Diabetic Retinopathy — MCQs
Retinopathy is most likely to be seen with which of the following conditions?
Which of the following ocular findings is not associated with diabetes?
Treatment of choice for clinically significant macular edema in a diabetic is?
In infants of diabetic mothers (IDM), when is ophthalmologic evaluation indicated?
A diabetic patient presents to you with visual acuity of 6/9 in one eye. Further investigations revealed preretinal hemorrhages with neovascularization at the optic disc. What is the next step in management?
All are seen in non-proliferative diabetic retinopathy except which of the following?
Which of the following treatments is not suitable for advanced proliferative diabetic retinopathy with extensive vitreoretinal fibrosis and tractional retinal detachment?
In diabetic retinopathy, which layer of the retina is primarily affected?
Cause of sudden loss of vision in a diabetic is due to:
Which of the following is NOT a feature of Fuchs' Heterochromic Uveitis?
Diabetic Retinopathy Indian Medical PG Practice Questions and MCQs
Question 1: Retinopathy is most likely to be seen with which of the following conditions?
- A. Gestational diabetes
- B. Juvenile diabetes started before puberty
- C. Type 2 diabetes of 8 years duration (Correct Answer)
- D. Type 1 diabetes of 5 years duration
Explanation: **Type 2 diabetes of 8 years duration** - **Diabetic retinopathy** is a common microvascular complication of diabetes mellitus [1]. - The risk of retinopathy increases with the **duration of diabetes** and the **severity of hyperglycemia**, making an 8-year duration with type 2 diabetes a significant risk factor [1]. *Type 1 diabetes of 5 years duration* - While type 1 diabetes can cause retinopathy, a 5-year duration is generally considered relatively short for the development of significant retinopathy, especially in early stages. - The risk of retinopathy in **Type 1 diabetes** becomes more pronounced after 10-15 years, though it can occur earlier. *Gestational diabetes* - **Gestational diabetes** is a temporary condition occurring during pregnancy and does not typically lead to chronic complications like retinopathy. - Retinopathy is rare in gestational diabetes because the disease duration is short and usually resolves post-partum. *Juvenile diabetes started before puberty* - **Juvenile diabetes** is synonymous with Type 1 diabetes [2]. Although early onset of diabetes increases lifetime risk, the duration of diabetes is a more critical factor for retinopathy development. - Without a specified duration, it's less predictive than an established longer duration of Type 2 diabetes.
Question 2: Which of the following ocular findings is not associated with diabetes?
- A. Retinopathy
- B. Early senile cataract
- C. Neovascular glaucoma
- D. Blepharophimosis (Correct Answer)
Explanation: ***Blepharophimosis*** - This is a **congenital disorder** characterized by small palpebral fissures, ptosis, and epicanthus inversus, which is **not associated with diabetes**. - It is a **developmental anomaly** of the eyelids, with no known link to metabolic conditions like diabetes. *Retinopathy* - **Diabetic retinopathy** is a common and serious complication of diabetes, caused by damage to the blood vessels in the retina. - It can lead to vision loss if not managed, and is directly linked to **poor glycemic control**. *Early senile cataract* - Diabetes is a significant risk factor for the **earlier development and progression of cataracts**, including senile cataracts. - High blood sugar levels can cause changes in the lens, leading to **opacification** and impaired vision. *Neovascular glaucoma* - This severe form of **secondary glaucoma** is often a complication of advanced **diabetic retinopathy**. - Ischemia in the retina triggers the growth of **new blood vessels** on the iris and in the angle of the eye, obstructing aqueous outflow and raising intraocular pressure.
Question 3: Treatment of choice for clinically significant macular edema in a diabetic is?
