Viral Keratitis — MCQs
A patient presents with eye pain, redness, and blurred vision after sleeping in contact lenses. Fluorescein staining reveals a corneal ulcer. What is the most appropriate management?
Corneal sensations are decreased in all of the following conditions except:
Herpes zoster ophthalmicus is caused by:
Interstitial keratitis is associated with all of the following except:
Which virus is most commonly associated with disciform keratitis?
A 30 year old man presents to the clinic with pain in the eye, watering, redness, and photophobia. Examination of his eyes shows circumcorneal congestion and keratic precipitates. Assertion: Keratic precipitates (KPs) are proteinaceous deposits that can occur in various patterns on the corneal endothelium. Reason: Mutton fat KPs are seen in granulomatous iridocyclitis and are composed of epithelioid cells and macrophages.
Which of the following is a contraindication to topical steroids?
In a patient with acute anterior uveitis presenting with raised intraocular pressure, the PRIMARY treatment should be:
1% atropine is given in uveitis to:
Topical antiviral drugs are not indicated in:
Viral Keratitis Indian Medical PG Practice Questions and MCQs
Question 1: A patient presents with eye pain, redness, and blurred vision after sleeping in contact lenses. Fluorescein staining reveals a corneal ulcer. What is the most appropriate management?
- A. Topical antibiotics (Correct Answer)
- B. Oral antibiotics
- C. Topical corticosteroids
- D. Saline irrigation
Explanation: ***Topical antibiotics*** - A **corneal ulcer**, especially in a contact lens wearer, is highly suspicious for **bacterial infection**, necessitating immediate and aggressive topical antibiotic therapy. - **Broad-spectrum antibiotics** (e.g., fluoroquinolones) are often started empirically and adjusted based on culture results. *Oral antibiotics* - **Systemic antibiotics** are generally not indicated for uncomplicated bacterial corneal ulcers, as they don't achieve sufficient concentrations in the cornea to be effective. - They may be considered for severe cases with limbal involvement or scleral extension, or if there is a concern for concurrent systemic infection. *Topical corticosteroids* - **Corticosteroids** are contraindicated in the initial management of suspected infectious corneal ulcers because they can suppress the immune response and worsen the infection. - They may be cautiously used later in treatment to reduce inflammation after the infection is well-controlled. *Saline irrigation* - While helpful for removing foreign bodies or debris, **saline irrigation alone** is insufficient to treat a bacterial corneal ulcer. - It does not eradicate the infection and delaying definitive antibiotic treatment can lead to severe complications.
Question 2: Corneal sensations are decreased in all of the following conditions except:
- A. Neuroparalytic keratitis
- B. Leprosy
- C. Herpetic keratitis
- D. Recurrent corneal erosion syndrome (Correct Answer)
Explanation: ***Recurrent corneal erosion syndrome*** - This condition involves **defective adhesion** of the corneal epithelium to the underlying Bowman's layer and basement membrane, leading to sudden, severe pain upon waking. - While it causes **pain** and **epithelial defects**, it does not primarily involve nerve damage or decreased corneal sensation; rather, episodes are often very painful due to exposed nerve endings. *Herpetic keratitis* - Caused by the **herpes simplex virus (HSV)**, which can infect the trigeminal nerve and lead to **trophic changes** in the cornea. - This viral infection often results in **significant reduction** or loss of corneal sensation, making the eye more vulnerable to trauma and delayed healing. *Neuroparalytic keratitis* - This condition is also known as **neurotrophic keratitis** and results from damage to the **trigeminal nerve**, which supplies sensation to the cornea. - Loss of corneal sensation leads to impaired reflex tearing and blinking, making the cornea susceptible to epithelial breakdown and ulceration due to lack of protective mechanisms. *Leprosy* - In ocular leprosy, the **Mycobacterium leprae** directly invades the ciliary nerves, significantly impairing corneal sensation. - This reduced sensation in leprosy patients increases the risk of **corneal ulcers** and opacification due to undetected foreign bodies and trauma.
