Diseases of the Retina — MCQs

Diseases of the Retina Indian Medical PG Practice Questions and MCQs

Question 521: A patient presents with a sudden onset of flashes of light and a curtain falling over his vision. Fundoscopy reveals a retinal detachment. What is the most appropriate next step in management?

A. Laser photocoagulation
B. Cryopexy
C. Vitrectomy (Correct Answer)
D. Pneumatic retinopexy

Explanation: ***Vitrectomy*** - **Vitrectomy** is the most appropriate definitive surgical management for a symptomatic retinal detachment with acute visual symptoms as described (flashes and curtain-like visual field loss). - This procedure involves removing the vitreous gel to relieve traction on the retina, allowing the retina to be reattached with internal tamponade (gas or silicone oil). - It is increasingly the **first-line surgical option** for most retinal detachments, particularly those with unclear break location, multiple breaks, or inferior detachments. - Vitrectomy offers excellent anatomical and visual outcomes and is the most versatile approach for various types of retinal detachment. *Laser photocoagulation* - **Laser photocoagulation** is used prophylactically for **retinal breaks or tears** to prevent progression to detachment. - It creates a chorioretinal adhesion around the tear, but is **not sufficient for established retinal detachment** where the retina is already separated from the underlying retinal pigment epithelium. - Once a symptomatic detachment has occurred, laser alone cannot reattach the retina. *Cryopexy* - **Cryopexy** uses freezing temperatures to create a chorioretinal scar around retinal breaks, similar to laser photocoagulation. - It is useful for **peripheral tears** that are difficult to access with laser, particularly during scleral buckling procedures. - Like laser, cryopexy alone is **insufficient for treating an established retinal detachment** with significant separation and visual symptoms. *Pneumatic retinopexy* - **Pneumatic retinopexy** involves injecting a gas bubble into the vitreous cavity to tamponade the retinal break, followed by laser or cryopexy to seal it. - This procedure is appropriate only for **specific, favorable cases**: superior detachments with single or few closely grouped breaks in the upper quadrants, and patients who can maintain strict head positioning. - It has a **lower success rate** (60-80%) compared to vitrectomy or scleral buckle and is suitable for only 15-20% of retinal detachments. - Without specific information indicating favorable criteria, it is not the most appropriate initial choice for a presenting retinal detachment.

Question 522: Which diagnostic test is the most sensitive for detecting early diabetic macular edema?

A. Fluorescein angiography
B. Ultrasound B-scan
C. Visual field testing
D. Optical coherence tomography (Correct Answer)

Explanation: ***Optical coherence tomography*** - **Optical coherence tomography (OCT)** is considered the gold standard for detecting and quantifying **macular edema** due to its ability to provide high-resolution, cross-sectional imaging of the retina. - It can visualize and measure **intraretinal and subretinal fluid**, as well as monitor treatment response. - OCT has the highest sensitivity for detecting **early diabetic macular edema** before it becomes clinically apparent on fundoscopy. *Fluorescein angiography* - While useful for detecting **leakage from microaneurysms** and identifying areas of **ischemia**, it primarily provides information about vascular integrity rather than quantifying edema directly. - It is an invasive procedure and does not offer the same detailed anatomical resolution of retinal layers as OCT. - Better suited for assessing capillary non-perfusion and neovascularization. *Ultrasound B-scan* - This test is typically used for imaging the posterior segment when ocular media opacities (e.g., **dense cataracts**, **vitreous hemorrhage**) preclude direct visualization. - It has a much lower resolution compared to OCT and is not precise enough to detect subtle or early **macular edema**. - Primarily used for detecting gross structural abnormalities like retinal detachment or intraocular masses. *Visual field testing* - **Visual field testing** assesses the extent of a person's peripheral and central vision, which is more relevant for conditions like **glaucoma** or **optic nerve damage**. - It can detect functional visual loss but does not directly visualize or quantify **macular edema**. - Changes in central vision may occur with advanced DME, but this is a functional test, not a diagnostic imaging modality for detecting anatomical changes.

