Diseases of the Retina Practice Questions

Q: A 45-year-old AIDS patient was started on anti-retroviral therapy following which he develops decrease in visual acuity. Fundus examination was done. All are used for management of the patient except?

CMV hyperimmunoglobulin. ***CMV hyperimmunoglobulin*** - CMV hyperimmunoglobulin is typically used for prevention or treatment of CMV disease, particularly in transplant recipients or immunocompromised individuals, but **not as a primary treatment for established CMV retinitis**. - Its role is minimal in direct management of vision-threatening retinitis where antiviral agents are the mainstay. *Ganciclovir intraocular pellets* - **Ganciclovir intraocular pellets** are a form of localized therapy directly implanted into the eye to provide sustained release of the antiviral drug. - This method ensures high local drug concentrations, effective against **CMV retinitis**, especially in cases where systemic treatment is problematic or retinitis is severe. *Valganciclovir* - **Valganciclovir** is an oral prodrug of ganciclovir, which is commonly used as a systemic treatment for **CMV retinitis** due to its good bioavailability. - It is effective in both the induction and maintenance phases of treatment for CMV retinitis. *Foscarnet* - **Foscarnet** is an antiviral agent effective against **CMV**, particularly useful in cases of ganciclovir resistance or intolerance due to its different mechanism of action. - It is administered intravenously and is a well-established treatment option for **CMV retinitis**.

Q: What is incorrect about the disease shown below?

Blood and thunderstorm fundus. ***Blood and thunderstorm fundus*** - This is **NOT** a feature of Retinitis Pigmentosa shown in the image, making it the correct answer. - "Blood and thunderstorm" fundus describes the appearance of **Central Retinal Vein Occlusion (CRVO)**, characterized by widespread retinal hemorrhages, dilated tortuous veins, cotton-wool spots, and optic disc edema. - The image shown is characteristic of **Retinitis Pigmentosa**, which presents with **bone-spicule pigmentation**, **attenuated retinal vessels**, and a **waxy pale optic disc** - completely different from CRVO. *Night blindness* - This **IS** a feature of Retinitis Pigmentosa, making it an incorrect answer choice. - Night blindness is often the **earliest symptom** of RP, caused by progressive degeneration of **rod photoreceptors**. - It refers to difficulty seeing in low light conditions, a hallmark of the disease. *Thin arteries* - This **IS** a feature of Retinitis Pigmentosa, making it an incorrect answer choice. - **Retinal vascular attenuation**, particularly of the arteries, is a classic sign of advanced RP. - This thinning reflects the underlying widespread retinal atrophy and reduced metabolic demand. *Pale disc* - This **IS** a feature of Retinitis Pigmentosa, making it an incorrect answer choice. - A **waxy pallor of the optic disc** is a characteristic finding in RP, indicative of optic nerve atrophy. - This results from the chronic degeneration of retinal ganglion cells and their axons.

Q: What is the fundus finding shown below?

Cotton wool spots. ***Cotton wool spots*** - The image shows multiple **whitish, fluffy lesions** scattered across the retina, which are characteristic of cotton wool spots. - These lesions represent **microinfarcts** in the nerve fiber layer caused by occlusion of precapillary arterioles, leading to accumulation of axoplasmic debris. - Commonly seen in **diabetic retinopathy**, **hypertensive retinopathy**, and **HIV retinopathy**. *Astrocytic hamartoma* - Astrocytic hamartomas (retinal astrocytomas) are typically seen in **tuberous sclerosis** and appear as **mulberry-like lesions** on the optic disc or retina. - These are well-defined, often calcified nodular masses that are more raised and discrete than cotton wool spots. - The findings in the image do not resemble these characteristic hamartomas. *Hemorrhagic retinitis* - **Hemorrhagic retinitis**, as seen in **CMV retinitis**, presents with a characteristic **"cheese and ketchup"** appearance due to widespread necrosis, hemorrhage, and retinal edema. - The lesions show extensive hemorrhage and areas of whitish necrosis, often following blood vessels. - The discrete white lesions in the image lack the extensive hemorrhage and necrotic areas typical of CMV retinitis. *Cattle trucking appearance* - **"Cattle trucking"** or **"boxcar segmentation"** refers to the appearance of discontinuous segments of blood in retinal veins due to extremely slow blood flow. - Often seen in conditions like **central retinal vein occlusion** or **hyperviscosity syndromes**. - This is a flow phenomenon within vessels and does not describe the white retinal lesions shown in the image.

