:** While usually idiopathic, recurrent SCH should prompt an investigation into systemic causes like **hypertension**, bleeding diathesis, or the use of anticoagulants (e.g., Aspirin, Warfarin). * **Trauma:** If SCH is associated with trauma and is "posteriorly limitless" (the posterior border of the hemorrhage cannot be seen), it is a classic sign of **Base of Skull Fracture**. * **Management:** Reassurance is the mainstay. Cold compresses in the first 24 hours may limit bleeding, followed by warm compresses to aid absorption.

Question 167: "Ropy discharge" from the eye is seen in which of the following conditions?

A. Phlyctenular conjunctivitis
B. Swimming pool conjunctivitis
C. Spring catarrh (Correct Answer)
D. Epidemic keratoconjunctivitis

Explanation: **Explanation:** **Spring Catarrh (Vernal Keratoconjunctivitis - VKC)** is a bilateral, recurrent, seasonal allergic inflammation of the conjunctiva, typically affecting young boys. The hallmark clinical finding is a **"ropy" or "stringy" discharge**. This occurs because the allergic response triggers an increase in goblet cell activity and mucus production. The discharge is thick, tenacious, and elastic due to high mucus content and the presence of eosinophils. **Analysis of Incorrect Options:** * **Phlyctenular conjunctivitis:** This is a Type IV hypersensitivity reaction to endogenous bacterial proteins (most commonly Tubercle bacilli). It is characterized by a localized nodule (phlycten) and typically presents with **mucopurulent discharge** or watery tearing, but not ropy discharge. * **Swimming pool conjunctivitis:** Caused by *Chlamydia trachomatis* (Serotypes D-K), this is a form of Adult Inclusion Conjunctivitis. It typically presents with a **mucopurulent discharge** and follicular reaction. * **Epidemic keratoconjunctivitis (EKC):** Caused by Adenovirus (types 8 and 19), this is a highly contagious viral infection. It is characterized by a **watery (serous) discharge**, follicles, and subepithelial corneal infiltrates. **High-Yield Clinical Pearls for NEET-PG:** * **VKC Triad:** Itching (most constant symptom), ropy discharge, and photophobia. * **Cobblestone Papillae:** Large, flat-topped papillae seen on the superior palpebral conjunctiva (Palpebral form). * **Trantas Dots:** White limbal dots consisting of eosinophils and epithelial debris (Limbal form). * **Maxwell-Lyons Sign:** A thin film of fibrin (pseudomembrane) over the giant papillae. * **Shield Ulcer:** A sterile, transverse oval ulcer in the upper part of the cornea, a serious complication of VKC.

Question 168: Acute hemorrhagic conjunctivitis is associated with which type of infection?

A. Enterovirus type 70 (Correct Answer)
B. Staphylococci
C. Pneumococcus
D. Hemophilus

Explanation: **Explanation:** **Acute Hemorrhagic Conjunctivitis (AHC)** is a highly contagious, self-limiting viral infection characterized by sudden onset of ocular pain, lid edema, and pathognomonic **subconjunctival hemorrhages**. 1. **Why Enterovirus 70 is correct:** AHC is primarily caused by **Enterovirus type 70** and **Coxsackievirus A24**. These are picornaviruses transmitted via the feco-oral route or direct hand-to-eye contact. Enterovirus 70 is particularly high-yield for exams because it is uniquely associated with rare neurological complications, such as **polio-like radiculomyelitis** (cranial nerve palsies or flaccid paralysis). 2. **Why the other options are incorrect:** * **Staphylococci (Option B):** *S. aureus* is the most common cause of acute bacterial conjunctivitis, typically presenting with mucopurulent discharge rather than frank hemorrhages. * **Pneumococcus (Option C):** *Streptococcus pneumoniae* causes acute bacterial conjunctivitis, often associated with petechial hemorrhages, but it does not cause the explosive, epidemic-scale hemorrhagic outbreaks seen with Enteroviruses. * **Hemophilus (Option D):** *H. influenzae* (specifically the Koch-Weeks bacillus) is a common cause of bacterial conjunctivitis in children and can cause subconjunctival spots, but it is not the primary agent of AHC. **High-Yield Clinical Pearls for NEET-PG:** * **Incubation Period:** Very short (12–48 hours), leading to rapid "explosive" epidemics. * **Clinical Sign:** Subconjunctival hemorrhages usually begin in the upper bulbar conjunctiva and spread. * **Preauricular Lymphadenopathy:** Often present (characteristic of viral conjunctivitis). * **Differential Diagnosis:** Adenovirus (Serotypes 8, 11, 19) causes **Epidemic Keratoconjunctivitis (EKC)**, which is distinguished by significant corneal involvement (subepithelial infiltrates) rather than primary hemorrhage.