Question 523: A 60-year-old patient with age-related macular degeneration presents with a sudden onset of central vision loss. Fundoscopy reveals subretinal hemorrhage. What is the recommended treatment?

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

Explanation: ***Intravitreal anti-VEGF injection*** - The sudden onset of **central vision loss** and **subretinal hemorrhage** in a patient with age-related macular degeneration (AMD) indicates **wet AMD**, which is characterized by the growth of abnormal new blood vessels in the choroid (choroidal neovascularization, **CNV**). - **Anti-VEGF agents** (vascular endothelial growth factor inhibitors) are the **first-line treatment** for wet AMD, as they target the underlying angiogenesis and reduce leakage and hemorrhage from these abnormal vessels, thereby preserving or improving vision. *Laser photocoagulation* - **Laser photocoagulation** was historically used for some types of CNV; however, it causes **permanent destruction** of the treated area, leading to a **scotoma** (blind spot) in the visual field. - Its use has been largely superseded by anti-VEGF therapy, especially for lesions involving the **fovea**, due to the significant risk of vision loss. *Intravitreal corticosteroids* - While sometimes used in other retinal conditions with inflammation or edema, **intravitreal corticosteroids** are **not the primary treatment** for wet AMD. - They do not address the fundamental angiogenic process of wet AMD and carry risks such as **cataract formation** and **increased intraocular pressure**. *Observation* - Wet AMD, particularly with **subretinal hemorrhage**, is a **sight-threatening condition** that requires prompt intervention. - **Observation** without treatment would invariably lead to **progressive vision loss** due to ongoing bleeding, fluid leakage, and scarring from the untreated CNV.

Question 524: A diabetic patient presents with blurred vision. Fundoscopy reveals microaneurysms, dot-blot hemorrhages, and hard exudates in the macular region. OCT confirms center-involving diabetic macular edema. What is the most appropriate next step in management?

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

Explanation: ***Intravitreal anti-VEGF injection*** - **Diabetic macular edema (DME)**, especially when center-involving, is primarily treated with **intravitreal anti-VEGF injections** to reduce vascular leakage and swelling. - This therapy aims to improve or stabilize vision by targeting the underlying pathophysiology of increased vascular permeability in DME. *Panretinal photocoagulation* - This treatment is primarily used for **proliferative diabetic retinopathy (PDR)** to ablate ischemic peripheral retina and prevent neovascularization. - It is not the first-line treatment for **center-involving DME**, where the goal is to reduce macular swelling and improve vision. *Focal laser treatment* - **Focal laser** can be used for **clinically significant macular edema** but is less effective for **center-involving DME** compared to anti-VEGF agents, particularly when the edema is diffuse. - It targets specific leaking microaneurysms, but its role has largely been supplanted by anti-VEGF for widespread macular edema. *Vitrectomy* - **Vitrectomy** is typically reserved for advanced complications of diabetic retinopathy such as **vitreous hemorrhage** that doesn't clear, **tractional retinal detachment**, or severe **epiretinal membranes**. - It is not the primary treatment for **diabetic macular edema**, even when center-involving.

Question 525: Which of the following is a characteristic of retinoblastoma?

A. Leukocoria (Correct Answer)
B. Buphthalmos
C. Hypopyon
D. Phthisis bulbi

Explanation: **Leukocoria (White Pupillary Reflex)** - *Correct Answer* - **Leukocoria**, also known as "cat's eye reflex" or white pupillary reflex, is the **most common presenting sign of retinoblastoma** (seen in 50-60% of cases), often first noticed by parents in photographs. - It results from the **tumor mass reflecting light** back through the pupil, creating a characteristic white appearance instead of the normal red reflex. - Other presentations include strabismus, painful red eye with secondary glaucoma, or vision loss. *Buphthalmos* - Incorrect - **Buphthalmos** refers to an abnormally enlarged globe (eyeball), which is the **classic sign of congenital glaucoma**, not retinoblastoma. - While advanced retinoblastomas can rarely cause secondary glaucoma with some globe changes, buphthalmos is not a characteristic or primary presentation. *Hypopyon* - Incorrect - **Hypopyon** is the presence of pus or inflammatory cells in the anterior chamber of the eye, typically seen in severe intraocular inflammation, endophthalmitis, or certain types of uveitis. - Retinoblastoma can rarely present with pseudohypopyon (tumor cells in anterior chamber), but true hypopyon is not a characteristic feature. *Phthisis bulbi* - Incorrect - **Phthisis bulbi** refers to a shrunken, disorganized, non-functional eye resulting from severe trauma, chronic inflammation, or end-stage ocular disease. - This represents severe ocular damage and is not a primary presentation or characteristic of retinoblastoma.

