Diseases of the Retina — MCQs

Diseases of the Retina Indian Medical PG Practice Questions and MCQs

Question 251: Argon laser is used in all except:

A. Retinal detachment
B. Retinitis pigmentosa (Correct Answer)
C. Retinal vein occlusion
D. Eales' disease

Explanation: **Explanation:** The Argon laser (Blue-Green, 488–514 nm) works on the principle of **photocoagulation**. It is absorbed primarily by the pigment epithelium and hemoglobin, converting light energy into heat to create localized tissue destruction or "welding." **Why Retinitis Pigmentosa (RP) is the correct answer:** Retinitis Pigmentosa is a **hereditary rod-cone dystrophy** characterized by progressive degeneration of the photoreceptors. Since the pathology is a genetic cellular decay rather than a vascular or structural defect amenable to "burning," laser treatment has no therapeutic role. In fact, unnecessary photocoagulation could further damage the already compromised visual field. **Analysis of other options:** * **Retinal Detachment:** Argon laser is used for **prophylactic photocoagulation** to create chorioretinal adhesions around retinal breaks or holes, preventing fluid from entering the subretinal space. * **Retinal Vein Occlusion (RVO):** In ischemic CRVO or BRVO, laser is used to treat macular edema (Grid/Focal) or to perform **Pan-Retinal Photocoagulation (PRP)** to regress neovascularization. * **Eales' Disease:** This is an idiopathic peripheral perivasculitis. Laser is the mainstay of treatment to ablate peripheral areas of non-perfusion (ischemia) to prevent vitreous hemorrhage and tractional detachment. **High-Yield Clinical Pearls for NEET-PG:** * **Wavelength:** Argon Green (514 nm) is preferred over Blue to avoid absorption by xanthophyll in the macula. * **Primary Use:** PRP is the gold standard for **Proliferative Diabetic Retinopathy (PDR)**. * **RP Triad:** Bone-spicule pigmentation, arteriolar attenuation, and waxy disc pallor. * **Laser of choice for After-Cataract:** Nd:YAG laser (Photodisruption). * **Laser of choice for Glaucoma (PI):** Nd:YAG laser.

Question 252: Which of the following is NOT a complication of pathological myopia?

A. Complicated cataract
B. Vitreous hemorrhage
C. Tractional Retinal detachment (Correct Answer)
D. Lacquer cracks

Explanation: **Explanation:** Pathological myopia (Degenerative Myopia) is characterized by an axial length >26.5 mm and progressive degenerative changes in the posterior segment. **Why Tractional Retinal Detachment (TRD) is the correct answer:** TRD is typically caused by proliferative membranes that pull the retina away from the RPE, most commonly seen in **Proliferative Diabetic Retinopathy (PDR)** or Eales disease. In pathological myopia, the characteristic type of detachment is **Rhegmatogenous Retinal Detachment (RRD)**, caused by peripheral retinal degenerations like lattice degeneration and subsequent retinal holes/tears. **Analysis of Incorrect Options:** * **Complicated Cataract:** High myopia is strongly associated with early-onset **posterior subcapsular cataracts** and nuclear sclerosis. * **Vitreous Hemorrhage:** This occurs due to mechanical stretching and rupture of retinal vessels or as a result of bleeding from a **Fuchs’ Spot** (Choroidal Neovascularization). * **Lacquer Cracks:** These are pathognomonic linear breaks in the **Bruch’s membrane**. They appear as yellowish-white horizontal streaks and are a major risk factor for developing subretinal neovascular membranes. **High-Yield Clinical Pearls for NEET-PG:** * **Posterior Staphyloma:** The hallmark sign of pathological myopia (bulging of the weakened sclera). * **Fuchs’ Spot:** A pigmented circular lesion at the macula caused by healed CNVM. * **Foster-Kennedy Syndrome vs. Pseudo-Foster Kennedy:** High myopia can cause "tilted discs," which may mimic optic nerve pathology. * **Management:** Prophylactic barrier laser photocoagulation is indicated for symptomatic retinal breaks to prevent RRD.

Question 253: The risk of rhegmatogenous retinal detachment is increased in all of the following except?

