Diseases of the Retina Practice Questions

Q: What does the following image show?

Vitreous cells and flare. ***Correct: Vitreous cells and flare*** - The image exhibits **vitreous cells**, seen as tiny dots within the vitreous gel, indicating **inflammatory cells** in the vitreous cavity - **Vitreous flare** is also visible as haziness of the vitreous due to **increased protein content** from breakdown of the blood-aqueous barrier - This combination is characteristic of **intermediate uveitis (vitritis)** and indicates active intraocular inflammation - Seen on **slit-lamp biomicroscopy** with a narrow beam in the vitreous cavity *Incorrect: Asteroid hyalosis* - Would show **yellowish-white, spherical deposits** composed of calcium-lipid complexes - These deposits are typically **asymptomatic** and do not indicate inflammation - Appears as **star-like or asteroid-shaped opacities** that move with eye movement - Usually **bilateral** and associated with aging, not inflammation *Incorrect: Posterior vitreous detachment* - Would show a **Weiss ring** (circular opacity from detached vitreous around the optic disc) - Patient would report **photopsia** (flashes of light) and **floaters** - The vitreous would appear **more mobile** and separated from the retina - No inflammatory cells or protein flare would be present *Incorrect: Vitreous hemorrhage* - Would show **red blood cells** in the vitreous, appearing as **dense red opacity** - The view would be more **obscured** with reduced red reflex - Causes include **trauma, diabetic retinopathy, retinal tears**, or vascular occlusions - No specific cellular inflammatory pattern or protein flare as seen here

Q: During annual medical check-up, a 55-year-old hypertensive corporate executive is found to have ophthalmoscopic findings as shown in the image given below. What is it composed of?

Cholesterol crystals. ***Cholesterol crystals*** - The image depicts **synchysis scintillans**, a condition characterized by numerous tiny, golden-brown, refractile particles often seen in a **liquefied vitreous** humour. These particles are composed of **cholesterol crystals**. - This condition is typically associated with a history of **vitreous haemorrhage** or trauma and is often seen in eyes with retinal detachment or chronic inflammation. The crystals are mobile within the vitreous and "snow" down with eye movement. *Residue of primitive hyaloid vascular system* - Remnants of the **hyaloid artery** or **Mittendorf dot** usually appear as a small, white or grey dense spot on the posterior lens capsule or as a fine strand in the vitreous, not as multiple free-floating crystals. - These are **congenital anomalies** and generally do not resorb or multiply to form widespread vitreous opacities in this manner. *Calcium containing salts* - **Asteroid hyalosis** is composed of **calcium-lipid complexes**, often described as "star-like" or "asteroid" bodies, which are typically yellow-white and tend to remain suspended in the vitreous rather than floating freely. - While both conditions are types of vitreous opacities, synchysis scintillans crystals are more numerous, mobile, and have a distinct golden, shimmering appearance distinct from the static, star-like appearance of asteroid hyalosis. *Degenerated blood in vitreous hemorrhage* - Degenerated blood from a vitreous hemorrhage typically appears as **reddish-brown clumping**, haziness, or strands, which eventually resolve or get resorbed over time. - While synchysis scintillans can follow vitreous hemorrhage, the crystals themselves are a **later development** resulting from the breakdown of blood products and cholesterol, not the blood itself.

Q: All of the following are responsible for the condition shown in the image except:

Kaposi sarcoma. ***Kaposi sarcoma*** - The image depicts **neovascularization of the iris**, also known as **rubeosis iridis**, characterized by abnormal blood vessel growth on the iris surface. - Kaposi sarcoma is a vascular tumor that would typically present as a distinct **raised, reddish-purple lesion** on the iris, NOT as diffuse neovascularization. - **This is the correct answer** as Kaposi sarcoma does NOT cause rubeosis iridis. *Diabetes mellitus* - **Diabetic retinopathy** is one of the most common causes of **rubeosis iridis**, especially in advanced proliferative stages. - Widespread retinal ischemia leads to upregulation of **VEGF (vascular endothelial growth factor)**, stimulating abnormal vessel growth on the iris. - These new vessels can grow into the anterior chamber angle and cause **neovascular glaucoma**, a severe sight-threatening complication. *Central retinal venous occlusion* - **Central retinal venous occlusion (CRVO)** leads to significant **retinal ischemia** and release of **angiogenic factors** (primarily VEGF). - This often results in **rubeosis iridis** within 2-3 months (classic "90-day glaucoma"). - The ischemic retina drives neovascularization as a compensatory but pathological response. *Fuchs heterochromic cyclitis* - **Fuchs heterochromic iridocyclitis (FHI)** is a form of chronic anterior uveitis associated with **heterochromia** (different colored irises) and **stellate keratic precipitates**. - While FHI can show **fine vessels on the iris surface**, these are typically **pre-existing vessels that become visible** due to iris stromal atrophy, NOT true neovascularization. - **True rubeosis iridis is NOT a characteristic feature** of FHI, making this an uncommon association at best.