Question 526: A 45-year-old woman with diabetes presents with worsening vision. Fundoscopy reveals proliferative diabetic retinopathy. Which treatment option has been shown to be effective in reducing the risk of severe vision loss?

A. Panretinal photocoagulation (Correct Answer)
B. Focal laser treatment
C. Vitrectomy
D. Intravitreal corticosteroids

Explanation: ***Panretinal photocoagulation*** - This treatment uses a laser to create burns in the peripheral retina, destroying ischemic tissue and reducing the production of **vascular endothelial growth factor (VEGF)**, thereby preventing new, fragile blood vessel formation and ultimately reducing the risk of severe vision loss in **proliferative diabetic retinopathy (PDR)**. - PRP is the standard of care for severe non-proliferative and proliferative diabetic retinopathy to prevent progression to **vitreous hemorrhage** or **tractional retinal detachment**. - **Note**: Intravitreal anti-VEGF therapy (bevacizumab, ranibizumab, aflibercept) is also highly effective for PDR and may be used as an alternative or adjunct to PRP in current practice. *Focal laser treatment* - **Focal laser photocoagulation** primarily targets specific leaking microaneurysms in the macula to treat **diabetic macular edema (DME)**, which causes central vision loss. - It is not the primary treatment for proliferative retinopathy where new blood vessel growth (neovascularization) is the main concern. *Vitrectomy* - **Vitrectomy** is a surgical procedure performed to remove blood from a **vitreous hemorrhage** or to repair a **tractional retinal detachment** that has already occurred as a complication of advanced proliferative diabetic retinopathy. - While effective for these complications, it is a surgical intervention for existing damage rather than a primary preventative treatment to reduce the risk of initial severe vision loss from developing PDR. *Intravitreal corticosteroids* - **Intravitreal corticosteroids** are typically used to treat **diabetic macular edema (DME)**, especially in cases unresponsive to anti-VEGF therapy. - While they can reduce inflammation and leakage, they are not the primary treatment for preventing the progression of neovascularization in proliferative diabetic retinopathy.

Question 527: In the context of retinal conditions, what is the primary cause of shifting fluid beneath the retina?

A. Exudative Retinal detachment (Correct Answer)
B. Tractional Retinal Detachment
C. Rhegmatogenous retinal detachment
D. Retinodialysis

Explanation: ***Exudative Retinal detachment*** - This condition is characterized by the accumulation of **serous fluid** beneath the retina without a retinal break, causing the retina to detach. The fluid can shift with changes in head position due to gravity, leading to a **"shifting fluid" phenomenon**. - It results from conditions that compromise the **retinal pigment epithelium (RPE)** or choroidal vasculature, such as **choroidal tumors**, **inflammatory diseases**, or **severe hypertension**, leading to leakage of fluid. *Tractional Retinal Detachment* - This type of detachment occurs when **fibrovascular membranes** on the retinal surface contract and pull the neurosensory retina away from the RPE. - The detachment is usually **immobile** or minimally mobile because it is held in place by fibrous adhesions, and therefore, does not typically exhibit shifting fluid. *Rhegmatogenous retinal detachment* - This is the most common type of retinal detachment and occurs due to a **full-thickness break or tear** in the retina, allowing vitreous fluid to pass into the subretinal space. - While fluid is present, the key feature is a retinal break, and the detached retina is typically more fixed by the flow through the break rather than gravitationally shifting. *Retinodialysis* - Retinodialysis is a specific type of **rhegmatogenous retinal detachment** characterized by a **disinsertion of the retina from its ora serrata attachment**, often due to trauma. - Similar to other rhegmatogenous detachments, fluid accumulates in the subretinal space, but the primary cause is the tear/disinsertion, and it doesn't primarily manifest as a shifting fluid characteristic, which is more indicative of exudative causes.

