Dry Eye Disease — MCQs
A 67-year-old man with Parkinson disease has experienced an increasingly dry mouth for the past 3 months, and this interferes with eating and swallowing. He has noted dry eyes as well. On physical examination, he has minimal tremor at rest; there are no other abnormal findings. Laboratory studies show no detectable autoantibodies. Which of the following is the most likely cause for his findings?
Which of the following conditions is NOT associated with xerostomia?
A patient presented with dryness in the eye with a gritty sensation along with corneal softening. What is the most probable cause?
Most sensitive test for detecting microfilariae?
Identify the correct sequence of staining in dry eyes? 1. Fluorescein stain 2. Lissamine green 3. Rose Bengal stain
Which of the following is not a treatment option for vernal keratoconjunctivitis?
Gland that secretes an oily substance is:
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
Which of the following is not a primary symptom of Sjögren's syndrome?
In a 30-year-old male smoker, the commonest cause of dry gangrene of foot will be
Dry Eye Disease Indian Medical PG Practice Questions and MCQs
Question 1: A 67-year-old man with Parkinson disease has experienced an increasingly dry mouth for the past 3 months, and this interferes with eating and swallowing. He has noted dry eyes as well. On physical examination, he has minimal tremor at rest; there are no other abnormal findings. Laboratory studies show no detectable autoantibodies. Which of the following is the most likely cause for his findings?
- A. Alcohol ingestion
- B. Anticholinergic drug use (Correct Answer)
- C. Candidiasis
- D. Sialadenitis with blockage of salivary duct
Explanation: ***Anticholinergic drug use***- Many medications used to treat **Parkinson disease** have **anticholinergic effects**, which can lead to **dry mouth (xerostomia)** and **dry eyes (xerophthalmia)** due to reduced glandular secretions [1].- The patient's presentation of worsening dry mouth and dry eyes aligns well with the side effects of such medications.*Alcohol ingestion*- While chronic alcohol use can contribute to **dehydration** and indirectly affect salivary production, it is typically not the primary cause of such pronounced and progressive symptoms in this context, nor does it commonly cause dry eyes.- The patient's symptoms are more consistent with a direct pharmacological effect rather than general dehydration from alcohol.*Candidiasis*- Oral candidiasis usually presents with **white plaques** on the oral mucosa, **soreness**, or difficulty swallowing due to pain, not primarily dry mouth and dry eyes.- The physical examination did not reveal any other abnormal findings, making candidiasis less likely as the primary cause.*Sialadenitis with blockage of salivary duct*- **Sialadenitis** (inflammation of salivary glands) or salivary duct obstruction typically causes **pain**, **swelling**, and localized tenderness in the affected gland, often exacerbated by eating.- This condition generally affects salivation but does not explain the concurrent dry eyes, making it an unlikely sole cause for both symptoms.
Question 2: Which of the following conditions is NOT associated with xerostomia?
- A. Sjogren syndrome
- B. RA
- C. Sarcoidosis
- D. Midline granuloma (Correct Answer)
Explanation: ***Midline granuloma*** - This condition is not typically associated with **xerostomia** as it primarily affects nasal structures with lesions in the midline of the face. - Xerostomia is not a common symptom, as it relates more to inflammatory processes or conditions affecting salivary glands. *Sjogren syndrome* - Characterized by **autoimmune destruction** of salivary glands, leading to dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca) [1] [2]. - It is the most classic condition associated with **xerostomia** due to its direct impact on salivary gland function [1]. *Sarcoidosis* - This systemic granulomatous disease can cause **salivary gland involvement**, which may lead to xerostomia in some patients. - Other systemic features like **lymphadenopathy** and pulmonary symptoms are also considered in the context of sarcoidosis. *RA (Rheumatoid arthritis)* - RA can result in **dry mouth** due to secondary Sjogren's syndrome or direct involvement of glands, contributing to xerostomia. - It is common for patients with RA to experience **autoimmune conditions** affecting salivary gland function. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 749-750. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, p. 236.
Question 3: A patient presented with dryness in the eye with a gritty sensation along with corneal softening. What is the most probable cause?