Q: The FFA given below shows:

Flower petal appearance. ***Flower petal appearance*** - This appearance is characteristic of **macular edema** on fluorescein angiography, specifically **cystoid macular edema**. - The dye leaks from perifoveal capillaries and accumulates in the intraretinal cystic spaces, outlining the **Henle's layer** in a radial, flower-petal-like pattern. *Ink blot pattern* - The **ink blot pattern** is seen in **central serous chorioretinopathy** where fluorescein leaks from a single point in the retinal pigment epithelium into the subretinal space, gradually expanding. - This differs from the multifocal cystic accumulation seen in the image. *Smoke stack pattern* - The **smoke stack pattern** is another feature of **central serous chorioretinopathy**, characterized by vertical leakage of fluorescein that expands upwards like smoke from a chimney. - This is not consistent with the diffuse, radial pattern observed in the image. *Puff of smoke appearance* - The **puff of smoke appearance** is typically associated with **moyamoya disease**, an angiographic finding of abnormal collateral vessels at the base of the brain. - This term is unrelated to retinal fluorescein angiography findings.

Q: Identify the appearance:

Salt and pepper retinopathy. ***Salt and pepper retinopathy*** - This image demonstrates diffuse **pigmentary changes** in the retina, characterized by alternating areas of **hypopigmentation** and hyperpigmentation, resembling salt and pepper. - This appearance is classically associated with certain **retinal degenerations** or congenital infections like congenital rubella. *Splashed tomato appearance* - This term describes severe **fundic hemorrhage**, typically seen in conditions like Purtscher's retinopathy or acute hemorrhagic maculopathy, which is not evident here. - It involves large, confluent areas of **blood** on the retina. *Cottage cheese and tomato ketchup appearance* - This distinctive appearance is characteristic of **cytomegalovirus (CMV) retinitis**, where white, fluffy lesions (cottage cheese) are intermingled with retinal hemorrhages (tomato ketchup), none of which are present in this image. - CMV retinitis is commonly seen in **immunocompromised individuals**. *Headlight in fog appearance* - This refers to a specific funduscopic finding in **ocular toxoplasmosis**, where a bright white active retinochoroidal lesion (headlight) is surrounded by significant vitritis (fog). - The image does not show active inflammation or dense vitreal haze.

Q: Identify the fundus appearance seen on examination:

Cottage cheese and tomato ketchup appearance. ***Cottage cheese and tomato ketchup appearance*** - This description is **pathognomonic for cytomegalovirus (CMV) retinitis**, particularly in immunocompromised patients (HIV/AIDS, transplant recipients, immunosuppressive therapy). - The image shows extensive **retinal infiltrates appearing white** (resembling cottage cheese, representing areas of retinal necrosis) mixed with **hemorrhages appearing red** (resembling tomato ketchup). - This is the classic appearance that confirms the diagnosis of CMV retinitis. *Splashed tomato appearance* - This term describes severe **proliferative diabetic retinopathy** with diffuse intraretinal hemorrhages, microaneurysms, and cotton wool spots. - While hemorrhages are present in the image, the extensive white necrotic infiltrates are not consistent with diabetic retinopathy. - Diabetic retinopathy lacks the confluent white areas of retinal necrosis seen here. *Headlight in fog appearance* - This describes **toxoplasmosis retinochoroiditis**, where a focal area of active inflammation (the "headlight") is surrounded by vitritis (the "fog"). - The image shows widespread, confluent retinal involvement with both necrosis and hemorrhage, not a single focal lesion with vitreous haze. - Toxoplasmosis typically presents with more localized disease. *Salt and pepper retinopathy* - This refers to a fine, speckled pattern of hyperpigmentation and depigmentation of the retinal pigment epithelium, seen in **congenital rubella syndrome** or **syphilis**. - The image shows large, confluent areas of active inflammation and hemorrhage, not the fine diffuse pigmentary changes characteristic of "salt and pepper" retinopathy. - This is an inactive, chronic pigmentary change, not acute retinitis.