Question 3: Herpes zoster ophthalmicus is caused by:
- A. VZV (Correct Answer)
- B. HPV
- C. HSV
- D. CMV
Explanation: ***Correct Answer: VZV*** - **Varicella-zoster virus (VZV)** is the causative agent of **herpes zoster ophthalmicus**, which is a reactivation of the virus in the ophthalmic division of the trigeminal nerve. - The initial infection with VZV causes **chickenpox (varicella)**, and the virus remains dormant in sensory ganglia to reactivate later as shingles. *Incorrect - HPV* - **Human papillomavirus (HPV)** is primarily known for causing **warts** and is a significant risk factor for certain **cancers**, particularly cervical cancer. - HPV does not cause vesicular rashes associated with herpes zoster or ophthalmic involvement. *Incorrect - HSV* - **Herpes simplex virus (HSV)** causes different forms of herpes infections, such as **oral (cold sores)** and **genital herpes**, and can also cause keratitis but is distinct from zoster ophthalmicus. - While HSV can affect the eye, leading to **herpes simplex keratitis**, it produces a different clinical picture and does not involve the dermatomal rash characteristic of zoster. *Incorrect - CMV* - **Cytomegalovirus (CMV)** is a common virus often causing asymptomatic infections in healthy individuals. - In immunocompromised patients, CMV can cause serious diseases, including **retinitis**, but it does not cause herpes zoster ophthalmicus.
Question 4: Interstitial keratitis is associated with all of the following except:
- A. Syphilis
- B. Acanthamoeba (Correct Answer)
- C. Chlamydia Trachomatis
- D. Herpes Zoster Virus (HZV)
Explanation: ***Acanthamoeba*** - **Acanthamoeba keratitis** is a **suppurative keratitis** characterized by a painful, ring-shaped infiltrate with epithelial ulceration, typically associated with contact lens use and contaminated water exposure. - It causes **ulcerative stromal inflammation**, not the **non-ulcerative deep stromal inflammation** that characterizes classic interstitial keratitis. - **This is NOT a cause of interstitial keratitis.** *Syphilis* - **Congenital syphilis** is the **CLASSIC cause** of bilateral **interstitial keratitis**, often presenting in late childhood with "salmon patch" appearance, photophobia, lacrimation, and eventual ghost vessels. - The inflammation is **non-ulcerative and chronic**, affecting the **deep corneal stroma** with preservation of epithelium. - This is the most important association with interstitial keratitis to remember. *Chlamydia Trachomatis* - **Chlamydia trachomatis** causes **trachoma**, a chronic keratoconjunctivitis leading to **superficial keratitis with pannus formation** (superficial vascularization from the limbus). - The corneal involvement in trachoma is **superficial**, not the deep stromal inflammation seen in classic interstitial keratitis. - While listed in some references, **Chlamydia is NOT a standard cause of interstitial keratitis** in major ophthalmology textbooks. - **Note:** This option is potentially debatable, but Acanthamoeba is the more definitively incorrect answer. *Herpes Zoster Virus (HZV)* - **Herpes zoster ophthalmicus** can lead to **interstitial keratitis** and **disciform keratitis** (immune-mediated stromal inflammation with disc-shaped corneal edema). - Similarly, **HSV (Herpes Simplex Virus)** causes stromal keratitis, a form of interstitial keratitis. - The corneal involvement includes **deep stromal inflammation, scarring**, and potential neurotrophic changes leading to vision impairment.
Question 5: Which virus is most commonly associated with disciform keratitis?
- A. Rubella Virus
- B. Herpes Simplex Virus (HSV) (Correct Answer)
- C. Human Immunodeficiency Virus (HIV)
- D. Hepatitis B Virus (HBV)
Explanation: ***Herpes Simplex Virus (HSV)*** - **HSV** is the most common cause of **infectious disciform keratitis**, often following a primary ocular HSV infection or reactivation. - Disciform keratitis caused by HSV is a form of **immune-mediated stromal keratitis**, characterized by corneal edema, inflammation, and potential vision loss. *Rubella Virus* - While Rubella can cause ocular manifestations, such as **congenital cataracts** and **glaucoma** in infants, it is not typically associated with disciform keratitis in adults or children. - **Congenital rubella syndrome** is the primary context for ophthalmic issues related to this virus. *Human Immunodeficiency Virus (HIV)* - HIV can lead to various ocular complications, such as **CMV retinitis**, **Kaposi's sarcoma** of the conjunctiva, and **HIV retinopathy**. - However, HIV itself is **not directly linked** to disciform keratitis. *Hepatitis B Virus (HBV)* - HBV infection primarily affects the **liver** and is not commonly associated with direct ocular infections like keratitis. - Ocular manifestations are rare and often nonspecific, mainly related to systemic immune responses rather than direct viral replication in the eye.
