Subconjunctival Hemorrhage — 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?
A 33-year-old patient suffers from blunt trauma to the eye. Fundoscopy shows a cherry red spot, the probable diagnosis is
Acute Hemorrhagic Conjunctivitis is primarily caused by which type of Enterovirus?
Sudden painful loss of vision seen in
Which of the following conditions does not typically cause subconjunctival hemorrhages?
Which of the following is NOT a feature of iridocyclitis?
In which of the following conditions is the intraocular pressure very high, and inflammation is minimal?
What is the immediate management approach for severe vitreous hemorrhage in the eye?
In a patient with head injury black eye associated with subconjunctival hemorrhage occurs when there is
A 22-year-old Air-force test pilot presents after flying a sortie. He reports no pain or vision changes. Eye examination reveals a localized red patch on the sclera. What is the most likely diagnosis?
Subconjunctival Hemorrhage 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: A 33-year-old patient suffers from blunt trauma to the eye. Fundoscopy shows a cherry red spot, the probable diagnosis is
- A. Central Retinal Artery Occlusion (Correct Answer)
- B. Retinoblastoma
- C. Optic nerve transection
- D. Posterior Vitreous Detachment
Explanation: ***Central Retinal Artery Occlusion*** - A **cherry red spot** on fundoscopy is a classic sign of **central retinal artery occlusion (CRAO)**, occurring due to the opaque retina surrounding the fovea, which maintains its blood supply from the choroid. - While blunt trauma can cause CRAO, the primary mechanism is often an **arterial embolism** or thrombus, leading to acute, painless vision loss. *Retinoblastoma* - Retinoblastoma is a **childhood eye cancer** most commonly presenting with **leukocoria** (white pupillary reflex) and strabismus, not typically a cherry red spot. - Although it can present with retinal detachment, the characteristic fundoscopic finding is a **white intraocular mass**, not an ischemic retinal appearance. *Optic nerve transection* - Optic nerve transection results in immediate, severe vision loss and a **positive relative afferent pupillary defect (RAPD)**, but it generally does not cause a cherry red spot. - Fundoscopy after optic nerve transection would initially appear normal, with subsequent **optic disc pallor** developing over weeks to months. *Posterior Vitreous Detachment* - **Posterior vitreous detachment (PVD)** is a common age-related condition presenting with **floaters** and **flashes of light**. - Fundoscopy typically reveals a **Weiss ring** (a ring of glial tissue) and vitreous opacities, not a cherry red spot, and vision loss is often not as sudden or severe as CRAO.
Question 3: Acute Hemorrhagic Conjunctivitis is primarily caused by which type of Enterovirus?
- A. Enterovirus type 68
- B. Enterovirus type 69
- C. Enterovirus type 70 (Correct Answer)
- D. Enterovirus type 71
Explanation: ***Enterovirus type 70*** - **Enterovirus type 70** is the most common cause of **Acute Hemorrhagic Conjunctivitis (AHC)**, particularly in epidemic outbreaks. - AHC presents with rapid onset of **ocular pain**, **redness**, **swelling**, and **subconjunctival hemorrhages**. *Enterovirus type 68* - **Enterovirus D68 (EV-D68)** is primarily known for causing **respiratory illnesses**, ranging from mild to severe, and is associated with acute flaccid myelitis. - While it can cause respiratory symptoms, it is not a primary cause of **Acute Hemorrhagic Conjunctivitis**. *Enterovirus type 69* - **Enterovirus type 69** is a rare serotype and is not typically associated with specific human diseases or large-scale outbreaks. - Unlike EV70, it is not recognized as a significant cause of **conjunctivitis**. *Enterovirus type 71* - **Enterovirus A71 (EV-A71)** is a common cause of **hand, foot, and mouth disease (HFMD)**, especially in children, and can also lead to severe neurological complications. - While it causes various infections, it is not the primary cause of **hemorrhagic conjunctivitis**.
Question 4: Sudden painful loss of vision seen in
- A. Angle closure glaucoma (Correct Answer)
- B. Endophthalmitis
- C. Acute uveitis
- D. Central retinal artery occlusion
Explanation: ***Angle closure glaucoma*** - This is the **classic presentation** of sudden, painful vision loss in ophthalmology - Characterized by **acute increase in intraocular pressure** (often >40 mmHg) causing severe eye pain, headache, nausea, and vomiting - Vision loss is rapid due to damage to the **optic nerve** and corneal edema - The pain is intense and sharp due to stretching of ocular structures - **Key distinguishing feature**: Mid-dilated fixed pupil, corneal edema, shallow anterior chamber *Endophthalmitis* - Also causes **sudden painful vision loss** and is a sight-threatening emergency - Pain is severe with rapid onset of vision loss, redness, and hypopyon - **Differentiating features**: History of recent ocular surgery, trauma, or intravitreal injection; presence of hypopyon (layered pus in anterior chamber) - While both can present similarly, endophthalmitis typically has **obvious intraocular inflammation** and relevant preceding history *Acute uveitis* - Presents with **ocular pain**, **redness**, **photophobia**, and blurred vision - Vision loss is usually **gradual**, not sudden and complete - Pain is moderate, described as dull aching rather than severe acute pain - Rarely causes sudden severe vision loss unless complicated *Central retinal artery occlusion* - Causes **sudden, painless loss of vision** - this is the key distinguishing feature - Described as "curtain coming down" or sudden blackout of vision - **Absence of pain** differentiates it from acute angle-closure glaucoma - Cherry-red spot on fundoscopy is pathognomonic
Question 5: Which of the following conditions does not typically cause subconjunctival hemorrhages?