A. Pseudophakia
B. Trauma
C. Hyperopia (Correct Answer)
D. Lattice degeneration

Explanation: **Explanation:** Rhegmatogenous Retinal Detachment (RRD) occurs when a break (hole or tear) in the neurosensory retina allows liquefied vitreous to enter the subretinal space. The risk is primarily increased by conditions that cause vitreoretinal traction or thinning of the peripheral retina. **Why Hyperopia is the correct answer:** **Hyperopia (Option C)** is associated with a shorter axial length of the eyeball. In contrast, **Myopia** (especially high myopia) is a major risk factor for RRD because the elongated globe leads to thinning of the retina and early vitreous liquefaction. Hyperopic eyes are generally "sturdier" regarding retinal breaks and are actually associated with a *decreased* risk of RRD compared to the general population. **Why the other options are incorrect:** * **Pseudophakia (Option A):** Post-cataract surgery (especially if the posterior capsule is ruptured) leads to biochemical changes in the vitreous and increased mobility (endophthalmodonesis), significantly raising the risk of RRD. * **Trauma (Option B):** Direct ocular trauma can cause immediate retinal tears (dialysis) or late-onset detachment due to vitreous base traction. * **Lattice Degeneration (Option C):** This is the most important peripheral retinal degeneration predisposing to RRD. It involves thinning of the inner retinal layers and strong vitreoretinal adhesions at the margins of the lesion. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of a retinal break:** Superotemporal quadrant. * **Most common type of RD:** Rhegmatogenous. * **Shafer’s Sign:** Presence of "tobacco dust" (RPE cells) in the anterior vitreous; pathognomonic for a retinal tear. * **Horseshoe tear:** The most common type of tear leading to RRD, caused by posterior vitreous detachment (PVD).

Question 254: All of the following are true for colloid bodies (drusens) except?

A. Hyaline excrescences of Bruch's membrane.
B. Secreted by pigment epithelial cells.
C. Usually associated with marked loss of vision. (Correct Answer)
D. A precursor of disciform macular degeneration in some eyes.

Explanation: **Explanation:** Drusen (colloid bodies) are extracellular deposits of metabolic waste products that accumulate between the retinal pigment epithelium (RPE) and the inner collagenous layer of Bruch’s membrane. **Why Option C is the correct answer (The "Except"):** In most cases, drusen are asymptomatic and do not cause significant visual impairment. They are often incidental findings during a fundus examination in elderly patients. Marked loss of vision only occurs if drusen progress to advanced stages of Age-Related Macular Degeneration (ARMD), such as geographic atrophy or choroidal neovascularization (CNV). Therefore, saying they are "usually" associated with marked loss of vision is clinically incorrect. **Analysis of Incorrect Options:** * **Option A:** Drusen are histologically described as hyaline excrescences (nodular thickenings) of Bruch’s membrane. * **Option B:** They are formed by the accumulation of lipids and proteins secreted by the RPE cells as a result of failing metabolic clearance. * **Option D:** Large, soft, confluent drusen are a major risk factor and precursor for "wet" (exudative) ARMD, also known as disciform macular degeneration. **NEET-PG High-Yield Pearls:** * **Hard Drusen:** Small, discrete, and carry a lower risk of progression. * **Soft Drusen:** Large, fuzzy borders, and carry a high risk for ARMD. * **Fundus Appearance:** They appear as small, yellow-white spots at the posterior pole. * **Fluorescein Angiography (FFA):** Drusen show **"Point Hyperfluorescence"** due to a window defect (RPE atrophy) or staining.

Question 255: Both soft and hard exudates are seen in which of the following conditions?