Question 6: A 30 year old man presents to the clinic with pain in the eye, watering, redness, and photophobia. Examination of his eyes shows circumcorneal congestion and keratic precipitates. Assertion: Keratic precipitates (KPs) are proteinaceous deposits that can occur in various patterns on the corneal endothelium. Reason: Mutton fat KPs are seen in granulomatous iridocyclitis and are composed of epithelioid cells and macrophages.
- A. Both Assertion and Reason are true, and Reason is the correct explanation for Assertion
- B. Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion (Correct Answer)
- C. Assertion is true, but Reason is false
- D. Assertion is false but reason is true
Explanation: ***Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion*** **Why both statements are true:** - The **Assertion** is correct: Keratic precipitates (KPs) are inflammatory cell and protein deposits that adhere to the **corneal endothelium** and can present in various patterns including fine dusty KPs, medium-sized KPs, and large mutton fat KPs. - The **Reason** is also correct: **Mutton fat KPs** are characteristic of **granulomatous anterior uveitis** (granulomatous iridocyclitis) and consist of aggregations of **epithelioid cells and macrophages**, appearing as large, greasy, white deposits. **Why Reason does NOT explain Assertion:** - The Reason describes a **specific type** of KP (mutton fat) and its cellular composition in one particular form of inflammation (granulomatous). - The Assertion makes a **general statement** about KPs occurring in various patterns. - The Reason does not explain **why** KPs can occur in various patterns or what determines these different patterns - it only describes one specific pattern. *Incorrect: Both true with Reason explaining Assertion* - The Reason is too specific and only describes one type of KP, not the general mechanism of pattern variation. *Incorrect: Assertion true, Reason false* - Both statements are medically accurate and well-established in ophthalmology literature. *Incorrect: Assertion false, Reason true* - KPs are well-documented deposits on the corneal endothelium in various forms of uveitis, making the Assertion true.
Question 7: Which of the following is a contraindication to topical steroids?
- A. Dendritic ulcer (Correct Answer)
- B. Herpetic stromal keratitis without epithelial defect
- C. Elevated intraocular pressure
- D. Non-infectious anterior uveitis
Explanation: ***Dendritic ulcer*** - A **dendritic ulcer** is characteristic of **herpes simplex keratitis**, which is an active viral infection of the cornea. - **Topical steroids** are contraindicated because they can suppress the immune response, leading to viral replication, corneal melt, and potentially severe vision loss or perforation. *Herpetic stromal keratitis without epithelial defect* - In cases of **stromal keratitis**, where the infection is deeper and an intact epithelium is present, topical steroids may be used cautiously in conjunction with antiviral agents to reduce inflammation and scarring. - The primary concern with steroids in herpes simplex keratitis is activating viral replication in the presence of an **epithelial defect**, which is not present here. *Elevated intraocular pressure* - **Elevated intraocular pressure** is a known side effect of topical steroid use, especially with prolonged administration, but it is not an absolute contraindication in itself. - It necessitates careful monitoring and may require concurrent glaucoma treatment, but the primary condition needing steroids may still warrant their use. *Non-infectious anterior uveitis* - **Topical corticosteroids** are the **mainstay of treatment** for non-infectious anterior uveitis to reduce inflammation and prevent complications such as synechiae and vision loss. - The benefits of controlling inflammation in uveitis generally outweigh the risks associated with judicious steroid use.