Q: All are true about the recording shown except:

C wave is due to activation of optic nerve. ***C wave is due to activation of optic nerve*** - The **C wave** in an electroretinogram (ERG) primarily reflects the activity of the **retinal pigment epithelium (RPE)** and its interaction with the photoreceptors, not the optic nerve. - The optic nerve's activity (ganglion cell action potentials) is usually recorded as part of the **pattern ERG** or visual evoked potentials (VEPs), not directly as the C wave on a full-field ERG. *R1 is due to photochemical reactions in outer segment of rods and cones* - The early receptor potential (**ERP**), which includes R1 and R2 components, is indeed a very early electrical event generated by the **photochemical changes** in the outer segments of photoreceptors (rods and cones) upon light stimulation. - It occurs almost instantaneously after light absorption due to molecular changes in the photopigments. *A wave is due to photoreceptor activity* - The **A wave** (or a-wave) of the ERG represents the **hyperpolarization of photoreceptors** (rods and cones) in response to light. - It is typically a negative deflection and its amplitude reflects the number and function of the photoreceptors. *B wave is due to response of bipolar cells* - The **B wave** (or b-wave) is a positive deflection and is primarily generated by the activity of **on-bipolar cells** and Müller cells in the inner retina. - Its amplitude is often used to assess the function of these retinal layers.

Q: A 25-year-old young male presented with complaints of diminished vision in the right eye. On examination vision in left eye is 6/6 and right eye is 6/18. Shown are the FFA and optical coherence topography of the patient. The pathology lies in which layer of retina?

Retinal pigment epithelium. ***Retinal pigment epithelium*** - The FFA image shows a "hot spot" of hyperfluorescence, and the OCT image reveals an **irregularity and detachment of the RPE** with overlying subretinal fluid, characteristic of central serous chorioretinopathy. - The primary pathology in **central serous chorioretinopathy** is a dysfunction or defect in the RPE barrier, leading to fluid leakage from the choroidal vasculature into the subretinal space. *Neurosensory retina* - The neurosensory retina itself is detached due to fluid accumulation, but its primary structure appears generally intact without intrinsic pathology like retinal tears or degeneration. - While there is **subretinal fluid** (between the neurosensory retina and the RPE), the underlying cause is typically an RPE defect, not a primary neurosensory retinal pathology. *Outer nuclear layer* - This layer contains the cell bodies of photoreceptors and is typically involved in degenerations like retinitis pigmentosa, which would present differently on imaging. - There is no specific evidence in the provided OCT of primary pathology directly affecting the integrity or structure of the **outer nuclear layer**. *Inner nuclear layer* - This layer contains cell bodies of bipolar, horizontal, and amacrine cells and is typically involved in pathologies affecting these retinal interneurons. - The images do not show specific changes or damage to the **inner nuclear layer**, such as edema or thinning, that would suggest it as the primary site of pathology.