- A. Whooping cough
- B. Scurvy
- C. Pellagra (Correct Answer)
- D. Purpura
Explanation: ***Pellagra*** - Pellagra is a **nutritional deficiency disease** caused by a lack of **niacin (vitamin B3)**, characterized by symptoms affecting the **skin, gastrointestinal tract, and nervous system** (dermatitis, diarrhea, dementia, and death if untreated) [1]. - It does **not typically cause subconjunctival hemorrhages** as it primarily affects other organ systems and isn't associated with vascular fragility in the conjunctiva like the other conditions listed [2]. *Whooping cough* - **Violent coughing paroxysms** in whooping cough (pertussis) can significantly increase **venous pressure in the head and neck**. - This elevated pressure can rupture small conjunctival blood vessels, leading to **subconjunctival hemorrhages**. *Scurvy* - Scurvy is caused by **vitamin C deficiency**, which is essential for collagen synthesis and maintaining **blood vessel integrity**. - Lack of vitamin C leads to **fragile capillaries**, making patients prone to bleeding, including **subconjunctival hemorrhages**. *Purpura* - Purpura refers to **purple-colored spots on the skin caused by bleeding underneath the skin**. It is a general term for various conditions characterized by **small vessel bleeding**. - These conditions often involve **vascular fragility or platelet abnormalities**, making individuals susceptible to bleeding in different sites, including the conjunctiva, resulting in **subconjunctival hemorrhages**.
Question 6: Which of the following is NOT a feature of iridocyclitis?
- A. Pain
- B. Mucopurulent discharge (Correct Answer)
- C. Circum corneal congestion
- D. Constricted pupil
Explanation: ***Mucopurulent discharge*** * **Mucopurulent discharge** is a hallmark symptom of bacterial conjunctivitis, indicating an infection of the conjunctiva rather than the iris and ciliary body. * **Iridocyclitis** involves inflammation inside the eye, which does not typically produce external discharge. *Pain* * **Pain** is a common symptom of iridocyclitis, often described as a throbbing ache due to inflammation and ciliary body spasm. * The pain can worsen with eye movement or exposure to bright light (photophobia). *Constricted pupil* * A **constricted pupil** (miosis) is characteristic of acute iridocyclitis, caused by spasm of the pupillary sphincter muscle and inflammation. * This differentiates it from acute angle-closure glaucoma where the pupil may be mid-dilated. *Circum corneal congestion* * **Circumcorneal congestion**, also known as ciliary flush, is an important sign of iridocyclitis, appearing as a deep red or violet ring of injection around the cornea. * This type of redness indicates inflammation of the deeper structures of the eye, such as the iris and ciliary body.
Question 7: In which of the following conditions is the intraocular pressure very high, and inflammation is minimal?
- A. Glaucomatocyclic crises (Correct Answer)
- B. Angle closure glaucoma
- C. Acute iridocyclitis
- D. Hypertensive uveitis
Explanation: ***Glaucomatocyclic crises*** - This condition is characterized by recurrent, self-limiting episodes of markedly **elevated intraocular pressure (IOP)** with minimal or no overt signs of inflammation in the anterior chamber. - The elevated IOP is thought to result from **altered humor outflow** due to subtle inflammation of the trabecular meshwork. *Acute iridocyclitis* - Presents with significant signs of **intraocular inflammation**, including **cells and flare** in the anterior chamber, typically with pain and photophobia. - While IOP can be elevated, it's a direct result of inflammation reducing outflow, and the inflammation itself is prominent. *Angle closure glaucoma* - This condition involves a sudden and severe rise in **IOP** due to blockage of the aqueous humor outflow pathway by the peripheral iris, but it's not primarily an inflammatory process. - While the eye can appear red and painful, this is due to ischemia and corneal edema, not marked **intraocular inflammation** like that seen in uveitis. *Hypertensive uveitis* - Refers to any **uveitis** that causes a rise in **intraocular pressure**, meaning significant inflammation is present. - The high IOP is secondary to the inflammation, which can obstruct the trabecular meshwork or stimulate prostaglandin release, both causing reduced outflow.
