Intravitreal Pharmacotherapy — MCQs
Drug commonly used as immunosuppressive therapy for non-infectious uveitis is -
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:
Which of the following is the most important factor in the prevention of endophthalmitis in cataract surgery?
In which of the following conditions does IOL implantation after cataract surgery require the greatest caution and specialized management?
Normal intraocular pressure is typically in the range of:
Topical antiviral drugs are not indicated in:
Which of the following anesthetics is known to increase intraocular pressure?
In which of the following clinical conditions does the use of anticoagulants provide maximum benefit?
A 56 year old patient presents after 3 days of cataract surgery with a history of increasing pain and diminution of vision after an initial improvement. The most likely cause would be:
Intravitreal Pharmacotherapy Indian Medical PG Practice Questions and MCQs
Question 1: Drug commonly used as immunosuppressive therapy for non-infectious uveitis is -
- A. Methotrexate
- B. Infliximab
- C. Voclosporin
- D. Cyclosporine (Correct Answer)
Explanation: ***Cyclosporine*** - **Cyclosporine** is a **calcineurin inhibitor** that is commonly used as an immunosuppressive agent for **non-infectious uveitis**, particularly for sight-threatening or refractory cases [3]. - It works by inhibiting T-lymphocyte activation, thereby reducing intraocular inflammation [3]. - While effective, its use may be limited by side effects including **nephrotoxicity, hypertension, and hirsutism**. *Methotrexate* - **Methotrexate** is also **commonly used** as a first-line systemic immunosuppressive agent for non-infectious uveitis [1]. - It is an **antimetabolite** that inhibits dihydrofolate reductase, reducing inflammation and cell proliferation. - Often preferred due to its **favorable side effect profile** compared to cyclosporine, though both drugs are considered standard options. *Infliximab* - **Infliximab** is a **TNF-alpha inhibitor** (biologic agent) used for **severe or treatment-resistant uveitis**, particularly in cases associated with systemic inflammatory diseases like **Behçet's disease or ankylosing spondylitis** [2]. - It is generally considered a **second-line or third-line agent** after conventional immunosuppressants have failed. *Voclosporin* - **Voclosporin** is a **next-generation calcineurin inhibitor** primarily approved for **lupus nephritis**. - It is **not a standard therapy** for non-infectious uveitis and has limited data in this indication.
Question 2: 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 3: 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 4: Which of the following is the most important factor in the prevention of endophthalmitis in cataract surgery?
- A. Preoperative preparation with povidone iodine (Correct Answer)
- B. One week antibiotic therapy prior to surgery
- C. Trimming of eyelashes
- D. Use of intravitreal antibiotics
Explanation: **Preoperative preparation with povidone iodine** - **Povidone-iodine (5%)** applied to the ocular surface is the **single most evidence-based intervention** for preventing endophthalmitis in cataract surgery. - Multiple randomized controlled trials, including the **ESCRS study**, demonstrate up to **75% reduction** in endophthalmitis risk with proper povidone-iodine antisepsis. - It rapidly reduces bacterial load on the conjunctiva and periocular skin, which are the primary sources of intraocular contamination. *One week antibiotic therapy prior to surgery* - Prolonged preoperative antibiotic therapy is **not recommended** and lacks evidence for reducing endophthalmitis. - Can lead to **antibiotic resistance** and disruption of normal ocular flora without proven benefit. - Current guidelines do not support routine preoperative systemic or prolonged topical antibiotic prophylaxis. *Trimming of eyelashes* - **Not routinely recommended** and may actually increase bacterial counts temporarily due to microtrauma. - While maintaining a clean surgical field is important, eyelash trimming has **no proven benefit** in reducing endophthalmitis rates. - Good draping technique is more important than eyelash manipulation. *Use of intravitreal antibiotics* - **Intravitreal antibiotics** are injected into the vitreous cavity and are used for **treating established endophthalmitis**, not for prophylaxis. - For prophylaxis, **intracameral antibiotics** (e.g., cefuroxime or moxifloxacin injected into the anterior chamber at surgery end) are sometimes used, but they are adjunctive measures, not the primary preventive intervention. - **Povidone-iodine antisepsis** remains the most critical and cost-effective prophylactic measure with the strongest evidence base.
Question 5: In which of the following conditions does IOL implantation after cataract surgery require the greatest caution and specialized management?
- A. Fuchs' heterochromic iridocyclitis
- B. Psoriatic arthritis
- C. Reiter's syndrome
- D. Juvenile rheumatoid arthritis (Correct Answer)
Explanation: ***Juvenile rheumatoid arthritis*** - Patients with **juvenile rheumatoid arthritis (JRA)**, particularly those with **pauciarticular JRA** and **ANA positivity**, are at high risk for developing chronic uveitis, which can lead to significant cataract formation and severe postoperative complications. - Due to the high risk of severe postoperative inflammation, glaucoma, and vision loss, IOL implantation in JRA patients requires extensive preoperative optimization of inflammation and careful intraoperative/postoperative management. *Fuchs' heterochromic iridocyclitis* - This condition presents with chronic, low-grade, **non-granulomatous anterior uveitis** and often leads to cataract formation. - While IOL implantation in these patients is generally well-tolerated, it does not pose the same high risk of severe postoperative inflammation and complications as seen in JRA-associated uveitis. *Psoriatic arthritis* - Psoriatic arthritis can be associated with acute anterior uveitis, but it typically presents as an acute, intermittent inflammation. - The risk of chronic, severe uveitis leading to complex cataract surgery and significant postoperative complications is not as consistently high or as severe as in JRA. *Reiter's syndrome* - Reiter's syndrome (now part of **reactive arthritis**) is another seronegative spondyloarthropathy that can cause acute anterior uveitis. - Similar to psoriatic arthritis, the uveitis is usually acute and self-limiting, and while ocular inflammation needs to be controlled, the risk profile for IOL implantation is not as challenging as in JRA.
