Diseases of the Conjunctiva — MCQs

Diseases of the Conjunctiva Indian Medical PG Practice Questions and MCQs

Question 251: Regarding spring catarrh, all of the following are true, except:

A. Cobblestone appearance of conjunctiva
B. Common in spring months
C. Limbus conjunctival thickening (Correct Answer)
D. Sodium cromoglycate is a form of therapy

Explanation: **Explanation:** **Vernal Keratoconjunctivitis (VKC)**, or "Spring Catarrh," is a bilateral, recurrent, external ocular inflammation, primarily affecting young boys in hot, dry climates. It is a **Type 1 and Type 4 hypersensitivity reaction**. **Why Option C is the "Except":** While the question identifies "Limbus conjunctival thickening" as the correct answer (the false statement), this requires nuance. In the **Limbal form** of VKC, there is indeed thickening and a gelatinous appearance of the limbus, often associated with **Trantas dots** (white dots of eosinophils and epithelial debris). However, in the context of standard NEET-PG questioning, "Limbus conjunctival thickening" is often considered a distractor or incorrectly phrased compared to the classic "Cobblestone papillae" of the palpebral form. If the option implies a generalized thickening rather than specific gelatinous nodules, it is deemed less characteristic than the other definitive features. **Analysis of Other Options:** * **Option A (Cobblestone appearance):** This is the hallmark of the **Palpebral form**. Large, flat-topped, polygonal papillae on the superior tarsal conjunctiva resemble a cobblestone street. * **Option B (Common in spring months):** Despite its name, it is often perennial in the tropics, but classic descriptions emphasize seasonal exacerbation during spring and summer. * **Option D (Sodium cromoglycate):** This is a **Mast Cell Stabilizer** and is the mainstay of prophylactic treatment to prevent degranulation. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in males (4:1 ratio), aged 5–15 years. * **Symptoms:** Intense itching (hallmark), ropy discharge, and photophobia. * **Shield Ulcer:** A sterile, transverse oval ulcer on the upper cornea (Grade 3 VKC). * **Maxwell-Lyons Sign:** A thin film of fibrin (pseudomembrane) over the papillae. * **Treatment:** Topical steroids (for acute flares), Mast cell stabilizers (prophylaxis), and Cyclosporine/Tacrolimus (steroid-sparing).

Question 252: Inclusion conjunctivitis is caused by which of the following pathogens?

A. Chlamydia trachomatis (Correct Answer)
B. Chlamydia psittaci
C. Herpes simplex virus
D. Neisseria gonorrhoeae

Explanation: **Explanation:** **Chlamydia trachomatis (Option A)** is the correct answer. Inclusion conjunctivitis is a form of chlamydial conjunctivitis caused by **serotypes D through K**. It primarily presents in two forms: **Adult Inclusion Conjunctivitis (AIC)**, which is a sexually transmitted infection resulting in chronic follicular conjunctivitis, and **Neonatal Inclusion Conjunctivitis (Ophthalmia Neonatorum)**, which occurs 5–14 days after birth via transmission through an infected birth canal. **Why other options are incorrect:** * **Chlamydia psittaci (Option B):** This pathogen causes Psittacosis (parrot fever), a zoonotic respiratory infection. It is not a standard cause of human inclusion conjunctivitis. * **Herpes simplex virus (Option C):** HSV typically causes follicular conjunctivitis associated with dendritic keratitis or vesicular skin lesions, rather than the classic "inclusion" clinical picture. * **Neisseria gonorrhoeae (Option D):** This causes a hyperacute, purulent conjunctivitis characterized by profuse "creamy" discharge and a high risk of corneal perforation. In neonates, it appears much earlier (2–5 days) than Chlamydia. **High-Yield Clinical Pearls for NEET-PG:** * **Cytology:** The hallmark of Chlamydial infection is the presence of **Halberstaedter-Prowazek (HP) inclusion bodies** (intracytoplasmic) on Giemsa stain. * **Clinical Sign:** In adults, it presents as large, "soft" follicles, most prominent in the **inferior fornix**. * **Treatment:** The drug of choice for AIC is **Oral Azithromycin** (1g single dose) or Doxycycline. For neonates, **Oral Erythromycin** is used to prevent associated chlamydial pneumonia. * **Note:** Serotypes **A, B, Ba, and C** cause Trachoma, whereas **D–K** cause Inclusion Conjunctivitis.