Question 8: What is the immediate management approach for severe vitreous hemorrhage in the eye?
- A. Steroids
- B. Antibiotics
- C. Conservative management (observation) (Correct Answer)
- D. Vitrectomy
Explanation: ***Correct: Conservative management (observation)*** - **Conservative management with observation** is the immediate approach for severe vitreous hemorrhage, as most cases resolve spontaneously over 2-3 months - Initial management includes **bed rest with head elevation** to allow blood to settle inferiorly and **bilateral eye patching** to reduce eye movement - This approach allows time for **spontaneous resorption** of blood while monitoring for complications like retinal detachment - **Vitrectomy is reserved for later** if there's no improvement after 2-3 months, or if there are urgent indications like retinal detachment *Incorrect: Vitrectomy* - While vitrectomy is definitive treatment, it is **not immediate management** for uncomplicated vitreous hemorrhage - **Indications for vitrectomy** include: failure to clear after 2-3 months of observation, bilateral hemorrhage in diabetics, suspected retinal detachment, or ghost cell glaucoma - Immediate vitrectomy would expose patients to **unnecessary surgical risks** when most cases resolve spontaneously *Incorrect: Steroids* - **Steroids** reduce inflammation but do not address the blood in the vitreous cavity - They have **no role** in managing vitreous hemorrhage itself, though they may be used for associated inflammatory conditions *Incorrect: Antibiotics* - **Antibiotics** treat bacterial infections and have **no role** in vitreous hemorrhage management, which is a bleeding issue, not an infection - Inappropriate antibiotic use contributes to resistance without providing benefit for this condition
Question 9: In a patient with head injury black eye associated with subconjunctival hemorrhage occurs when there is
- A. Fracture of roof and anterior cranial fossa (Correct Answer)
- B. Bleeding between the skin and galea aponeurotica
- C. Hemorrhage between galea aponeurotica and pericranium
- D. Fracture of greater wing of sphenoid bone
Explanation: ***Fracture of roof and anterior cranial fossa*** - A **fracture involving the anterior cranial fossa** can lead to extravasation of blood into the periorbital tissues, causing a **"raccoon eyes"** or **periorbital ecchymosis** appearance. - This blood can track forward into the subconjunctival space, resulting in **subconjunctival hemorrhage**. *Bleeding between the skin and galea aponeurotica* - Bleeding in this superficial plane would lead to a **subgaleal hematoma** or scalp swelling, but it typically does not directly extend to cause a black eye or subconjunctival hemorrhage. - The **galea aponeurotica** is superficial to the orbit and does not directly communicate with the orbital contents in a way that would cause these specific signs. *Hemorrhage between galea aponeurotica and pericranium* - This space is known as the **subgaleal space** and bleeding here would manifest as a diffuse, fluctuating swelling of the scalp. - It is separated from the orbital contents by the **supraorbital ridge** and orbital septum, making it unlikely to directly cause a black eye and subconjunctival hemorrhage without a direct fracture communication. *Fracture of greater wing of sphenoid bone* - A fracture of the **greater wing of the sphenoid** is located more posteriorly and laterally in the skull base. - While significant, it is less likely to directly cause **periorbital ecchymosis** and **subconjunctival hemorrhage** compared to a fracture of the anterior cranial fossa, which is anatomically closer to the orbits.
Question 10: A 22-year-old Air-force test pilot presents after flying a sortie. He reports no pain or vision changes. Eye examination reveals a localized red patch on the sclera. What is the most likely diagnosis?
- A. Hyphema
- B. Subconjunctival hemorrhage (Correct Answer)
- C. Keratitis
- D. Allergic conjunctivitis
Explanation: ***Subconjunctival hemorrhage*** - A **localized red patch on the sclera** with no pain or vision changes, especially after activities that can increase venous pressure (like flying a sortie or straining), is characteristic of a **subconjunctival hemorrhage**. - It results from the rupture of small blood vessels beneath the conjunctiva, causing blood to pool. *Hyphema* - This involves blood in the **anterior chamber of the eye**, usually visible as a fluid level and often causing pain or blurred vision. - It typically results from **trauma** and is not described as a localized red patch on the sclera. *Keratitis* - **Keratitis** is inflammation of the cornea, causing pain, redness, photophobia, and often blurred vision. - The patient has no pain or vision changes, and the presentation is a localized scleral patch, not diffuse corneal involvement. *Allergic conjunctivitis* - Presents with **redness**, itching, tearing, and often bilateral involvement, sometimes with discharge. - The description of a solitary, localized red patch without other allergic symptoms makes this diagnosis unlikely.
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