- A. Intravitreal anti-VEGF injections (Correct Answer)
- B. Control of Diabetes
- C. Panretinal Photocoagulation
- D. Focal Photocoagulation
Explanation: ***Intravitreal anti-VEGF injections*** - **Anti-VEGF agents** (e.g., ranibizumab, aflibercept) are the first-line treatment for **clinically significant diabetic macular edema (DME)** as they effectively reduce vascular leakage and improve vision. - They target **vascular endothelial growth factor (VEGF)**, a key mediator of increased vascular permeability and neovascularization in diabetic retinopathy. *Control of Diabetes* - While essential for preventing the **progression of diabetic retinopathy** and overall health, it is not the primary direct treatment for *existing* clinically significant macular edema. - Good glycemic control can reduce the *risk* of developing DME but does not acutely resolve established edema. *Panretinal Photocoagulation* - **Panretinal photocoagulation (PRP)** is primarily used for **proliferative diabetic retinopathy (PDR)** to ablate ischemic retina and reduce neovascularization. - It is not the treatment of choice for macular edema, as it can sometimes worsen macular function and visual acuity due to treatment-induced damage. *Focal Photocoagulation* - **Focal laser photocoagulation** was historically used for DME, targeting discrete leaking microaneurysms. - While effective for specific focal leakage, it has largely been superseded by **anti-VEGF injections** due to their superior efficacy in diffuse edema and better visual outcomes, especially when edema involves the fovea.
Question 4: In infants of diabetic mothers (IDM), when is ophthalmologic evaluation indicated?
- A. At the time of diagnosis
- B. Only if visual symptoms develop (Correct Answer)
- C. After 5 years routinely
- D. After developing diabetes
Explanation: ***Only if visual symptoms develop*** - Unlike **retinopathy of prematurity**, infants of diabetic mothers (IDMs) do not have a higher incidence of **retinopathy** or other **ocular abnormalities** at birth or in early infancy. - **Ophthalmologic evaluation** is generally reserved for IDMs who develop specific **visual symptoms** or signs of ocular pathology. *At the time of diagnosis* - Routine ophthalmologic screening at the time of diagnosis of IDM is **not standard practice**, as the risk of **congenital ocular anomalies** is not substantially elevated to warrant universal screening. - Initial management focuses on metabolic stability, especially **glucose control**, and screening for other common IDM-related complications like **cardiac defects** or **respiratory distress**. *After 5 years routinely* - There is **no evidence or recommendation** for routine ophthalmologic screening of IDMs specifically at the age of 5 years. - Regular **well-child check-ups** include basic vision screening, which would identify significant refractive errors or strabismus, but not specifically for diabetes-related ocular issues. *After developing diabetes* - While it is true that individuals with **type 1 or type 2 diabetes** require regular **ophthalmologic evaluations** for **diabetic retinopathy**, this refers to the child developing diabetes later in life, not being an IDM. - Being an IDM is a **risk factor for developing diabetes** later in life, but it doesn't automatically mean they have diabetes-related ocular issues from birth.
Question 5: A diabetic patient presents to you with visual acuity of 6/9 in one eye. Further investigations revealed preretinal hemorrhages with neovascularization at the optic disc. What is the next step in management?
- A. Focal laser photocoagulation
- B. Pan-retinal photocoagulation (Correct Answer)
- C. Grid laser photocoagulation
- D. Scleral buckling
Explanation: ***Pan-retinal photocoagulation*** - The presence of **preretinal hemorrhages** and **neovascularization at the optic disc (NVD)** indicates **high-risk proliferative diabetic retinopathy (PDR)**. - **NVD is a high-risk characteristic** for severe vision loss and requires urgent treatment with **pan-retinal photocoagulation (PRP)**. - PRP aims to ablate ischemic peripheral retina, which reduces the production of **VEGF** and other angiogenic factors that stimulate neovascularization. *Focal laser photocoagulation* - This treatment targets discrete leaking microaneurysms in cases of **clinically significant macular edema (CSME)**, which is not the primary issue here. - It is used for **non-proliferative diabetic retinopathy** with macular involvement, not for neovascularization. *Grid laser photocoagulation* - Grid laser is a type of focal laser used for **diffuse macular edema** where specific leaking microaneurysms cannot be identified. - It is not indicated for **neovascularization** or **preretinal hemorrhages**, which are signs of PDR. *Scleral buckling* - **Scleral buckling** is a surgical procedure primarily used to treat **retinal detachment** by indenting the sclera to relieve vitreoretinal traction. - It is not the initial or primary treatment for **proliferative diabetic retinopathy** or **neovascularization**.
Question 6: All are seen in non-proliferative diabetic retinopathy except which of the following?