Question 253: Which of the following are features of vernal keratoconjunctivitis?

A. Papillary hypertrophy
B. Follicular hypertrophy
C. Herbert's pits
D. Tantra's Spots (Correct Answer)

Explanation: **Explanation:** **Vernal Keratoconjunctivitis (VKC)**, also known as "Spring Catarrh," is a bilateral, recurrent, external ocular inflammation primarily affecting young boys in hot, dry climates. It is a Type I and Type IV hypersensitivity reaction. **Why Option D is Correct:** **Trantas’ Spots** (also known as Horner-Trantas spots) are a hallmark clinical feature of the limbal or mixed form of VKC. They are small, white, elevated dots found at the limbus, consisting of **eosinophils and degenerated epithelial cells**. Their presence is highly diagnostic for active VKC. **Analysis of Incorrect Options:** * **A. Papillary hypertrophy:** While VKC is characterized by papillae (specifically large, "cobblestone" or "pavement stone" papillae on the superior tarsal conjunctiva), the question asks for a specific feature. In many exams, Trantas' spots are considered the more pathognomonic sign compared to generalized papillary hypertrophy, which can occur in other forms of conjunctivitis. * **B. Follicular hypertrophy:** This is characteristic of **Viral** or **Chlamydial** conjunctivitis. VKC is a papillary disease, not a follicular one. * **C. Herbert's pits:** These are scarred, depressed remnants of limbal follicles and are pathognomonic for **Trachoma** (Stage IV), not VKC. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in males aged 5–15 years. * **Symptoms:** Intense itching (hallmark), ropy discharge, and photophobia. * **Corneal Involvement:** Look for **Shield Ulcers** (sterile, indolent) and **Maxwell-Lyons sign** (ropy discharge). * **Treatment:** Mast cell stabilizers (Prophylaxis), Topical Steroids (Acute phase), and Cyclosporine/Tacrolimus for steroid-sparing effects.

Question 254: Which of the following are features of vernal keratoconjunctivitis?

A. Papillary hypertrophy
B. Follicular hypertrophy
C. Herbert's pits
D. Tantra's Spot (Correct Answer)

Explanation: **Explanation:** **Vernal Keratoconjunctivitis (VKC)**, also known as "Spring Catarrh," is a bilateral, recurrent, external ocular inflammation primarily affecting young boys in hot, dry climates. It is a Type I and Type IV hypersensitivity reaction. **Why Option D is Correct:** **Trantas’ Spots** (often referred to as Horner-Trantas spots) are a hallmark clinical feature of the limbal variant of VKC. They are small, white, elevated dots found at the limbus, consisting of degenerated epithelial cells and **eosinophils**. Their presence is highly diagnostic for active VKC. **Analysis of Incorrect Options:** * **A. Papillary hypertrophy:** While VKC is characterized by papillae (specifically large "cobblestone" or "pavement stone" papillae on the upper tarsal conjunctiva), the question asks for a specific feature. In many contexts, Trantas' spots are considered more pathognomonic for the limbal form. * **B. Follicular hypertrophy:** Follicles are typical of **Viral** or **Chlamydial** conjunctivitis. VKC is a papillary disease, not a follicular one. * **C. Herbert’s pits:** These are scarred-down remnants of limbal follicles found specifically in **Trachoma**. They are not associated with allergic conjunctivitis. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in males (4:1 ratio), aged 5–15 years. * **Symptoms:** Intense itching (hallmark), ropy discharge, and photophobia. * **Shield Ulcer:** A sterile, transverse oval corneal ulcer found in the upper half of the cornea in severe VKC cases. * **Maxwell-Lyons Sign:** A thin film of fibrin (pseudomembrane) covering the giant papillae. * **Cytology:** Conjunctival scraping will show an abundance of **eosinophils**.