- A. Follicular conjunctivitis
- B. Vitamin A deficiency (Correct Answer)
- C. Viral Keratitis
- D. Riboflavin Deficiency
Explanation: Vitamin A deficiency - **Dry eyes** with a **gritty sensation (xerophthalmia)** and **corneal softening (keratomalacia)** are classic signs of severe vitamin A deficiency [1], [2]. - This condition can lead to blindness if not treated promptly, as vitamin A is crucial for the health of the **cornea** and **retina** [1], [2]. *Follicular conjunctivitis* - Characterized by the presence of **lymphoid follicles** on the conjunctiva, often due to viral infections like **adenovirus** or **chlamydia**. - While it can cause dryness, it does not typically lead to **corneal softening** or the severe vision-threatening complications seen with vitamin A deficiency. *Viral Keratitis* - Involves inflammation of the **cornea** due to a viral infection, commonly by **herpes simplex virus**. - Symptoms include pain, redness, blurred vision, and sensitivity to light, but **generalized dryness** and **corneal softening** as the primary presentation are less characteristic. *Riboflavin Deficiency* - Also known as **ariboflavinosis**, this deficiency can cause ocular symptoms like **photophobia**, **corneal vascularization**, and **conjunctivitis**. - However, it typically does not present with **severe dry eyes** or **corneal softening (keratomalacia)** as seen in vitamin A deficiency.
Question 4: Most sensitive test for detecting microfilariae?
- A. Membrane filtration technique (Correct Answer)
- B. Diethylcarbamazine (DEC) challenge test
- C. Fluorescence-based immunoassay
- D. Thick blood smear
Explanation: ***Membrane filtration technique*** - The **membrane filtration technique** is considered the most sensitive test for detecting **microfilariae** because it concentrates microfilariae from a larger volume of blood (typically 1 mL or more) onto a filter membrane, increasing detection rates, especially in low-parasite density infections. - This method physically traps the microfilariae, allowing for microscopic examination of the concentrated sample after staining, which enhances visualization. *Diethylcarbamazine (DEC) challenge test* - The **DEC challenge test** uses **diethylcarbamazine** to provoke the release of microfilariae into the peripheral blood, especially in cases of occult filariasis or when microfilaria numbers are low. - While it can be useful in certain diagnostic situations, it is **less sensitive** than membrane filtration for directly detecting circulating microfilariae and carries the risk of inducing severe adverse reactions due to rapid parasite killing. *Fluorescence-based immunoassay* - **Fluorescence-based immunoassays** detect **antigens** or **antibodies** related to filarial infection, providing evidence of exposure or active infection. - While valuable for diagnosis, especially in antibody detection for chronic or occult infections, they do not directly detect live microfilariae and thus are not the most sensitive method for *detecting microfilariae themselves*. *Thick blood smear* - A **thick blood smear** is a common and quick method for detecting microfilariae by examining a drop of blood for their presence. - However, it is **less sensitive** than the membrane filtration technique, particularly in persons with low microfilaremia, as it examines a much smaller volume of blood.
Question 5: Identify the correct sequence of staining in dry eyes? 1. Fluorescein stain 2. Lissamine green 3. Rose Bengal stain
- A. i, iii, ii
- B. i, ii, iii
- C. ii, iii, i
- D. iii, ii, i (Correct Answer)
Explanation: ***iii, ii, i*** - The correct order for staining in dry eyes is **Rose Bengal, Lissamine Green, and then Fluorescein**. This sequence minimizes the discomfort and potential interference between the dyes. - **Rose Bengal** and **Lissamine Green** stain devitalized or damaged epithelial cells and mucus, while **Fluorescein** stains areas where the epithelium is absent, indicating corneal or conjunctival abrasions or erosions. *i, iii, ii* - This sequence is incorrect because applying fluorescein first could mask the interpretation of epithelial damage by Lissamine Green or Rose Bengal, as it highlights epithelial defects rather than devitalized cells. - The dyes should be applied in an order that optimizes the visualization of different aspects of ocular surface health. *i, ii, iii* - Applying **Fluorescein** first is generally not recommended as it can spread over the ocular surface and potentially interfere with the specific staining patterns of other vital dyes like Lissamine Green or Rose Bengal. - This order does not follow the standard clinical practice for efficient and accurate dry eye assessment. *ii, iii, i* - While Lissamine Green can be used before Fluorescein, placing Rose Bengal after Lissamine Green but still before Fluorescein is not the optimal sequence. - The standard practice aims to assess different layers or types of damage sequentially for a comprehensive evaluation.
Question 6: Which of the following is not a treatment option for vernal keratoconjunctivitis?