Question 6: Normal intraocular pressure is typically in the range of:
- A. 2.1-6 mm Hg
- B. 7-14 mm Hg
- C. 10-21 mm Hg (Correct Answer)
- D. 16-32 mm Hg
Explanation: ***10-21 mm Hg*** - This range is widely accepted as the **normal intraocular pressure (IOP)** in healthy individuals. - Maintaining IOP within this range is crucial for preventing damage to the **optic nerve** and conditions like **glaucoma**. *2.1-6 mm Hg* - This range is significantly **lower** than the normal physiological IOP. - Pressures in this range could indicate conditions like **hypotony**, which can lead to vision problems. *7-14 mm Hg* - While closer to the normal range, this range is still generally considered to be at the **lower end of normal** or slightly below. - Many individuals would fall within 10-21 mm Hg, making this a less accurate representation of the typical normal range. *16-32 mm Hg* - The upper part of this range (above 21 mm Hg) is considered **elevated IOP**, a significant risk factor for **glaucoma**. - Pressures above 21 mm Hg require closer monitoring and potentially treatment to prevent **optic nerve damage**.
Question 7: 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.
Question 8: Which of the following anesthetics is known to increase intraocular pressure?
- A. Thiopental
- B. Alfentanil
- C. Ketamine (Correct Answer)
- D. Propofol
Explanation: ***Ketamine*** - **Ketamine** is known to increase **intraocular pressure (IOP)**, making it generally avoided in patients with **glaucoma** or those undergoing ocular surgery. - This effect is due to its influence on sympathetic nervous system activity and extraocular muscle tone. *Thiopental* - **Thiopental**, a barbiturate, typically causes a **reduction in intraocular pressure**, which can be beneficial in certain ocular procedures. - Its mechanism involves decreasing cerebral blood flow and metabolic rate, indirectly leading to a decrease in IOP. *Alfentanil* - **Alfentanil**, an opioid, generally has **minimal to no significant effect on intraocular pressure**. - Its primary actions are analgesia and sedation, without direct impact on oculomotor tone or fluid dynamics. *Propofol* - **Propofol** is known to **decrease intraocular pressure**, making it a favorable agent for ophthalmic surgery. - This effect is attributed to a reduction in cerebral blood flow and an inhibition of aqueous humor production.
Question 9: In which of the following clinical conditions does the use of anticoagulants provide maximum benefit?
- A. Prevention of recurrences of myocardial infarction
- B. Prevention of venous thrombosis and pulmonary embolism (Correct Answer)
- C. Prevention of cerebrovascular accident (stroke)
- D. Retinal artery thrombosis
Explanation: ***Prevention of venous thrombosis and pulmonary embolism*** - Anticoagulants are highly effective in inhibiting the formation and extension of **venous thrombi**, thereby directly preventing **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**. - The mechanism of action targets the **coagulation cascade**, directly reducing the risk of these venous thromboembolic events, which are a major indication for anticoagulant therapy. *Prevention of recurrences of myocardial infarction* - While anticoagulants may play a secondary role, **antiplatelet agents** (e.g., aspirin, clopidogrel) are the primary therapy for preventing recurrent myocardial infarction, as **arterial thrombi** are predominantly platelet-rich. - Anticoagulants are used in specific high-risk situations post-MI (e.g., **atrial fibrillation**, left ventricular thrombus) but are not generally considered the primary preventive strategy. *Cerebrovascular accident* - The benefit of anticoagulants for stroke prevention is primarily significant in cases of **cardioembolic stroke** (e.g., due to **atrial fibrillation**) where they prevent clot formation in the heart. - For non-cardioembolic **ischemic strokes** (e.g., thrombotic or lacunar), antiplatelet agents are generally preferred for secondary prevention. *Retinal artery thrombosis* - **Retinal artery thrombosis** is often caused by **arterial atherosclerosis** and **embolism** from the carotid arteries or heart, where antiplatelet agents are typically primary. - The role of anticoagulants here is limited to specific causes like **atrial fibrillation** or in patients already on anticoagulation for other indications.
Question 10: A 56 year old patient presents after 3 days of cataract surgery with a history of increasing pain and diminution of vision after an initial improvement. The most likely cause would be:
- A. Endophthalmitis (Correct Answer)
- B. Central retinal vein occlusion
- C. Posterior capsular opacification (PCO)
- D. Retinal detachment
Explanation: ***Endophthalmitis*** - **Endophthalmitis** is a severe inflammation of the intraocular fluids (vitreous and aqueous humor), most commonly caused by infection following cataract surgery. - The presentation of **increasing pain** and **diminution of vision** a few days after initial improvement is a classic sign of acute post-operative endophthalmitis. *Central retinal vein occlusion* - **Central retinal vein occlusion (CRVO)** typically causes sudden, painless vision loss. - It is not commonly associated with **increasing pain** or a temporal relationship to recent cataract surgery in this manner. *Posterior capsular opacification (PCO)* - **Posterior capsular opacification (PCO)** develops weeks or months after cataract surgery, not within a few days. - It presents as gradual, painless blurring of vision without significant pain. *Retinal detachment* - **Retinal detachment** typically presents with sudden vision loss, flashes of light (photopsia), and floaters. - While it can occur after cataract surgery, it is less likely to present with **increasing pain** as the primary symptom described.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free