Q: The fundus shown below indicates presence of:

Forster-Fuchs' spots. ***Forster-Fuchs' spots*** - The image shows a **dark, pigmented lesion** in the macula surrounded by a **lighter halo**, characteristic of **Fuchs' spot**, which is a sign of **choroidal neovascularization (CNV)** in **pathological myopia**. - These spots are a sign of **subretinal hemorrhage** and subsequent **fibrosis** found in very severe, **degenerative myopia**. *Papilledema* - **Papilledema** is characterized by **bilateral optic disc edema** due to increased **intracranial pressure**, causing blurring of the disc margins, venous engorgement, and often hemorrhage. - The image does not show typical signs of papilledema, such as a **swollen optic disc** with blurred margins, loss of the optic cup, and surrounding hemorrhages or exudates. *Papillitis* - **Papillitis** is an **inflammatory condition** affecting the **optic disc**, presenting as unilateral or bilateral disc edema with significant vision loss. - While it involves optic disc swelling, it is usually due to inflammation within the optic nerve head, and the image's macular changes are not consistent with primary isolated papillitis. *Optic neuritis* - **Optic neuritis** is typically an **inflammation of the optic nerve**, often causing **acute, painful vision loss** and can be associated with normal or swollen optic discs (papillitis if visible disc edema). - The fundus image displays profound **macular changes and significant degeneration**, which are not primarily characteristic of optic neuritis unless there are massive acute changes, which are not depicted here.

Q: What pathology is shown in this fundus image?

Toxoplasmosis. ***Toxoplasmosis*** - The image shows a **focal retinochoroidal scar** with surrounding retinal inflammation and pigmentary changes, characteristic of reactivated **ocular toxoplasmosis**. - This typically presents as a necrotizing retinitis lesion, often adjacent to a pre-existing scar, and can be associated with vitritis. *Rubella* - **Congenital rubella syndrome** can cause ocular manifestations like "salt-and-pepper" retinopathy, which is a diffuse pigmentary change, not the focal scar seen here. - Other ocular signs of rubella include cataracts and microphthalmia, which are not visible in a fundal image of this type. *CMV* - **Cytomegalovirus (CMV) retinitis** typically presents as large, confluent areas of yellow-white retinal opacification with associated hemorrhage ("cotton-wool spots" or "brushfire" appearance), primarily seen in immunocompromised patients. - The focal, well-demarcated scar with less hemorrhage seen in the image is not typical for CMV retinitis. *Babesiosis* - **Babesiosis** is a tick-borne parasitic disease that primarily affects red blood cells and can cause a malaria-like illness; it does not typically cause direct fundus lesions or retinochoroidal scars. - Ocular involvement in babesiosis is rare and usually manifests as non-specific findings related to systemic illness rather than specific infectious retinitis.

Q: A 25-year-old male patient came with history of progressive night blindness and decreased vision since childhood. Now he has tubular vision. Retinal examination as shown below revealed jet black, spidery spots similar to bone corpuscles. Which of the following statements is true?

The diagnosis is retinitis pigmentosa. ***The diagnosis is retinitis pigmentosa*** - The patient's history of **progressive night blindness**, **decreased vision since childhood**, and **tubular vision** are classic symptoms of retinitis pigmentosa. - The retinal examination finding of **jet black, spidery spots similar to bone corpuscles** in the image is pathognomonic for retinitis pigmentosa, representing retinal pigment epithelial migration and clumping. *Most commonly inherited as X-linked recessive* - While retinitis pigmentosa can be inherited in various patterns (autosomal dominant, autosomal recessive, X-linked), the **autosomal recessive** form is the most common, followed by autosomal dominant. - **X-linked recessive inheritance** is responsible for about 10-15% of cases and often leads to the most severe phenotype, but it is not the most common overall. *Papilledema occurs* - **Papilledema** is swelling of the optic disc due to increased intracranial pressure, which is not characteristic of retinitis pigmentosa. - In retinitis pigmentosa, the optic disc often appears **waxy pallor** and the retinal blood vessels are attenuated, not swollen. *The retinal changes typically start at the posterior pole and spread anteriorly* - The retinal changes in retinitis pigmentosa typically begin in the **mid-peripheral retina** and gradually spread both centrally towards the macula and peripherally. - This progressive loss of photoreceptors and RPE cells leads to the characteristic **ring scotoma** that eventually progresses to tubular vision by sparing central vision until later stages.