- A. Steroids
- B. Chromaglycate
- C. Olopatadine
- D. Antibiotics (Correct Answer)
Explanation: ***Antibiotics*** - **Vernal keratoconjunctivitis (VKC)** is a non-infectious, **allergic inflammatory condition** of the conjunctiva. - Antibiotics are primarily used to treat bacterial infections and have **no direct role** in the management of VKC. *Steroids* - **Topical corticosteroids** (e.g., prednisolone, loteprednol, fluorometholone) are a mainstay of VKC treatment, especially for severe cases and acute exacerbations. - They significantly reduce inflammation and associated symptoms by **suppressing the immune response**. *Chromaglycate* - **Sodium cromoglycate** is a **mast cell stabilizer** commonly used in the treatment of VKC. - It works by preventing the degranulation of mast cells, thereby **inhibiting the release of inflammatory mediators** like histamine. *Olopatadine* - **Olopatadine** is a dual-acting medication that functions as both an **antihistamine** and a **mast cell stabilizer**. - It provides rapid relief from itching and other allergic symptoms by blocking histamine receptors and stabilizing mast cells.
Question 7: Gland that secretes an oily substance is:
- A. Meibomian gland (Correct Answer)
- B. Sweat gland
- C. Lacrimal gland
- D. Salivary gland
Explanation: ***Meibomian gland*** - These glands secrete **oily lipids** (meibum) that form the outermost layer of the tear film, preventing evaporation. - They are a type of **sebaceous gland** located within the eyelids. *Sweat gland* - Sweat glands produce a watery solution of electrolytes and metabolic waste products, primarily for **thermoregulation**. - They do not secrete an **oily substance**, but rather a clear, aqueous fluid. *Lacrimal gland* - The lacrimal gland produces the **aqueous layer of tears**, primarily for lubrication, washing away debris, and providing oxygen to the cornea. - Its secretion is predominantly **watery**, not oily. *Salivary gland* - Salivary glands produce **saliva**, a fluid containing enzymes (like amylase), mucins, and antibodies, important for digestion, lubrication, and oral hygiene. - Saliva is a **mucoserous or aqueous substance**, not an oily secretion.
Question 8: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 9: Which of the following is not a primary symptom of Sjögren's syndrome?
- A. Parotid gland enlargement
- B. Dry eyes
- C. Dry mouth
- D. Systemic manifestations (Correct Answer)
Explanation: ***Systemic manifestations*** - While Sjögren's syndrome can have **systemic manifestations**, they are secondary complications or features, not among the **primary, defining symptoms** that establish the diagnosis. - The primary symptoms directly relate to **exocrine gland dysfunction**, specifically lacrimal and salivary glands. *Dry eyes* - This is a cardinal symptom, resulting from damage to the **lacrimal glands** leading to decreased tear production. - Patients typically report a **gritty or burning sensation** in their eyes. *Dry mouth* - Another core symptom, resulting from dysfunction of the **salivary glands** and reduced saliva flow. - This can lead to difficulties in **speaking, swallowing**, increased dental carries, and oral discomfort. *Parotid gland enlargement* - This is a common and often **visible clinical sign** of Sjögren's syndrome, indicating inflammation of the **major salivary glands**. - It results from lymphocytic infiltration and is typically recurrent or persistent.
Question 10: In a 30-year-old male smoker, the commonest cause of dry gangrene of foot will be
- A. Diabetes mellitus
- B. Embolism
- C. Atherosclerosis
- D. Buerger's disease (Correct Answer)
Explanation: Buerger's disease - **Buerger's disease** (**thromboangiitis obliterans**) is strongly associated with **heavy smoking** and typically affects young to middle-aged adult males, leading to dry gangrene in the extremities. - It involves **inflammation and thrombosis** of small and medium-sized arteries and veins, predominantly in the limbs, often manifesting as **ischemic pain**, ulcerations, and gangrene. *Diabetes mellitus* - While **diabetes** can cause dry gangrene due to **peripheral artery disease** and small vessel disease, it is more commonly associated with **wet gangrene** due to increased infection risk, and the age and smoking history point away from it being the *commonest* cause in this specific demographic for dry gangrene [1]. - Diabetic neuropathy can also mask symptoms, leading to delayed presentation and worsening tissue damage [1]. *Embolism* - An **embolic event** would typically present with **sudden onset** severe pain, pallor, pulselessness, paresthesia, and paralysis (the "6 Ps"), leading to acute limb ischemia rather than the progressive dry gangrene described implied in the question. - While it can cause tissue necrosis, it's usually an acute event rather than a chronic process leading to gradual gangrene. *Atherosclerosis* - While **atherosclerosis** is a significant cause of peripheral artery disease and gangrene, especially in smokers, it typically affects an **older population** than the 30-year-old male described [2]. - In younger smokers with gangrene, **Buerger's disease** is a more specific and common diagnosis, as atherosclerosis tends to manifest later in life unless other significant risk factors are present [2].
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