- A. Microaneurysm
- B. Neovascularization (Correct Answer)
- C. Cotton wool spots
- D. Retinal hemorrhages
Explanation: ***Neovascularization*** - **Neovascularization** signifies the growth of new, fragile blood vessels and is a hallmark feature of **proliferative diabetic retinopathy**, not non-proliferative. - These new vessels can bleed, leading to vitreous hemorrhage and tractional retinal detachment, which are severe complications. *Microaneurysm* - **Microaneurysms** are the earliest clinical sign of diabetic retinopathy, visible as small, red dots on funduscopic examination due to capillary outpouchings. - They are characteristic findings in **non-proliferative diabetic retinopathy (NPDR)**. *Cotton wool spots* - **Cotton wool spots** are soft exudates resulting from microinfarcts in the retinal nerve fiber layer due to occluded precapillary arterioles. - They are findings commonly seen in **non-proliferative diabetic retinopathy (NPDR)**. *Retinal hemorrhages* - **Retinal hemorrhages** (dot-blot hemorrhages) occur when blood leaks from damaged capillaries in the retina. - They are a common occurrence in **non-proliferative diabetic retinopathy (NPDR)**.
Question 7: Which of the following treatments is not suitable for advanced proliferative diabetic retinopathy with extensive vitreoretinal fibrosis and tractional retinal detachment?
- A. Removal of epiretinal membrane
- B. Photocoagulation (Correct Answer)
- C. Vitrectomy
- D. Reattachment of detached or torn retina
Explanation: ***Photocoagulation*** - The question asks for a treatment **not suitable** for **advanced proliferative diabetic retinopathy** with **extensive vitreoretinal fibrosis** and **tractional retinal detachment (TRD)**. - **Panretinal photocoagulation (PRP)** is a laser treatment used to ablate ischemic peripheral retina and prevent neovascularization in proliferative diabetic retinopathy. However, it is a **preventive measure** used in **earlier stages of PDR** before the development of extensive fibrosis and tractional detachment. - Once **tractional retinal detachment** has developed with **extensive vitreoretinal fibrosis**, photocoagulation alone **cannot relieve the mechanical traction** on the retina or **reattach the detached retina**. At this advanced stage, **surgical intervention is required**. - While endolaser photocoagulation can be performed **during vitrectomy** as an adjunctive measure, standalone photocoagulation is not suitable as a primary treatment for established TRD with extensive fibrosis. *Vitrectomy* - **Pars plana vitrectomy** is the **definitive surgical treatment** for advanced PDR with tractional retinal detachment and extensive vitreoretinal fibrosis. - The procedure involves removal of the vitreous gel, fibrovascular membranes, and blood, which relieves traction on the retina and allows for retinal reattachment. - This is the **gold standard treatment** for this condition. *Removal of epiretinal membrane* - **Membrane peeling** (removal of epiretinal and fibrovascular membranes) is an **essential component** of vitrectomy for tractional retinal detachment. - Removing these membranes relieves the mechanical traction causing the retinal detachment, making this a **suitable and necessary** treatment step. - This is performed as part of the comprehensive vitrectomy procedure. *Reattachment of detached or torn retina* - **Retinal reattachment** is the primary **therapeutic goal** for tractional retinal detachment in advanced PDR. - This is achieved through vitrectomy with membrane peeling, often combined with endolaser, fluid-gas exchange, or silicone oil tamponade. - This is clearly a **suitable treatment objective** for this condition.
Question 8: In diabetic retinopathy, which layer of the retina is primarily affected?
