Diseases of the Retina — MCQs

Diseases of the Retina Indian Medical PG Practice Questions and MCQs

Question 511: A patient with a history of myopia presents with new floaters and flashes of light. Fundoscopy reveals a retinal tear. What is the initial management?

A. Laser photocoagulation (Correct Answer)
B. Vitrectomy
C. Scleral buckle
D. Cryotherapy

Explanation: ***Laser photocoagulation*** - **Laser photocoagulation** is the **preferred initial management** for a **retinal tear** without retinal detachment, as it creates a chorioretinal adhesion around the tear, preventing fluid from passing through. - This procedure aims to seal the edges of the tear, thereby **preventing progression to retinal detachment**. - It is **preferred** due to its **precision, minimal inflammation, and ability to treat posterior tears** with excellent visualization. *Vitrectomy* - **Vitrectomy** is generally reserved for more complex cases, such as **retinal detachment with vitreous hemorrhage** or significant vitreous traction. - It involves removing the vitreous gel, which is a more invasive procedure than laser photocoagulation. *Scleral buckle* - A **scleral buckle** is typically used to repair a **retinal detachment** by indenting the sclera and bringing the choroid into contact with the detached retina. - It is not the primary treatment for an isolated retinal tear without detachment. *Cryotherapy* - **Cryotherapy** is an **alternative** to laser photocoagulation for **retinal tears**, especially useful when the view to the tear is obstructed, for **anterior peripheral tears**, or when laser equipment is unavailable. - While equally effective at creating chorioretinal adhesion, laser photocoagulation is **more commonly used** in modern practice due to better control, less inflammation, and superior results for posterior tears.

Question 512: Cotton wool spots on fundoscopic examination are characteristically seen in all of the following EXCEPT:

A. Hypertensive retinopathy
B. Diabetic retinopathy
C. Retinal detachment
D. Glaucoma (Correct Answer)

Explanation: ***Glaucoma*** - Glaucoma is characterized by **optic nerve damage** with **optic disc cupping** and **pallor**, along with visual field defects. - **Cotton wool spots are NOT a feature** of glaucoma; the primary pathology involves elevated intraocular pressure causing optic neuropathy. - Fundoscopic findings include increased **cup-to-disc ratio** (>0.5), vertical elongation of the cup, and **RNFL defects**. *Hypertensive retinopathy* - Cotton wool spots are a hallmark of **grade III-IV hypertensive retinopathy**, resulting from **ischemic infarction** of the nerve fiber layer. - They appear as **white, fluffy patches** and indicate severe hypertension with arteriolar occlusion. - Associated with flame-shaped hemorrhages, arteriovenous nicking, and copper/silver wiring. *Diabetic retinopathy* - Cotton wool spots are commonly seen in **severe NPDR and PDR**, indicating **capillary non-perfusion** and ischemia. - They result from **focal retinal ischemia** due to microvascular occlusion from chronic hyperglycemia. - Other features include microaneurysms, dot-blot hemorrhages, hard exudates, and neovascularization. *Retinal detachment* - **Central retinal vein occlusion (CRVO)**, which can lead to retinal detachment, classically presents with cotton wool spots. - Cotton wool spots can be seen in **ischemic CRVO** along with extensive retinal hemorrhages ("blood and thunder" appearance). - True rhegmatogenous retinal detachment presents with flashes, floaters, and visual field defects but may have preceding vascular changes.

Question 513: What is the primary function of the macula in terms of visual field?

A. Central vision (Correct Answer)
B. Peripheral vision
C. Night vision
D. Color vision

Explanation: ***Central vision*** - The **macula** is a small, specialized area within the retina responsible for **sharp, detailed central vision** necessary for tasks like reading and recognizing faces. - It has a high concentration of **cone photoreceptors**, which are essential for high-acuity vision in the **central visual field**. - The macula, particularly the **fovea centralis**, provides the highest visual acuity in the retina. *Peripheral vision* - Peripheral vision detects objects and movement outside the direct line of sight and is primarily mediated by the **peripheral retina** with its rod photoreceptors. - Damage to the macula typically spares peripheral vision, whereas damage to the peripheral retina affects this type of vision. - Conditions like **age-related macular degeneration** demonstrate how macular damage causes central vision loss while preserving peripheral vision. *Night vision* - **Night vision** is primarily mediated by **rod photoreceptors**, which are highly sensitive to low light levels. - The macula is dominated by **cone photoreceptors**, which function best in bright light conditions (photopic vision). - Rods are concentrated in the peripheral retina, not the macula. *Color vision* - While **color vision** is indeed mediated by **cone photoreceptors** concentrated in the macula, this is a **functional characteristic** rather than a **spatial/field function**. - The question asks about the macula's role in terms of visual field distribution, where it specifically serves **central vision**. - Color perception occurs throughout the visual field wherever cones are present, though it's most acute in the macula.