A. Hypertension
B. Diabetes Mellitus
C. Eale's disease
D. All of the above (Correct Answer)

Explanation: ### Explanation The presence of both soft and hard exudates is a hallmark of retinal vascular diseases characterized by both **increased vascular permeability** and **retinal ischemia**. **1. Understanding the Concepts:** * **Hard Exudates:** These are yellowish, waxy-looking deposits with distinct margins. They are composed of lipid and proteinaceous material that leaks from damaged, hyperpermeable capillaries (e.g., microaneurysms). They are typically found in the Outer Plexiform Layer (Henle’s layer in the macula). * **Soft Exudates (Cotton Wool Spots):** These are not true exudates but rather **micro-infarcts** of the Retinal Nerve Fiber Layer (RNFL). They occur due to the occlusion of terminal retinal arterioles, leading to axoplasmic stasis. **2. Why "All of the Above" is Correct:** * **Diabetes Mellitus:** Hard exudates are a classic feature of Diabetic Macular Edema (DME). Soft exudates appear as the disease progresses to the Pre-proliferative (PPDR) stage, signaling significant ischemia. * **Hypertension:** In Grade 3 and 4 Hypertensive Retinopathy (Keith-Wagener-Barker classification), both are seen. Hard exudates often form a "macular star," while soft exudates indicate acute arteriolar narrowing and ischemia. * **Eale’s Disease:** This is an idiopathic peripheral perivasculitis. It involves peripheral non-perfusion (leading to soft exudates/ischemia) and vascular leakage (leading to hard exudates and vitreous hemorrhage). **Clinical Pearls for NEET-PG:** * **Hard Exudates Location:** Outer Plexiform Layer (OPL). * **Soft Exudates Location:** Nerve Fiber Layer (NFL). * **Differential for Macular Star:** Hypertension, Neuroretinitis, Papilledema, and Cat-scratch disease. * **Roth Spots:** Hemorrhages with a white center (fibrin), seen in Subacute Bacterial Endocarditis (SBE) and Leukemia.

Question 256: Retinoblastoma stage III is treated by which of the following?

A. Enucleation
B. Exenteration (Correct Answer)
C. Radiotherapy
D. None of the above

Explanation: **Explanation:** The management of Retinoblastoma (RB) is determined by the extent of the disease, categorized by the Reese-Ellsworth or International Classification. **Why Exenteration is correct:** **Stage III Retinoblastoma** refers to **extraocular extension** where the tumor has breached the sclera and involves the orbital tissues, but remains confined to the orbit. In such cases, **Exenteration** (removal of the eyeball along with all orbital contents including muscles, fat, and connective tissue) is the surgical treatment of choice to ensure complete removal of the extraocular tumor mass. This is typically followed by adjuvant chemotherapy and radiotherapy to prevent systemic spread. **Why other options are incorrect:** * **A. Enucleation:** This is the treatment of choice for **Stage II** (intraocular tumor where the eye cannot be saved, e.g., Group E) or when there is involvement of the optic nerve. It is insufficient for Stage III because it leaves behind the extraocular orbital tumor. * **C. Radiotherapy:** While used as an adjuvant therapy in Stage III or as a primary treatment for small, bilateral tumors (to preserve vision), it is not the definitive surgical management for orbital extension (Stage III). **High-Yield Clinical Pearls for NEET-PG:** * **Most common intraocular tumor in children:** Retinoblastoma. * **Most common presentation:** Leukocoria (White pupillary reflex), followed by strabismus. * **Pathognomonic Histology:** Flexner-Wintersteiner rosettes. * **Calcification:** Present in 90% of cases (visible on CT scan; "fine, gritty" appearance). * **Genetics:** Mutation in the **RB1 gene** on chromosome **13q14**. * **Trilateral Retinoblastoma:** Bilateral RB associated with Pinealoblastoma.

Question 257: A 25-year-old male presents with decreased vision in both eyes following a viral illness. On examination, he has mild decrease in visual acuity and paracentral scotomas. Examination of the fundus shows wedge-shaped parafoveal retinal lesions. What is he MOST likely suffering from?

A. Serpiginous Choroidopathy
B. Birdshot Retinochoroidopathy
C. Acute Macular Neuroretinopathy (Correct Answer)
D. Acute zonal occult outer retinopathy