Question 528: Vitrectomy should be considered if the vitreous haemorrhage is not absorbed within:

A. 1 month
B. 3 months (Correct Answer)
C. 6 months
D. 2 months

Explanation: ***3 months*** - Vitrectomy is typically considered if a **vitreous hemorrhage** does not clear within **3 months** to prevent complications like **retinal detachment** or **hemosiderosis**. - Prolonged vitreous hemorrhage can lead to **fibrous proliferation**, which can cause **tractional retinal detachment**. *1 month* - This period is generally too short to consider surgical intervention unless there are signs of **retinal detachment** or other urgent complications. - Many **vitreous hemorrhages** can spontaneously resolve within this timeframe, especially if they are small. *6 months* - Waiting this long to perform a **vitrectomy** for a persistent **vitreous hemorrhage** would be considered a delay. - This delay could lead to increased risks of **permanent vision loss** due to **hemosiderosis** or the progression of **proliferative vitreoretinopathy**. *2 months* - While closer to the recommended timeline, **2 months** may still be too early to definitively conclude that the hemorrhage will not resolve spontaneously. - However, if there are specific concerns or if the hemorrhage is dense, earlier intervention might be considered.

Question 529: Keith Wagener classification is for?

A. Hypertensive retinopathy (Correct Answer)
B. CRVO
C. CRAO
D. Diabetic maculopathy

Explanation: ***Hypertensive retinopathy*** - The **Keith-Wagner classification** (or Keith-Wagener-Barker classification) is a historical grading system used to describe the severity of **hypertensive retinopathy**. - It categorizes retinal changes into four grades based on findings like **arteriolar narrowing**, **hemorrhages**, **exudates**, and **papilledema**, correlating them with the patient's prognosis. *Diabetic maculopathy* - **Diabetic maculopathy** is classified using systems like the ETDRS (Early Treatment Diabetic Retinopathy Study) criteria, focusing on the presence of **edema**, **exudates**, and **ischemia** in the macula. - While both relate to vascular damage, the specific classifications and features differ significantly. *CRVO* - **Central Retinal Vein Occlusion (CRVO)** is typically classified based on its **ischemic** or **non-ischemic** status, determined by fluorescein angiography and visual acuity. - The Keith-Wagner classification is not used for grading CRVO. *CRAO* - **Central Retinal Artery Occlusion (CRAO)** is primarily diagnosed by the sudden, profound vision loss and retinal whitening, often with a **cherry-red spot** on the macula. - There isn't a widely used grading classification system for CRAO analogous to Keith-Wagner.

Question 530: Subretinal haemorrhage at the macula in myopia is known as?

A. Lacquer cracks
B. Foster Fuchs spot (Correct Answer)
C. Staphyloma
D. Macular retinoschisis

Explanation: ***Foster Fuchs spot*** - This refers to a **subretinal hemorrhage** or **pigmentary change** at the macula due to choroidal neovascularization, a common complication in **pathologic myopia**. - It is a specific clinical sign indicating severe retinal damage and potential vision loss in highly myopic eyes. *Lacquer cracks* - These are **breaks in Bruch's membrane** that appear as fine, yellow-white lines in the fundus. - While they can lead to choroidal neovascularization and hemorrhage in myopic eyes, **lacquer cracks themselves are not the hemorrhage**. *Staphyloma* - A staphyloma is an **outpouching or ectasia of the sclera** (often with choroid and retina) due to thinning and weakening of the scleral wall. - It is a structural abnormality related to high myopia but does not directly describe a subretinal hemorrhage at the macula. *Macular retinoschisis* - This is a **splitting of the retinal layers**, typically in the outer plexiform layer, and is common in high myopia. - It leads to fluid accumulation within the retina, but it is a **separation of retinal layers, not a hemorrhage**.

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

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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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