Question 514: A 70-year-old man presents with gradual, painless vision loss and a history of smoking. What is the most likely diagnosis?

A. Cataracts
B. Glaucoma
C. Age-related macular degeneration (Correct Answer)
D. Diabetic retinopathy

Explanation: ***Age-related macular degeneration*** - **Gradual, painless vision loss** in an older individual, especially with a history of **smoking**, is highly suggestive of **age-related macular degeneration** (AMD) - AMD specifically affects the **macula**, leading to loss of **central vision** and difficulty with tasks like reading and recognizing faces - **Smoking is the most significant modifiable risk factor** for developing AMD *Cataracts* - While cataracts also cause gradual, painless vision loss and are common in older adults, they typically present with **cloudy or blurry vision**, problems with glare, and reduced night vision - Smoking is a risk factor for cataracts, but the specific pattern of **central vision loss** points more strongly to AMD *Glaucoma* - Glaucoma is characterized by **optic nerve damage** and is typically associated with **elevated intraocular pressure**, leading to **peripheral vision loss** first - The patient's presentation of painless, gradual vision loss, particularly without mention of tunnel vision, is less typical for glaucoma *Diabetic retinopathy* - **Diabetic retinopathy** occurs in individuals with **diabetes mellitus** and can lead to blurred vision, floaters, or sudden vision loss due to macular edema or retinal hemorrhage - The patient's history does not mention diabetes, making this diagnosis less likely in the absence of that key risk factor

Question 515: A 65-year-old patient presents with acute vision loss and is diagnosed with central retinal artery occlusion. What is the most appropriate immediate intervention to attempt to restore vision?

A. Ocular massage (Correct Answer)
B. Laser photocoagulation
C. Intravitreal injection of anti-VEGF
D. Intravenous thrombolysis

Explanation: ***Ocular massage*** - **Ocular massage** is an immediate intervention used to attempt to dislodge the **embolic clot** and move it into a smaller branch of the retinal artery, potentially restoring some blood flow. - This maneuver aims to reduce intraocular pressure, which can also help improve retinal perfusion. - It is the **most appropriate immediate intervention** because it can be performed **instantly at bedside** without special equipment or screening. *Laser photocoagulation* - **Laser photocoagulation** is generally used to treat retinal conditions such as **diabetic retinopathy** or retinal tears, not for acute central retinal artery occlusion. - It works by creating small burns to seal blood vessels or destroy abnormal tissue, which would not address an acute arterial blockage. *Intravitreal injection of anti-VEGF* - **Anti-VEGF injections** are commonly used to treat conditions involving **neovascularization** or **macular edema**, such as wet age-related macular degeneration or diabetic macular edema. - They are not indicated for restoring blood flow in an acute arterial occlusion, whose primary pathology is embolic. *Intravenous thrombolysis* - While **intravenous thrombolysis (IV tPA)** has been explored for CRAO and is used in some specialized centers within a **very narrow time window** (typically <4.5 hours), it requires careful patient screening for contraindications and immediate availability of resources. - Compared to **ocular massage**, which can be performed immediately at bedside, IV thrombolysis is **not the most appropriate immediate intervention** due to time required for screening, contraindication assessment, and administration. - Evidence for its efficacy remains controversial, with some studies showing benefit and others showing no significant visual improvement compared to conservative measures.

Question 516: A 75-year-old male with a history of atrial fibrillation presents with sudden vision loss in the right eye. Fundoscopy reveals a cherry-red spot in the macula. Analyze the clinical findings and determine the most appropriate next step in management.

