Diseases of the Retina Practice Questions

Q: A young man presented with night blindness and tubular vision. On examination, the findings include an intraocular pressure of 18 mm, a normal anterior segment, and fundus examination reveals waxy pallor of the disc, attenuation of arterioles, and bony corpuscles resembling spicules of pigmentation in the midperipheral retina. Perimetry testing shows a ring scotoma with subnormal electroretinography. What is your most likely diagnosis?

Pigmented retinal dystrophy. ***Pigmented retinal dystrophy*** - **Night blindness**, **tubular vision** (due to **ring scotoma**), **waxy pallor of the optic disc**, **arteriolar attenuation**, and **bony spicule** retinal pigmentation are classic signs of **retinitis pigmentosa**, a form of pigmented retinal dystrophy. - **Subnormal electroretinography (ERG)** confirms widespread retinal dysfunction, particularly in photoreceptors. *Primary angle-closure glaucoma* - Characterized by **elevated intraocular pressure** (IOP) and optic nerve damage, often presenting with acute pain, redness, and blurred vision. - The presented IOP of 18 mmHg is normal, and the fundus findings do not correspond to typical glaucomatous changes. *Retinal lattice degeneration* - Involves **thinning of the peripheral retina** with a characteristic lattice-like appearance, which predisposes to retinal tears and detachment. - It does not present with **night blindness**, **pigmentary changes**, or **tubular vision**. *Retinal paving stone degeneration* - Consists of small, round, **hyperpigmented or depigmented lesions** in the far peripheral retina, typically benign and asymptomatic. - It is not associated with **night blindness**, **visual field constriction**, or the severe fundus changes described.

Q: Which of the following is not a feature in diabetic retinopathy on fundus examination?

Arteriolar dilatation. ***Arteriolar dilatation*** - **Arteriolar dilatation** is NOT a feature of diabetic retinopathy; instead, **arteriolar narrowing** or normal caliber arterioles are typically observed. - The vascular changes in diabetic retinopathy predominantly affect the **venous system** (venular dilatation, venous beading, venous loops) and **capillaries** (microaneurysm formation). - Diabetic retinopathy is characterized by **microvascular damage, increased permeability, and ischemia**, not primary arteriolar dilatation. *Microaneurysms* - **Microaneurysms** are the **earliest clinically detectable sign** of diabetic retinopathy, appearing as small red dots on fundus examination. - They result from **pericyte loss** and weakening of capillary walls, leading to localized outpouchings that may leak fluid and lipid exudates. *Retinal hemorrhages* - **Retinal hemorrhages** are common in diabetic retinopathy, including **dot-and-blot hemorrhages** (deep retinal layers) and **flame-shaped hemorrhages** (superficial nerve fiber layer). - They occur due to **rupture of weakened microaneurysms** and breakdown of the blood-retinal barrier from chronic hyperglycemia-induced endothelial damage. *Neovascularisation* - **Neovascularization** is the hallmark of **proliferative diabetic retinopathy** (PDR), involving growth of abnormal new vessels on the retina (NVE) or optic disc (NVD). - These fragile vessels lack normal structural support and are prone to **vitreous hemorrhage** and **tractional retinal detachment**, the major vision-threatening complications of PDR.

Q: A 25-year-old male presents with a history of sudden, painless loss of vision in one eye for the past two weeks, with no history of trauma. On examination, the anterior segment is normal, but there is no fundal glow. Which one of the following is the most likely cause?

Vitreous haemorrhage. ***Vitreous haemorrhage*** - Sudden, **painless loss of vision** and absence of **fundal glow** are classic signs of vitreous haemorrhage, as blood obscures the light path to the retina. - This condition can occur spontaneously due to vitreous detachment, proliferative diabetic retinopathy, or retinal tears, leading to **blood accumulation** in the **vitreous cavity**. *Optic atrophy* - **Optic atrophy** involves pallor of the optic disc due to nerve fiber loss, leading to gradual, often chronic, vision loss, which does **not typically present as sudden blindness**. - The fundal glow is usually preserved, though vision is impaired, unlike in vitreous haemorrhage where light is blocked. *Developmental cataract* - A **developmental cataract** would cause gradual blurring of vision or present as reduced acuity from birth or childhood, not sudden vision loss in an adult. - While it can obstruct the fundal glow in severe cases, the onset and presentation (sudden, painless) do not align with cataract. *Acute attack of angle closure glaucoma* - An **acute attack of angle-closure glaucoma** presents with sudden, severe eye pain, headache, fixed mid-dilated pupil, and often **halos around lights**, which are not reported here. - While vision loss is rapid, the overwhelming symptoms are pain and red eye, and the fundal glow is typically present, though the view may be hazy due to **corneal edema**.

Q: What type of laser is primarily used in confocal scanning laser ophthalmoscopy?