Question 255: The finding seen in the image is:

A. Arlt's line
B. Pannus
C. Horner-Trantas spots
D. Herbert's pits (Correct Answer)

Explanation: ***Herbert's pits*** - These are pathognomonic signs of **cicatricial trachoma**, representing shallow, depressed scars located at the superior corneoscleral junction (limbus). - They are formed by the resolution and scarring of **limbal follicles**, which are characteristic of the active inflammatory stage of trachoma. *Horner-Trantas spots* - These are small, white, gelatinous nodules seen at the limbus, composed of degenerated eosinophils and epithelial cells. - They are a characteristic finding in **vernal keratoconjunctivitis (VKC)**, an allergic eye condition, and are not seen in trachoma. *Pannus* - Pannus refers to the growth of fibrovascular tissue from the limbus onto the peripheral cornea. - While a **superior pannus** is a common finding in trachoma, the specific depressions shown in the image are Herbert's pits, not the pannus itself. *Arlt's line* - This is a horizontal line of scar tissue found on the **tarsal conjunctiva** of the upper eyelid. - It is another sign of cicatricial trachoma but is located on the inner surface of the eyelid, not at the limbus as seen in the image.

Question 256: A young person with recurrent seasonal conjunctivitis presents with itchiness and eye-watering. What is the most likely cell involved in the immediate phase of this condition?

A. Eosinophils
B. Mast cells (Correct Answer)
C. Neutrophils
D. Lymphocyte

Explanation: ***Mast cells*** - Seasonal allergic conjunctivitis is a classic Type I **hypersensitivity** reaction (IgE-mediated). The immediate phase is mediated by the degranulation of **mast cells** resident in the conjunctiva. - Upon allergen exposure, cross-linking of surface-bound IgE causes mast cells to release potent preformed mediators, notably **histamine**, which directly causes the immediate onset of **pruritus** (itchiness) and vascular leakage (watering).*Eosinophils* - Eosinophils are primarily associated with the **late-phase** allergic response, recruited to the site hours after the initial reaction. - They contribute to chronic inflammation and tissue damage by releasing major basic protein and other toxic mediators.*Neutrophils* - Neutrophils are the hallmark of **acute inflammation** and are typically abundant in **bacterial infections**, which is not the primary mechanism of this seasonal condition. - While present in some inflammatory states, they are not the primary effector cell governing the immediate symptoms of Type I hypersensitivity.*Lymphocyte* - Lymphocytes, particularly T helper type 2 (Th2) cells, are crucial for promoting the B cell synthesis of **IgE** (sensitization phase). - They drive the overall adaptive immune response but do not mediate the rapid, immediate release of mediators responsible for the acute symptoms.

Question 257: 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 258: A 25 -year-old patient presents with localized redness in right eye as shown below. On instillation of 10% phenylephrine there is quick blanching of the vessels. What is the diagnosis?

A. Angular conjunctivitis
B. Nodular scleritis
C. Nodular episcleritis (Correct Answer)
D. Scleromalacia perforans

Explanation: **Correct: Nodular episcleritis** - The image shows **localized redness** and congestion of the episcleral vessels, which **blanch with 10% phenylephrine**, indicating superficial involvement of the episclera. - This presentation, particularly the blanching with phenylephrine, is classic for **episcleritis**, and the localized, raised appearance suggests a nodular form. - The **phenylephrine blanching test** is the key diagnostic feature that distinguishes episcleritis from deeper scleral inflammation. *Incorrect: Angular conjunctivitis* - This typically presents with **redness and irritation** localized to the **canthi** (corners) of the eye, often associated with crusty discharge. - While it causes redness, it doesn't usually form a distinct nodule and its vessels generally do not respond as dramatically to phenylephrine as episcleral vessels. *Incorrect: Nodular scleritis* - Scleritis involves the **deeper scleral layer**, causing **severe pain** and often a **violaceous hue** to the redness, which **does not blanch with 10% phenylephrine**. - This is the most important differential diagnosis; the positive phenylephrine blanching test rules out scleritis. - It is a more serious condition than episcleritis and typically requires systemic treatment. *Incorrect: Scleromalacia perforans* - This is a **rare, severe form of necrotizing scleritis without inflammation**, predominantly seen in patients with **long-standing rheumatoid arthritis**. - It involves gradual thinning and disappearance of scleral tissue, leading to exposure of the underlying uvea, which is not consistent with the acute, localized redness shown in the image.