Question 8: In a patient with acute anterior uveitis presenting with raised intraocular pressure, the PRIMARY treatment should be:
- A. Topical steroids (Correct Answer)
- B. Topical beta-blockers
- C. Cycloplegics
- D. Miotics
Explanation: ***Topical steroids*** - **Topical corticosteroids** are the primary treatment for **anterior uveitis** to reduce inflammation, which is the underlying cause of both the uveitis and often the raised IOP. - While IOP is elevated, managing the inflammation with steroids is crucial, as the inflammation itself can lead to secondary **IOP elevation** due to trabecular meshwork dysfunction or synechiae formation. *Topical beta-blockers* - **Topical beta-blockers** are used to lower intraocular pressure, but they do not address the underlying **inflammation** in acute anterior uveitis. - Using them alone without treating the inflammation can lead to progression of the uveitis and further ocular damage. *Cycloplegics* - **Cycloplegics** (e.g., atropine, cyclopentolate) are important adjuncts in acute anterior uveitis to relieve pain from ciliary spasm and prevent posterior synechiae formation by dilating the pupil. - They do not, however, treat the **inflammation** directly or primarily address the elevated intraocular pressure. *Miotics* - **Miotics** (e.g., pilocarpine) **constrict the pupil**, which can worsen symptoms in acute anterior uveitis by increasing ciliary body spasm and potentially increasing the risk of posterior synechiae formation. - They are contraindicated in acute anterior uveitis as they exacerbate pain and inflammation, and do not treat the underlying cause.
Question 9: 1% atropine is given in uveitis to:
- A. Cause miosis and prevent formation of posterior synechiae
- B. Cause mydriasis and prevent formation of anterior synechiae
- C. Cause mydriasis and prevent formation of posterior synechiae (Correct Answer)
- D. Reduce inflammation and relieve pain
Explanation: ***Cause mydriasis and prevent formation of posterior synechiae*** - **Atropine** is a **cycloplegic** and mydriatic agent used in uveitis to dilate the pupil, which helps to separate the iris from the lens. - This dilation is crucial in preventing the formation of **posterior synechiae** (adhesions between the iris and the anterior lens capsule), which can lead to complications such as pupil distortion, secondary glaucoma, and cataracts. *Cause miosis and prevent formation of posterior synechiae* - **Atropine** causes **mydriasis** (pupil dilation), not miosis (pupil constriction). - Miosis would increase the risk of posterior synechiae formation by bringing the iris and lens closer together. *Cause mydriasis and prevent formation of anterior synechiae* - **Anterior synechiae** are adhesions between the iris and the cornea, which are less commonly affected by atropine in uveitis compared to posterior synechiae. - While atropine causes mydriasis, its primary role in preventing synechiae formation in uveitis is directed at **posterior synechiae**. *Reduce inflammation and relieve pain* - While **atropine** can indirectly relieve pain by reducing **ciliary spasm** (a component of uveitic pain), its primary mechanism of action is not to reduce inflammation. - **Corticosteroids** are the main treatment for reducing inflammation in uveitis.
Question 10: Topical antiviral drugs are not indicated in:
- A. Metaherpetic ulcer (Correct Answer)
- B. Dendritic ulcer
- C. Stromal necrotizing keratitis
- D. All of the options
Explanation: ***Metaherpetic ulcer*** - Metaherpetic ulcers are **neurotrophic ulcers** that develop as a result of chronic epithelial damage and impaired healing after a herpes simplex virus (HSV) infection, but they are not an active viral replication process. - Topical antivirals are ineffective because there is **no replicating virus** to target; management focuses on promoting corneal healing and preventing secondary infections. *Dendritic ulcer* - A dendritic ulcer is a classic sign of **active HSV keratitis** with replicating virus in the epithelial cells. - Topical antiviral drugs (e.g., acyclovir, ganciclovir) are the **first-line treatment** to inhibit viral replication and promote epithelial healing. *Stromal necrotizing keratitis* - This condition involves **inflammation and necrosis** in the corneal stroma, often due to an immune reaction to HSV antigens rather than direct viral invasion. - While topical antivirals may be used to suppress any residual replicating virus, **topical corticosteroids are often necessary** to control the inflammation, and close monitoring is crucial due to the risk of steroid-induced complications. *All of the options* - This option is incorrect because topical antiviral drugs *are* indicated for **dendritic ulcers** and sometimes as adjunctive therapy for **stromal necrotizing keratitis** where active viral replication might be contributing.
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