Explanation: **Explanation:** The clinical presentation of a young patient with a history of a recent viral illness, paracentral scotomas, and characteristic **wedge-shaped (petaloid) parafoveal lesions** is classic for **Acute Macular Neuroretinopathy (AMN)**. **1. Why Acute Macular Neuroretinopathy (AMN) is correct:** AMN is a rare condition characterized by the sudden onset of paracentral scotomas. It typically affects young adults and is often preceded by a **flu-like illness** or associated with oral contraceptive use. The hallmark fundus finding is one or more reddish-brown, wedge-shaped lesions pointing toward the fovea. On **Optical Coherence Tomography (OCT)**, it shows hyperreflectivity at the level of the Outer Plexiform Layer (OPL) and Outer Nuclear Layer (ONL), representing a microvascular insult to the deep retinal capillary plexus. **2. Why other options are incorrect:** * **Serpiginous Choroidopathy:** Presents with chronic, progressive, "snake-like" gray-white lesions starting from the peripapillary area and spreading centrifugally. It involves the choriocapillaris and RPE, not just the neurosensory retina. * **Birdshot Retinochoroidopathy:** Typically affects older patients (5th-6th decade) and is strongly associated with **HLA-A29**. It presents with multiple creamy-yellow "birdshot" spots scattered in the mid-periphery, not wedge-shaped parafoveal lesions. * **Acute Zonal Occult Outer Retinopathy (AZOOR):** Characterized by rapid loss of large zones of outer retinal function. While it presents with scotomas and photopsia, the fundus often appears **normal** initially (hence "occult"), later showing RPE atrophy. **Clinical Pearls for NEET-PG:** * **AMN Diagnosis:** Best visualized using **Near-Infrared Reflectance (NIR)** imaging, which highlights the wedge-shaped lesions better than standard fundoscopy. * **Demographics:** Most common in young females (often associated with OCPs, caffeine, or sympathomimetics). * **Prognosis:** Visual acuity usually remains relatively good, but scotomas may persist long-term.

Question 258: A 70-year-old man presents with deterioration of vision 3 weeks after cataract extraction and intraocular lens implantation. Slit lamp examination shows honeycomb maculopathy and fluorescein angiography shows 'flower petal' hyperfluorescence. What is the most likely diagnosis?

A. Age-related macular degeneration (ARMD)
B. Central Serous Retinopathy (CSR)
C. Macular Dystrophy
D. Cystoid Macular Edema (Correct Answer)

Explanation: **Explanation:** The clinical presentation and classic imaging findings point directly to **Cystoid Macular Edema (CME)**, specifically **Irvine-Gass Syndrome**, which occurs following cataract surgery. **1. Why the Correct Answer is Right:** CME involves the accumulation of fluid in the outer plexiform (Henle’s) and inner nuclear layers of the retina. * **Honeycomb Maculopathy:** On slit-lamp biomicroscopy, the fluid-filled cysts create a characteristic honeycomb appearance. * **Flower Petal Appearance:** On Fluorescein Angiography (FFA), dye leaks into the star-shaped Henle’s layer around the fovea, creating a "petalloid" or "flower petal" pattern of hyperfluorescence. * **Timing:** Post-cataract CME typically peaks 4–6 weeks after surgery, matching this patient's 3-week timeline. **2. Why Other Options are Incorrect:** * **ARMD:** Presents with drusen (Dry) or choroidal neovascularization/hemorrhage (Wet). FFA would show "stippled" fluorescence or a classic "smoke-stack/pedal" leak, not a petalloid pattern. * **CSR:** Typically affects younger males (20–50 years) and is associated with stress/steroids. FFA shows a "smoke-stack" or "ink-blot" appearance. * **Macular Dystrophy:** These are usually bilateral, genetic conditions (e.g., Stargardt’s) presenting at a younger age with specific patterns like "beaten bronze" macula or "dark choroid" on FFA. **High-Yield Clinical Pearls for NEET-PG:** * **Irvine-Gass Syndrome:** CME occurring specifically after cataract surgery. * **Gold Standard Investigation:** Optical Coherence Tomography (OCT) is now the investigation of choice (shows intraretinal cystic spaces), though FFA remains a classic exam favorite for its "flower petal" description. * **Treatment:** First-line management includes topical NSAIDs (e.g., Nepafenac or Ketorolac) and topical steroids.

Question 259: What is the investigation of choice for vitreous hemorrhage?