A. Intravenous tissue plasminogen activator
B. Emergent carotid endarterectomy
C. Intra-arterial thrombolysis
D. Immediate ophthalmology consultation (Correct Answer)

Explanation: ***Immediate ophthalmology consultation*** - **Sudden, painless vision loss** in one eye along with a **cherry-red spot** on fundoscopy are classic signs of **central retinal artery occlusion (CRAO)**, a medical emergency requiring urgent evaluation by an ophthalmologist. - Time is critical in CRAO as retinal tissue can suffer irreversible damage within hours, making prompt consultation essential for exploring potential interventions such as ocular massage or anterior chamber paracentesis to dislodge the embolus and restore blood flow. *Intravenous tissue plasminogen activator* - While tPA is used in acute ischemic stroke, its role in CRAO is **controversial and not standard practice**, primarily due to the high risk of hemorrhagic complications outweighing potential benefits given the short therapeutic window for retinal salvage. - The efficacy of systemic thrombolysis for CRAO is limited due to the small vessel size and the fact that most emboli are cholesterol plaques rather than fibrin clots that would respond to tPA. *Emergent carotid endarterectomy* - Carotid endarterectomy is indicated for symptomatic **carotid artery stenosis** to prevent future strokes, not as an acute treatment for CRAO. - Although CRAO can be caused by carotid artery emboli, performing an endarterectomy acutely would not address the immediate retinal ischemia and carries significant surgical risks. *Intra-arterial thrombolysis* - **Intra-arterial thrombolysis** can be considered in select cases of CRAO, but it is an invasive procedure with significant risks and requires a specialized interventional team, making an immediate ophthalmology consultation the more appropriate first step to confirm the diagnosis and assess suitability. - The decision to pursue intra-arterial thrombolysis is made by the ophthalmologist in conjunction with an interventional radiologist, often after initial conservative measures have failed or are deemed insufficient.

Question 517: A 5-year-old child is brought in with leukocoria and a family history of ocular tumors. Fundus examination reveals a white mass. What is the most likely diagnosis?

A. Retinoblastoma (Correct Answer)
B. Congenital cataract
C. Coats' disease
D. Persistent hyperplastic primary vitreous

Explanation: **Retinoblastoma** - **Leukocoria**, a **whitish pupillary reflex**, is the most common presenting sign of retinoblastoma, especially in children, and the **white mass** seen on fundus examination is characteristic of the tumor. - A **family history of ocular tumors** strongly suggests a genetic predisposition to retinoblastoma, as mutations in the **RB1 gene** are often inherited. - Retinoblastoma is the **most common intraocular malignancy in children**, typically presenting before age 5 years. *Congenital cataract* - While congenital cataracts can cause **leukocoria**, they typically present as a hazy or cloudy lens rather than a **solid white mass** on fundus examination. - A **family history of ocular tumors** is not typically associated with congenital cataracts. - The cataract would be seen in the **lens**, not as a retinal mass. *Coats' disease* - Coats' disease is characterized by **abnormal retinal blood vessels** and **exudative retinal detachment**, leading to leukocoria. - However, it typically presents with **telangiectatic vessels** and lipid exudates rather than a discrete white mass, and a **family history of ocular tumors** is not a common feature. - Usually **unilateral** and occurs in young males with **no hereditary pattern**. *Persistent hyperplastic primary vitreous* - This condition results from the **failure of the primary vitreous to regress** and can cause leukocoria due to a retrolental membrane. - While it presents with leukocoria, fundus examination would reveal a **retrolental fibrovascular membrane** rather than a distinct white intraocular mass, and it is not strongly linked to a **family history of ocular tumors**. - Typically **unilateral** and **non-hereditary**.

Question 518: A 55-year-old male with a history of diabetes presents with progressive vision loss. Fundoscopy reveals neovascularization of the disc and vitreous hemorrhage. What is the most appropriate treatment?

A. Panretinal photocoagulation (Correct Answer)
B. Intravitreal anti-VEGF injection
C. Focal laser photocoagulation
D. Vitrectomy