Q: This is the picture of the fundus of a female patient, who was on estrogen containing pills, and presents with sudden deterioration of vision. What is the likely diagnosis?

Central retinal vein occlusion. ***Central retinal vein occlusion*** - The fundus image shows widespread **hemorrhages**, **dilated and tortuous veins**, and **optic disc swelling** which are classic signs of central retinal vein occlusion (CRVO). - Estrogen-containing pills increase the risk of **thrombosis**, making CRVO a plausible diagnosis in a patient presenting with sudden vision deterioration. *Diabetic background retinopathy* - While diabetic retinopathy can cause hemorrhages and exudates, the extensive, diffuse hemorrhages and significant venous engorgement seen here are more characteristic of a **venous occlusion**. - Diabetic retinopathy typically presents with microaneurysms, blot hemorrhages, hard exudates, and sometimes cotton wool spots, usually without the widespread venous changes seen in the image. *Hypertensive retinopathy* - Hypertensive retinopathy typically features **arteriolar narrowing**, **arteriovenous nicking**, flame-shaped hemorrhages, cotton wool spots, and sometimes optic disc edema if severe, but not the widespread pan-retinal hemorrhage and venous dilation depicted. - The patient's history does not mention hypertension, making this less likely compared to a thrombotic event linked to estrogen use. *Central retinal artery occlusion* - Central retinal artery occlusion (CRAO) presents with a **pale retina** and a **cherry-red spot** in the macula, due to acute ischemia. - The fundus image provided shows **widespread hemorrhages and dilated veins**, which are not characteristic features of CRAO.

Question 1

A 45-year-old AIDS patient was started on anti-retroviral therapy following which he develops decrease in visual acuity. Fundus examination was done. All are used for management of the patient except?

Accepted Answer

CMV hyperimmunoglobulin

Answer

Ganciclovir intraocular pellets

Answer

Valganciclovir

Answer

Foscarnet

Question 2

What is incorrect about the disease shown below?

Accepted Answer

Blood and thunderstorm fundus

Answer

Night blindness

Answer

Thin arteries

Answer

Pale disc

Question 3

What is the fundus finding shown below?

Accepted Answer

Cotton wool spots

Answer

Astrocytic hamartoma

Answer

Hemorrhagic retinitis

Answer

Cattle trucking appearance

Question 4

The FFA given below shows:

Accepted Answer

Flower petal appearance

Answer

Ink blot pattern

Answer

Smoke stack pattern

Answer

Puff of smoke appearance

Question 5

Identify the appearance:

Accepted Answer

Salt and pepper retinopathy

Answer

Splashed tomato appearance

Answer

Cottage cheese and tomato ketchup appearance

Answer

Headlight in fog appearance

Question 6

Identify the fundus appearance seen on examination:

Accepted Answer

Cottage cheese and tomato ketchup appearance

Answer

Splashed tomato appearance

Answer

Headlight in fog appearance

Answer

Salt and pepper retinopathy

Question 7

The fundus shown below indicates presence of:

Accepted Answer

Forster-Fuchs' spots

Answer

Papilledema

Answer

Papillitis

Answer

Optic neuritis

Question 8

What pathology is shown in this fundus image?

Accepted Answer

Toxoplasmosis

Answer

Rubella

Answer

CMV

Answer

Babesiosis

Question 9

A 25-year-old male patient came with history of progressive night blindness and decreased vision since childhood. Now he has tubular vision. Retinal examination as shown below revealed jet black, spidery spots similar to bone corpuscles. Which of the following statements is true?

Accepted Answer

The diagnosis is retinitis pigmentosa

Answer

Most commonly inherited as X-linked recessive

Answer

Papilledema occurs

Answer

The retinal changes typically start at the posterior pole and spread anteriorly

Question 10

This is the picture of the fundus of a female patient, who was on estrogen containing pills, and presents with sudden deterioration of vision. What is the likely diagnosis?

Accepted Answer

Central retinal vein occlusion

Answer

Diabetic background retinopathy

Answer

Hypertensive retinopathy

Answer

Central retinal artery occlusion

Diseases of the Retina — MCQs

Diseases of the Retina — MCQs

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