Q: A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

6th nerve palsy. ***6th nerve palsy*** - The image shows the **right eye** is unable to **abduct** (move outwards) when looking to the right, and is **adducted** (turned inwards) when looking straight ahead, which is characteristic of a **sixth cranial nerve (abducens) palsy**. - The abducens nerve innervates the **lateral rectus muscle**, which is responsible for abduction of the eye. Its paralysis causes the affected eye to deviate medially due to the unopposed action of the medial rectus muscle. *2nd nerve palsy* - **Second nerve (optic nerve) palsy** would primarily present with **vision loss** or field defects, not with abnormal eye movements. - The optic nerve transmits visual information from the eye to the brain and does not control ocular motility. *3rd nerve palsy* - **Third nerve (oculomotor) palsy** typically presents with **ptosis**, **dilated pupil**, and the eye positioned **down and out**. - This is because the oculomotor nerve innervates most extraocular muscles (medial, superior, inferior rectus, inferior oblique) and the levator palpebrae superioris, as well as pupillary constrictors. *4th nerve palsy* - **Fourth nerve (trochlear) palsy** affects the **superior oblique muscle**, leading to **vertical diplopia** and the eye being unable to move down and in. - Patients often compensate by **tilting their head** to the opposite shoulder.

Q: Identify the FFA picture:

NPDR. ***NPDR*** - The image shows areas of **capillary non-perfusion** (dark areas without visible blood flow) and **microaneurysms** (small bright dots due to damaged capillaries). These are characteristic findings of **Non-Proliferative Diabetic Retinopathy (NPDR)** on fluorescein angiography. - There is no evidence of neovascularization, which is the hallmark of proliferative diabetic retinopathy. *PDR* - **Proliferative Diabetic Retinopathy (PDR)** is characterized by the presence of **neovascularization** (new, abnormal blood vessel growth) on the retina or optic disc. - This image does not show any signs of neovascularization, which would appear as brightly fluorescing, tangled vessels. *Familial dominant drusen* - **Familial dominant drusen** are typically seen as yellow-white deposits under the retinal pigment epithelium and would manifest on FFA as **hyperfluorescent spots**, but usually with a different distribution and appearance than the microaneurysms seen here. - This image reflects widespread microvascular damage consistent with a retinal vascular disease, not primarily drusen. *Birdshot choroidopathy* - **Birdshot choroidopathy** is a chronic, bilateral posterior uveitis characterized by multiple, depigmented choroidal lesions (birdshot lesions). - On FFA, these lesions would typically show **hypofluorescence** in the early phases due to blocked choroidal fluorescence and possible late staining, which is not depicted in this image.

Q: Identify the instrument:

Sponge-holding forceps. ***Sponge-holding forceps*** - This image clearly shows **sponge-holding forceps**, identifiable by their **long handles** and **fenestrated, serrated jaws** used for holding swabs or sponges during surgical procedures. - The jaws are designed to securely grip materials without crushing them, crucial for gentle tissue handling or applying antiseptics. *Ovum forceps* - **Ovum forceps** typically have **cup-shaped jaws** with or without teeth, specifically designed for removing placental fragments or uterine contents. - Their jaws are usually shorter and more rounded than those depicted. *Kocher forceps* - **Kocher forceps** are characterized by their **transverse serrations** and **1x2 teeth** at the tip, designed for strong and atraumatic grasping of tissue. - The jaws in the image are clearly fenestrated and do not have the characteristic teeth of Kocher forceps. *Allis forceps* - **Allis forceps** have **multiple fine teeth** at the tip that intermesh, providing a secure but potentially traumatic grip on tissue. - They are used for grasping and holding tissue that is to be removed, distinguishing them from the broader, fenestrated jaws shown.

Q: The following fundus finding is seen in:

ICSOL. ***ICSOL*** - The image depicts **papilledema**, characterized by a **swollen optic disc** with blurred margins and elevated appearance, often due to increased intracranial pressure. - Increased intracranial pressure commonly results from **Intracranial Space-Occupying Lesions (ICSOLs)** such as tumors, abscesses, or hematomas. *Retinitis pigmentosa* - This condition presents with **pigmentary deposits** (bone spicule appearance) in the peripheral retina and **attenuation of retinal vessels**, which are not seen in the image. - It leads to **progressive vision loss**, initially night blindness, and later tunnel vision. *Multiple sclerosis* - Multiple sclerosis can cause **optic neuritis**, leading to **pale optic disc** due to axonal loss, but not papilledema. - Typically, it involves demyelination in the central nervous system, with various neurological symptoms beyond isolated fundus findings. *Hysterical blindness* - Hysterical blindness (now often referred to as **functional neurological symptom disorder** with visual symptoms) is a diagnosis of exclusion. - It involves normal neurological and funduscopic examinations, including a normal optic disc appearance.