Explanation: ***Panretinal photocoagulation*** - **Panretinal photocoagulation** (PRP) is a definitive treatment for **proliferative diabetic retinopathy** (PDR) with **neovascularization** and **vitreous hemorrhage** as it destroys ischemic peripheral retina to reduce the angiogenic drive and prevent further neovascularization and associated bleeding. - PRP reduces the risk of severe vision loss by causing regression of new vessels and preventing further hemorrhage and **tractional retinal detachment**. - PRP remains the gold standard treatment especially in resource-limited settings and when close follow-up may not be possible. *Intravitreal anti-VEGF injection* - **Anti-VEGF injections** can rapidly reduce neovascularization and stabilize vision, and recent evidence (DRCR Protocol S) shows they are non-inferior to PRP for PDR. - However, anti-VEGF requires **multiple repeated injections** and close follow-up, and the effect is temporary if not maintained, whereas PRP provides a more **durable, one-time treatment**. - In the presence of significant **vitreous hemorrhage** that may obscure the macula, the benefit of anti-VEGF alone without addressing the underlying retinal ischemia with PRP may be limited. *Focal laser photocoagulation* - **Focal laser photocoagulation** is primarily used to treat **clinically significant macular edema** by targeting leaking microaneurysms, not for neovascularization or vitreous hemorrhage. - It would not be effective in treating the proliferative changes described, especially in the presence of **vitreous hemorrhage**. *Vitrectomy* - **Vitrectomy** is a surgical procedure usually reserved for severe complications of PDR, such as **non-clearing vitreous hemorrhage** (after a period of observation, typically 2-3 months) or **tractional retinal detachment** involving the macula. - While the vitreous hemorrhage may eventually require vitrectomy if it doesn't clear, it is not the initial most appropriate treatment for the neovascularization itself.

Question 519: A patient with a history of diabetes presents with sudden vision loss and a "shower of floaters." Fundoscopy reveals a dense vitreous hemorrhage. What is the immediate next step in management?

A. Observation
B. Panretinal photocoagulation
C. Intravitreal anti-VEGF injection
D. Vitrectomy (Correct Answer)

Explanation: ***Vitrectomy*** - A **dense vitreous hemorrhage** causing sudden vision loss, especially in a diabetic patient with proliferative diabetic retinopathy, may require surgical removal when the hemorrhage is severe and vision-threatening. - **Vitrectomy** involves removing the blood from the vitreous cavity and is considered when there is: (1) dense non-clearing hemorrhage after 2-3 months, (2) associated retinal detachment, or (3) bilateral involvement where the fellow eye has poor vision. - In cases of **severe, vision-obstructing hemorrhage**, early vitrectomy may be considered to restore vision and allow treatment of underlying retinopathy. *Observation* - **Observation** with head elevation is typically the **initial approach** for most vitreous hemorrhages, as many clear spontaneously within 2-3 months. - However, in this scenario with **dense hemorrhage** causing significant vision loss, prolonged observation may delay necessary intervention and risk complications like tractional retinal detachment or development of neovascular glaucoma. - B-scan ultrasonography should be performed to rule out retinal detachment during observation period. *Panretinal photocoagulation* - **Panretinal photocoagulation (PRP)** is the definitive treatment for **proliferative diabetic retinopathy** to prevent neovascularization and future hemorrhage. - However, in the presence of a **dense vitreous hemorrhage**, the retina is obscured, making PRP technically impossible until the media clears. - PRP would be performed after vitrectomy or after spontaneous clearing of the hemorrhage. *Intravitreal anti-VEGF injection* - **Anti-VEGF injections** help reduce neovascularization and may decrease the risk of recurrent bleeding in proliferative diabetic retinopathy. - They are often used as **adjunctive therapy** before or during vitrectomy, but do not remove existing blood from the vitreous cavity. - While useful for long-term management, they are not the primary immediate treatment for a **dense, vision-obstructing vitreous hemorrhage** that has already occurred.

Question 520: Which pattern of inheritance is commonly observed in Best's disease?

A. Autosomal recessive
B. X-linked recessive
C. Autosomal dominant (Correct Answer)
D. Mitochondrial inheritance

Explanation: ***Autosomal dominant*** - Best's disease, also known as **vitelliform macular dystrophy**, is characterized by its **autosomal dominant** inheritance pattern. - This means only one copy of the defective gene (BEST1 gene) is needed to cause the disorder, and affected individuals have a 50% chance of passing it to each child. *Autosomal recessive* - In **autosomal recessive** inheritance, two copies of the defective gene are required for the disease to manifest, meaning both parents must be carriers. - This pattern is not characteristic of Best's disease. *X-linked recessive* - **X-linked recessive** disorders primarily affect males, as the defective gene is located on the X chromosome, and females usually need two affected X chromosomes to show symptoms. - This mode of inheritance is not seen with Best's disease. *Mitochondrial inheritance* - **Mitochondrial inheritance** involves mutations in the mitochondrial DNA and is passed exclusively from the mother to all her children. - Best's disease is not associated with mitochondrial gene mutations.

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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