A. Ultrasound biomicroscopy
B. A-Scan
C. B-Scan (Correct Answer)
D. OCT

Explanation: **Explanation:** The investigation of choice for vitreous hemorrhage is **B-Scan (Brightness Scan) ultrasonography**. **Why B-Scan is the Correct Answer:** In cases of vitreous hemorrhage, the blood creates media opacity, making it impossible for the clinician to visualize the posterior segment (retina) using an ophthalmoscope. B-Scan is a two-dimensional, cross-sectional gray-scale ultrasound that can "see through" opaque media. It is essential to rule out underlying sight-threatening conditions such as **Retinal Detachment (RD)** or intraocular tumors, which may be the cause of the hemorrhage. On B-Scan, fresh vitreous hemorrhage appears as low-amplitude, mobile dots or echoes. **Why Other Options are Incorrect:** * **A. Ultrasound Biomicroscopy (UBM):** This uses high-frequency ultrasound to visualize the **anterior segment** (ciliary body, iris, angle) in high resolution. It cannot penetrate deep enough to evaluate the posterior vitreous or retina. * **B. A-Scan:** This is a one-dimensional linear scan used primarily for **biometry** (measuring axial length) to calculate IOL power. It does not provide a structural image of the retina. * **D. Optical Coherence Tomography (OCT):** OCT uses light waves (interferometry). Like ophthalmoscopy, light cannot penetrate dense blood; therefore, OCT is ineffective when a significant vitreous hemorrhage is present. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause** of vitreous hemorrhage: Diabetic Retinopathy (Proliferative). * **Most common cause in trauma:** Mechanical globe injury. * **B-Scan "Membrane" Differentiation:** On B-Scan, a **Retinal Detachment** appears as a high-amplitude, thick, bright membrane that is attached to the optic disc, whereas a **Posterior Vitreous Detachment (PVD)** is a thin, low-amplitude membrane that moves freely and is not attached to the disc.

Question 260: Anterior vitreous cells are least likely to be found in which of the following conditions?

A. Cytomegalovirus (CMV) retinitis
B. Serpiginous choroidopathy
C. Chronic cyclitis
D. Retinitis pigmentosa (Correct Answer)

Explanation: **Explanation:** The presence of anterior vitreous cells (vitritis) is a hallmark of inflammatory processes involving the retina, choroid, or ciliary body. **Why Retinitis Pigmentosa (RP) is the correct answer:** Retinitis Pigmentosa is a **non-inflammatory, hereditary rod-cone dystrophy**. It is characterized by the progressive degeneration of photoreceptors and the migration of pigment into the retina (bone-spicule formation). Because the primary pathology is degenerative rather than immunological or infectious, it typically does not present with inflammatory cells in the vitreous. While "dust-like" pigment particles may occasionally be seen in the vitreous in RP, true inflammatory cells (white blood cells) are characteristic of the other options. **Analysis of Incorrect Options:** * **CMV Retinitis:** This is a necrotizing viral infection common in immunocompromised patients. Although it is known for having "minimal" vitritis compared to other herpetic retinitis (like ARN), some degree of anterior vitreous cells is still expected. * **Serpiginous Choroidopathy:** This is an idiopathic inflammatory condition involving the choriocapillaris and RPE. As an inflammatory "white dot syndrome," it frequently presents with mild to moderate vitritis. * **Chronic Cyclitis (Pars Planitis):** This is a form of intermediate uveitis. By definition, it involves significant inflammation of the vitreous, often presenting with "snowballs" or "snowbanking" in the vitreous base. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of RP:** Arteriolar attenuation, Bone-spicule pigmentation, and Waxy pallor of the optic disc. * **CMV Retinitis Appearance:** Often described as "Pizza-pie" or "Cottage cheese and ketchup" fundus. * **Vitritis Rule:** If a question asks for "minimal" or "absent" vitritis in a posterior segment infection, think **CMV Retinitis** (in the context of AIDS) or **Retinitis Pigmentosa** (in the context of dystrophy).

Practice by Chapter

Retinal Anatomy and Physiology

Practice Questions

Age-Related Macular Degeneration

Practice Questions

Diabetic Retinopathy

Practice Questions

Retinal Vascular Diseases

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Retinal Detachment

Practice Questions

Hereditary Retinal Dystrophies

Practice Questions

Inflammatory Retinal Diseases

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Retinal Tumors

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Retinopathy of Prematurity

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Retinal Imaging Techniques

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Intravitreal Pharmacotherapy

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Vitreoretinal Surgery

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