Q: Consider the following causes of visual loss : 1. Obstruction of the central retinal artery 2. Vitreous and retinal haemorrhage 3. Cataract 4. Retinal detachment Which of the above causes are associated with acute visual loss in a patient?

1, 2 and 4. ***1, 2 and 4*** - **Obstruction of the central retinal artery**, **vitreous and retinal haemorrhage**, and **retinal detachment** all present as sudden, acute vision loss. - **Central retinal artery occlusion** causes complete, sudden, painless monocular vision loss. **Vitreous hemorrhage** is acute, painless, and can present with floaters or red haze. **Retinal detachment** is acute, painless vision loss, often preceded by flashes and floaters, and can present as a "curtain" coming across the vision. *1, 3 and 4* - While **central retinal artery obstruction** and **retinal detachment** cause acute vision loss, **cataracts** typically cause gradual, progressive vision loss over months to years. - Cataracts primarily affect lens clarity, leading to blurry vision, glare, and dull colors rather than an abrupt onset of blindness. *1, 2 and 3* - **Central retinal artery obstruction** and **vitreous/retinal hemorrhage** lead to acute vision loss, but **cataracts** are a cause of *chronic* and *gradual* vision impairment. - The onset and progression of a **cataract** are distinctly different from the sudden nature of acute vision loss conditions. *2, 3 and 4* - **Vitreous and retinal haemorrhage** and **retinal detachment** are causes of acute vision loss, but a **cataract** is not. - The defining characteristic of acute vision loss is its rapid onset, which does not align with the slow development of a cataract.

Question 1

What does the following image show?

Accepted Answer

Vitreous cells and flare

Answer

Asteroid hyalosis

Answer

Posterior vitreous detachment

Answer

Vitreous hemorrhage

Question 2

During annual medical check-up, a 55-year-old hypertensive corporate executive is found to have ophthalmoscopic findings as shown in the image given below. What is it composed of?

Accepted Answer

Cholesterol crystals

Answer

Residue of primitive hyaloid vascular system

Answer

Calcium containing salts

Answer

Degenerated blood in vitreous hemorrhage

Question 3

All of the following are responsible for the condition shown in the image except:

Accepted Answer

Kaposi sarcoma

Answer

Diabetes mellitus

Answer

Central retinal venous occlusion

Answer

Fuchs heterochromic cyclitis

Question 4

All are true about the recording shown except:

Accepted Answer

C wave is due to activation of optic nerve

Answer

R1 is due to photochemical reactions in outer segment of rods and cones

Answer

A wave is due to photoreceptor activity

Answer

B wave is due to response of bipolar cells

Question 5

A 25-year-old young male presented with complaints of diminished vision in the right eye. On examination vision in left eye is 6/6 and right eye is 6/18. Shown are the FFA and optical coherence topography of the patient. The pathology lies in which layer of retina?

Accepted Answer

Retinal pigment epithelium

Answer

Neurosensory retina

Answer

Outer nuclear layer

Answer

Inner nuclear layer

Question 6

A 60-year-old male underwent a cataract surgery. After 1 year he came with complaints of diminished vision and the finding shown in the image. Diagnosis is?

Accepted Answer

6th nerve palsy

Answer

2nd nerve palsy

Answer

3rd nerve palsy

Answer

4th nerve palsy

Question 7

Identify the FFA picture:

Accepted Answer

NPDR

Answer

PDR

Answer

Familial dominant drusen

Answer

Birdshot choroidopathy

Question 8

Identify the instrument:

Accepted Answer

Sponge-holding forceps

Answer

Ovum forceps

Answer

Kocher forceps

Answer

Allis forceps

Question 9

The following fundus finding is seen in:

Accepted Answer

ICSOL

Answer

Retinitis pigmentosa

Answer

Multiple sclerosis

Answer

Hysterical blindness

Question 10

Consider the following causes of visual loss :

1. Obstruction of the central retinal artery
2. Vitreous and retinal haemorrhage
3. Cataract
4. Retinal detachment Which of the above causes are associated with acute visual loss in a patient?

Accepted Answer

1, 2 and 4

Answer

1, 3 and 4

Answer

1, 2 and 3

Answer

2, 3 and 4

Diseases of the Retina — MCQs

Diseases of the Retina — MCQs

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