Question 169: Acute hemorrhagic conjunctivitis is seen with which of the following?

A. Adenovirus (Correct Answer)
B. Staphylococcal
C. Pneumococcus
D. Hemophilus

Explanation: **Explanation:** **Acute Hemorrhagic Conjunctivitis (AHC)** is a highly contagious, self-limiting viral infection characterized by sudden onset of ocular pain, lid edema, and prominent subconjunctival hemorrhages. 1. **Why Adenovirus is Correct:** Adenoviruses are the most common cause of viral conjunctivitis. Specifically, **Adenovirus Serotypes 7 and 11** are known to cause AHC. However, the most frequent global causes of AHC are **Enterovirus 70** and **Coxsackievirus A24**. In the context of the given options, Adenovirus is the only viral pathogen listed and is a well-documented cause of hemorrhagic ocular presentations (such as in Epidemic Keratoconjunctivitis). 2. **Why Other Options are Incorrect:** * **Staphylococcal (B):** Typically causes acute mucopurulent conjunctivitis. It is characterized by crusting of lids and yellow discharge rather than frank subconjunctival hemorrhage. * **Pneumococcus (C) & Hemophilus (D):** These are common causes of bacterial conjunctivitis in children. While they can occasionally cause petechial hemorrhages, they primarily present with purulent discharge and "pink eye" symptoms, not the explosive, widespread hemorrhagic clinical picture seen in AHC. **High-Yield Clinical Pearls for NEET-PG:** * **Epidemic Keratoconjunctivitis (EKC):** Caused by Adenovirus serotypes **8, 19, and 37**. It is characterized by "pseudomembranes" and subepithelial corneal infiltrates. * **Pharyngoconjunctival Fever (PCF):** Caused by Adenovirus serotypes **3, 4, and 7**. It presents with the triad of fever, pharyngitis, and follicular conjunctivitis. * **AHC Key Feature:** The incubation period is very short (12–48 hours), and it often occurs in large-scale epidemics.

Question 170: What is the primary treatment for Phlyctenular conjunctivitis?

A. Systemic steroids
B. Topical steroids (Correct Answer)
C. Antibiotics
D. Miotics

Explanation: **Explanation:** **Phlyctenular Keratoconjunctivitis** is a localized delayed hypersensitivity (Type IV) reaction of the conjunctiva and cornea to endogenous microbial proteins. Historically, it was most commonly associated with **Tuberculosis** (Mycobacterium tuberculosis), but in modern clinical practice, it is frequently triggered by **Staphylococcus aureus** (associated with blepharitis). **Why Topical Steroids are the Correct Answer:** Since the underlying pathology is an **allergic/inflammatory response** rather than a direct infection of the conjunctiva, the primary goal of treatment is to suppress the immune reaction. **Topical steroids** (e.g., Fluorometholone or Dexamethasone) provide a dramatic and rapid symptomatic response by reducing the inflammatory nodule (phlycten). **Analysis of Incorrect Options:** * **Systemic Steroids (A):** These are generally unnecessary as the condition is localized and responds well to topical therapy. They are reserved for severe, bilateral cases or systemic associations like Sarcoidosis. * **Antibiotics (C):** While topical antibiotics are often used as an *adjunct* to treat the underlying cause (like staphylococcal blepharitis) or prevent secondary infection, they do not treat the phlycten itself. * **Miotics (D):** These drugs (e.g., Pilocarpine) are used in glaucoma and have no role in treating allergic or inflammatory conjunctival diseases. **High-Yield Clinical Pearls for NEET-PG:** * **The Phlycten:** A characteristic pinkish-white nodule surrounded by a localized zone of hyperemia, typically near the limbus. * **Key Association:** Always look for **Blepharitis** or a history of **Tuberculosis** in the clinical stem. * **Fascicular Ulcer:** A specific type of corneal involvement where a phlycten migrates towards the center of the cornea, trailing a leash of blood vessels. * **Investigation:** In any case of phlyctenular disease, a **Chest X-ray and Mantoux test** are essential to rule out occult TB.

Practice by Chapter

Conjunctivitis: Bacterial

Practice Questions

Conjunctivitis: Viral

Practice Questions

Conjunctivitis: Allergic

Practice Questions

Conjunctivitis: Chronic

Practice Questions

Degenerations of Conjunctiva

Practice Questions

Benign Tumors of Conjunctiva

Practice Questions

Malignant Tumors of Conjunctiva

Practice Questions

Conjunctival Manifestations of Systemic Diseases

Practice Questions

Cicatricial Conjunctival Disorders

Practice Questions

Pterygium and Pinguecula

Practice Questions

Conjunctival Trauma

Practice Questions

Subconjunctival Hemorrhage

Practice Questions

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