- A. Layer of rods and cones
- B. Retinal pigment epithelium
- C. Outer plexiform layer
- D. Inner nuclear layer (Correct Answer)
Explanation: ***Inner nuclear layer*** - The inner nuclear layer contains the **retinal capillary network**, which is the primary site of pathology in diabetic retinopathy. - **Microangiopathy** (pericyte loss, basement membrane thickening, endothelial cell damage) occurs in the capillaries located within this layer. - **Microaneurysms**, the earliest ophthalmoscopic sign of diabetic retinopathy, form from damaged capillaries in the inner nuclear layer. - **Diabetic macular edema (DME)** involves fluid accumulation that begins at the level of the capillaries in the inner nuclear and inner plexiform layers, then extends to the outer plexiform layer. *Outer plexiform layer* - This layer is **secondarily affected** by leakage from damaged capillaries in deeper retinal layers (inner nuclear and inner plexiform layers). - **Hard exudates** (lipid and protein deposits) accumulate in the outer plexiform layer as a consequence of capillary leakage, but this is not the primary site of vascular pathology. - The outer plexiform layer itself has minimal vasculature and is not where the initial microvascular changes occur. *Layer of rods and cones* - Photoreceptors are affected only in advanced stages of diabetic retinopathy due to chronic ischemia and secondary damage. - The primary pathology is vascular and occurs in the inner retinal layers where capillaries are located, not in the avascular photoreceptor layer. *Retinal pigment epithelium* - The RPE is not directly affected by the microvascular changes that characterize diabetic retinopathy. - RPE dysfunction is more characteristic of **age-related macular degeneration (AMD)** and other degenerative conditions. - In diabetic retinopathy, the RPE may be affected indirectly in very advanced cases but is not a primary site of pathology.
Question 9: Cause of sudden loss of vision in a diabetic is due to:
- A. Central retinal vein occlusion
- B. Neovascular glaucoma
- C. Vitreous hemorrhage (Correct Answer)
- D. Central retinal artery occlusion
Explanation: ***Vitreous hemorrhage*** - **Vitreous hemorrhage** is the **most common cause** of sudden, painless vision loss in individuals with **proliferative diabetic retinopathy** - New, fragile blood vessels (neovascularization) on the retina in diabetes can rupture, leading to bleeding into the **vitreous gel** - Patients describe sudden onset of floaters, cobwebs, or a red haze obscuring vision *Central retinal vein occlusion* - **CRVO** causes sudden, painless vision loss with **retinal hemorrhages in all four quadrants** (blood and thunder appearance) - While diabetic patients are at increased risk, vision loss is typically less profound than vitreous hemorrhage - Fundoscopy shows widespread retinal hemorrhages, dilated tortuous veins, and cotton-wool spots *Neovascular glaucoma* - **Neovascular glaucoma** causes **painful** vision loss and elevated intraocular pressure due to new vessel growth on the iris and trabecular meshwork - While associated with diabetes, it usually presents with more **gradual onset** and pain, rather than sudden, painless vision loss - Characterized by rubeosis iridis and elevated IOP *Central retinal artery occlusion* - **CRAO** causes sudden, profound, painless monocular vision loss, often described as a "curtain coming down" - While diabetic patients are at higher risk for CRAO due to generalized atherosclerosis, it typically results in a **cherry-red spot** on the macula - This is usually embolic in nature and less specifically related to diabetic retinopathy itself
Question 10: Which of the following is NOT a feature of Fuchs' Heterochromic Uveitis?
- A. Heterochromia
- B. Rubeosis iridis
- C. Stellate Keratic precipitate
- D. Posterior Synechiae (Correct Answer)
Explanation: ***Posterior Synechiae*** - Posterior synechiae, which are **adhesions between the iris and the lens**, are notably absent in Fuchs' heterochromic uveitis. - This is because Fuchs' uveitis is characterized by a **mild, non-granulomatous inflammation** that does not typically lead to the formation of such adhesions. - The **absence of posterior synechiae** is a key distinguishing feature from other forms of chronic anterior uveitis. *Heterochromia* - **Heterochromia** (difference in iris color between the two eyes) is the **defining clinical feature** of this condition and gives it its name. - The affected eye typically shows a **lighter iris color** due to stromal atrophy and loss of pigment. - This feature is present in the majority of cases, though it may be subtle and sometimes only detected on careful examination. *Rubeosis iridis* - **Rubeosis iridis**, or the **formation of fine new blood vessels on the iris surface**, is a characteristic feature of Fuchs' heterochromic uveitis. - These fragile new vessels can lead to **spontaneous hyphema** (blood in the anterior chamber), particularly during intraocular surgery or paracentesis. *Stellate Keratic precipitate* - **Stellate keratic precipitates** (KPs), which are **small, star-shaped deposits** on the corneal endothelium, are a characteristic feature. - These KPs are **fine, diffuse, and scattered** over the entire corneal endothelium, unlike the larger, greasy KPs seen in granulomatous uveitis.
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