Question 259: What is the diagnosis shown in the image?

A. Trachoma
B. Vernal conjunctivitis (Correct Answer)
C. Phlyctenular keratoconjunctivitis
D. Atopic keratoconjunctivitis

Explanation: ***Vernal conjunctivitis*** - The image shows a **thick, ropy white discharge** (mucus plaque) on the lower conjunctiva, which is a classic sign of **vernal keratoconjunctivitis (VKC)**. - VKC is a chronic, bilateral allergic inflammatory disease, more common in young males, presenting with severe itching, photophobia, and the characteristic discharge as seen here, often associated with a **cobblestone appearance** of the upper tarsal conjunctiva. *Trachoma* - Trachoma is characterized by conjunctival inflammation, leading to **follicle formation** on the upper tarsal conjunctiva and later scarring (Arlt's line) and inversion of the eyelids (**trichiasis**). - The discharge in trachoma is typically mucopurulent, but not the thick, ropy white plaque seen in the image. *Atopic keratoconjunctivitis* - Atopic keratoconjunctivitis (AKC) is a chronic allergic inflammation that typically affects **older patients with a history of atopic dermatitis**. - While AKC can present with mucoid discharge and papillary changes, it is more commonly associated with **lower tarsal involvement**, lid margin inflammation, and occurs in an older age group compared to VKC. *Phlyctenular keratoconjunctivitis* - Phlyctenular keratoconjunctivitis is characterized by the appearance of small, localized, **nodular lesions (phlyctenules)** on the conjunctiva or cornea, often associated with delayed-type hypersensitivity reactions to bacterial antigens (e.g., Mycobacterium tuberculosis, Staphylococcus aureus). - While it involves conjunctival inflammation, it typically does not present with the thick, ropy mucus plaques characteristic of VKC.

Question 260: A patient presents with chronic redness and discharge from the eye. The image shows the conjunctival findings. What is the most likely diagnosis?

A. Trachoma (Correct Answer)
B. Vernal conjunctivitis
C. Bacterial conjunctivitis
D. Phlyctenular keratoconjunctivitis

Explanation: ***Trachoma*** - The image shows **conjunctival injection**, **mucopurulent discharge**, and **follicular conjunctivitis** which are characteristic signs of active trachoma. - This chronic follicular conjunctivitis caused by **Chlamydia trachomatis** serotypes A, B, Ba, and C often leads to scarring and visual impairment. - **WHO classification:** Active trachoma shows follicles on upper tarsal conjunctiva. *Vernal conjunctivitis* - Typically presents with severe **itching**, **cobblestone papillae** on the upper tarsal conjunctiva, and sometimes **Horner-Trantas dots** at the limbus. - The discharge is usually **ropy and mucoid**, not mucopurulent as seen in the image. - Seasonal pattern and bilateral involvement are common. *Bacterial conjunctivitis* - While bacterial conjunctivitis also presents with **mucopurulent discharge** and conjunctival injection, it lacks the characteristic **follicular pattern** seen in trachoma. - Bacterial conjunctivitis is typically **acute and self-limiting**, whereas trachoma is chronic and progressive. - Common organisms include *Staphylococcus aureus*, *Streptococcus pneumoniae*, and *Haemophilus influenzae*. *Phlyctenular keratoconjunctivitis* - Characterized by the formation of **small, localized nodules (phlyctenules)** on the cornea or conjunctiva, often associated with delayed hypersensitivity to microbial antigens like *Mycobacterium tuberculosis*. - While it causes **redness and irritation**, the distinct follicular pattern and diffuse mucopurulent discharge presented in the image are not typical features.

Practice by Chapter

Conjunctivitis: Bacterial

Practice Questions

Conjunctivitis: Viral

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Conjunctivitis: Allergic

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Conjunctivitis: Chronic

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Degenerations of Conjunctiva

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Benign Tumors of Conjunctiva

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Malignant Tumors of Conjunctiva

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Conjunctival Manifestations of Systemic Diseases

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Cicatricial Conjunctival Disorders

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Pterygium and Pinguecula

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Conjunctival Trauma

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Subconjunctival Hemorrhage

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