Diseases of the Retina — MCQs

Diseases of the Retina Indian Medical PG Practice Questions and MCQs

Question 441: Which of the following is seen in proliferative diabetic retinopathy?

A. Tractional retinal detachment (Correct Answer)
B. No retinal detachment
C. Exudative retinal detachment
D. Rhegmatogenous retinal detachment

Explanation: ***Tractional retinal detachment*** - This is the hallmark complication of **Proliferative Diabetic Retinopathy (PDR)**, caused by the contraction of **fibrovascular tissue** growing on the retinal surface. - The pulling force separates the sensory retina from the **retinal pigment epithelium (RPE)**, often leading to slow, progressive vision loss. *Rhegmatogenous retinal detachment* - This results from a **full-thickness retinal break** that allows fluid vitreous to pass into the subretinal space. - Pure rhegmatogenous detachment is less common in PDR; diabetic detachments are typically **tractional** or occasionally mixed **tractional-rhegmatogenous**. *Exudative retinal detachment* - This type is caused by fluid accumulation due to leakage through intact vessels, often associated with conditions like **posterior scleritis** or choroidal tumors. - It is characterized by highly mobile subretinal fluid that shifts with changes in head position, a finding not typical of PDR's primary mechanism. *No retinal detachment* - Although not all patients with PDR develop detachment, the condition is defined by the high risk of severe complications, including **tractional retinal detachment** and **vitreous hemorrhage**. - PDR is the stage where extensive **neovascularization** occurs, structurally predisposing the eye to retinal separation.

Question 442: Which of the following investigations allows examination of all layers of the retina?

A. OCT (Correct Answer)
B. B-scan ultrasonography
C. Perimetry
D. Fundus fluorescein angiography

Explanation: ***Optical Coherence Tomography (OCT)*** - **OCT provides high-resolution, cross-sectional images of the retina**, allowing visualization and precise measurement of **all retinal layers** from the **Internal Limiting Membrane (ILM)** to the **Retinal Pigment Epithelium (RPE)**. - It is the **gold standard** for detailed morphological analysis of retinal architecture. - Crucial for diagnosing and monitoring **macular edema**, **age-related macular degeneration (ARMD)**, **diabetic retinopathy**, and other macular pathologies. - Provides **in vivo histological imaging** of retinal layers with resolution approaching 3-5 microns. *B-scan ultrasonography* - Uses sound waves to image the eye, primarily utilized when **ocular media are opaque** (e.g., dense cataract, vitreous hemorrhage). - Provides a **general structural outline** of the posterior segment but **cannot resolve individual microscopic retinal layers**. - Useful for detecting retinal detachment, intraocular masses, and posterior segment pathology when direct visualization is not possible. *Perimetry* - **Visual field testing** that measures the **functional sensitivity** of vision across the visual field. - Assesses the **overall functional integrity** of the retina and visual pathway, correlating with retinal ganglion cell function. - Does **not provide anatomical imaging** or visualization of individual retinal layers. - Important for glaucoma assessment and neurological visual pathway disorders. *Fundus fluorescein angiography (FFA)* - Involves injecting fluorescent dye and capturing images to study the **circulation of the retina and choroid**. - Primarily evaluates **vascular leakage**, **non-perfusion areas**, **microaneurysms**, and **neovascularization**. - Provides **en face (surface) vascular imaging**, not cross-sectional layer visualization. - Does not display individual retinal layers in the manner that OCT does.

Question 443: A 40-year-old AIDS positive patient complains of seeing floaters followed by progressive reduction in visual acuity over next weeks. Fundus examination was performed. All are true about the causative agent except: (Recent NEET Pattern 2016-17)

A. Eosinophilic intranuclear inclusions (Correct Answer)
B. Shed in semen
C. Largest virus in human herpes virus
D. Leads to pizza pie retinopathy

Explanation: ***Eosinophilic intranuclear inclusions*** - The causative agent of **CMV retinitis** (Cytomegalovirus) typically forms **basophilic intranuclear inclusions** (owl's eye inclusions), not eosinophilic ones. - This statement is therefore incorrect regarding CMV. *Shed in semen* - **CMV** is commonly shed in various bodily fluids, including **semen**, urine, and saliva, contributing to its transmission. - This is a true characteristic of CMV. *Largest virus in human herpes virus* - **CMV** (Human herpesvirus 5) is indeed the **largest virus in the human herpesvirus family**, both in terms of genome size and virion size. - This is a true characteristic of CMV. *Leads to pizza pie retinopathy* - The classic description of **CMV retinitis** on fundus examination is often referred to as "**pizza pie retinopathy**" or "cottage cheese and ketchup" appearance, due to its characteristic retinal hemorrhages and white, necrotic areas. - This is a true clinical manifestation of CMV retinitis.

Question 444: What is incorrect about the disease shown below?

A. Night blindness
B. Thin arteries
C. Pale disc
D. Blood and thunderstorm fundus (Correct Answer)

Explanation: ***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.

Question 445: What is the fundus finding shown below?

A. Cotton wool spots (Correct Answer)
B. Astrocytic hamartoma
C. Hemorrhagic retinitis
D. Cattle trucking appearance

Explanation: ***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.

Question 446: The FFA given below shows:

A. Flower petal appearance (Correct Answer)
B. Ink blot pattern
C. Smoke stack pattern
D. Puff of smoke appearance

Explanation: ***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.

Question 447: Identify the appearance:

A. Splashed tomato appearance
B. Cottage cheese and tomato ketchup appearance
C. Headlight in fog appearance
D. Salt and pepper retinopathy (Correct Answer)

Explanation: ***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.

Question 448: Identify the fundus appearance seen on examination:

A. Splashed tomato appearance
B. Cottage cheese and tomato ketchup appearance (Correct Answer)
C. Headlight in fog appearance
D. Salt and pepper retinopathy

Explanation: ***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.

Question 449: The fundus shown below indicates presence of:

A. Forster-Fuchs' spots (Correct Answer)
B. Papilledema
C. Papillitis
D. Optic neuritis

Explanation: ***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.

Question 450: What is the diagnosis based on this fundus examination?

A. Optic atrophy
B. Papilledema (Correct Answer)
C. Cupping of the disc
D. Silver wire appearance

Explanation: ***Papilledema*** - The image shows a **swollen optic disc** with blurred margins, loss of the optic cup, and **hemorrhages** on and around the disc, all characteristic features of papilledema. - **Papilledema** is swelling of the optic disc due to increased intracranial pressure. *Optic atrophy* - **Optic atrophy** typically presents with a **pale optic disc**, sharply defined margins, and a reduction in the number of retinal nerve fibers. - There is no evidence of disc pallor or sharp margins in the provided image; instead, there is significant disc swelling and blurring. *Cupping of the disk* - **Cupping of the disc** refers to an enlargement of the physiological optic cup, often seen in glaucoma where there is a backward displacement of the lamina cribrosa. - The image clearly shows **loss of the optic cup** due to swelling, not an enlargement of it. *Silver wire appearance* - The **silver wire appearance** refers to a prominent light reflex off the blood column in retinal arterioles, indicating severe arterial narrowing and sclerosis, typically seen in advanced hypertensive retinopathy. - The primary findings in this image relate to the optic disc and surrounding tissue, not the general appearance of the retinal arterioles.

Practice by Chapter

Retinal Anatomy and Physiology

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Age-Related Macular Degeneration

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Diabetic Retinopathy

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Retinal Vascular Diseases

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Retinal Detachment

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Hereditary Retinal Dystrophies

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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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