Infrared laser. ***Infrared laser*** - **Confocal scanning laser ophthalmoscopy (CSLO)** primarily uses **near-infrared diode lasers** with wavelengths typically between **670-830 nm**. - Infrared wavelengths provide **optimal tissue penetration** with minimal light scatter, allowing high-resolution, three-dimensional imaging of the retina and optic nerve head. - The **Heidelberg Retina Tomograph (HRT)**, a widely used CSLO device, operates at **670 nm** (near-infrared range), making infrared laser the standard for this imaging modality. - The infrared spectrum is particularly useful for imaging through **media opacities** and provides excellent **contrast** for structural analysis. *Diode laser* - While CSLO does use **diode laser technology**, the distinguishing characteristic is the **wavelength** (infrared spectrum), not just the laser type. - Diode lasers can emit light across various wavelengths; the specific use of **infrared wavelengths** is what makes them suitable for CSLO. - In ophthalmology literature, CSLO is characterized by its use of **infrared** light rather than just being described as "diode laser" imaging. *Excimer laser* - **Excimer lasers** emit ultraviolet (UV) light and are used in **refractive surgery** such as **LASIK** for precise corneal ablation. - The high-energy UV spectrum is **not suitable for diagnostic imaging** such as CSLO, as it would cause tissue damage rather than provide safe, non-invasive imaging. *YAG laser* - **Nd:YAG lasers** (neodymium-doped yttrium aluminum garnet) are used for **photodisruptive procedures** such as **posterior capsulotomy** and **peripheral iridotomy**. - They produce **high-energy, short-duration pulses** at 1064 nm to create tissue disruption, not the continuous low-power scanning required for CSLO imaging.

Q: All of the following are true about the incidence of retinoblastoma except:

More common in African children than Caucasian children. ***More common in African children than Caucasian children*** - This statement is **false**, as retinoblastoma incidence shows **no significant racial predilection**. The reported incidence rates are globally consistent across different ethnic groups. - While healthcare access and outcomes may vary, the inherent genetic predisposition and occurrence rate are similar worldwide, independent of race. *Is the most common intraocular tumour of childhood* - This is a **true** statement; retinoblastoma is indeed the most frequently diagnosed primary **intraocular malignancy** in children. - It accounts for a significant proportion of childhood eye cancers, often presenting before the age of five. *No sex predisposition* - This is a **true** statement; studies consistently show that the incidence of retinoblastoma is **equal between male and female children**. - There is no statistically significant difference in the occurrence of this cancer based on sex. *Occurs in 1 in 14000-34000 live births* - This is a **true** statement; the worldwide incidence of retinoblastoma is estimated to be approximately **1 in 14,000 to 1 in 34,000 live births**. - This relatively low but consistent incidence makes it a rare but significant childhood cancer.

Q: Endophthalmitis involves inflammation of all of the following, except:

Sclera. ***Sclera*** - **Endophthalmitis** is an inflammation of the internal structures of the eye, specifically the **vitreous cavity**, **anterior chamber**, and sometimes the retina and uvea. - The **sclera** is the outer protective white layer of the eye and is typically not directly involved in endophthalmitis, although inflammation of surrounding structures could secondarily affect it. *Uvea* - The **uveal tract** (iris, ciliary body, and choroid) is frequently involved in endophthalmitis, as it is a highly vascularized layer within the eye. - Inflammation can spread to or originate from the uvea due to its proximity to the vitreous and its rich blood supply. *Retina* - The **retina**, particularly the inner retinal layers, can be significantly affected in endophthalmitis, especially if the infection or inflammation is severe. - **Retinal vasculitis** and **necrosis** are possible complications, leading to severe vision loss. *Vitreous* - The **vitreous cavity** is the primary site of inflammation in endophthalmitis, often filled with inflammatory cells and debris. - The presence of pus or inflammatory exudates in the vitreous is a hallmark of endophthalmitis.

Q: Not a common cause of night blindness is:

Pathological myopia. ***Pathological myopia*** - While high myopia can cause various visual disturbances, it is **not typically a common primary cause of night blindness**. - Significant **refractive error** itself does not directly impair rod function required for night vision to the extent of other conditions. *Cataract* - A **cataract** is a clouding of the eye's natural lens, which can scatter light and reduce the amount of light reaching the retina. - This reduction in light can make it difficult to see in dim conditions, thus causing **night blindness**. *RP* - **Retinitis pigmentosa (RP)** is a group of genetic disorders that result in progressive degeneration of the photoreceptors, particularly the **rod cells**, which are responsible for vision in low light. - The progressive loss of rod function directly leads to significant and often initial symptoms of **night blindness**. *Oguchi disease* - **Oguchi disease** is a rare form of **congenital stationary night blindness** characterized by a dark-adapted retina that appears golden-yellow or grayish upon fundus examination, known as Mizuo-Nakamura phenomenon. - Patients experience severe night blindness from birth due to a dysfunction of the phototransduction cascade in the rod photoreceptors.

Q: Which of the following is true about pericentral retinitis pigmentosa?

Central vision loss occurs first. ***Central vision loss occurs first*** - In **pericentral retinitis pigmentosa** (also called **central RP** or **inverse RP**), the primary pathology affects the **central retina and macula** first, unlike classical RP. - This leads to **early impairment of central vision**, including **loss of visual acuity** and **difficulty with reading and color vision**, before peripheral vision is significantly affected. - The **fovea and perifoveal regions** show early **photoreceptor degeneration** and **pigmentary changes**. *Bony spicule in the peripheral retina* - **Bony spicules** (pigment deposits) in the **peripheral retina** are characteristic features of **classical retinitis pigmentosa**, which typically causes **peripheral vision loss** first with **night blindness** as an early symptom. - Pericentral retinitis pigmentosa primarily affects the macula and central retina, and peripheral pigmentary changes occur later in the disease course, not initially. *Bony spicule in the fovea* - While **pigmentary changes** can occur in the **macular region** in pericentral RP, **bony spicules specifically in the fovea** are not a typical early feature. - **Foveal involvement** in pericentral RP is characterized by early **macular atrophy**, **pigment mottling**, and **photoreceptor degeneration**, rather than prominent spicule formation seen in peripheral classical RP. *Progressive choroid degeneration* - **Choroidal atrophy** can occur in advanced stages of various retinal dystrophies, but it is not the primary or initial defining characteristic of **pericentral retinitis pigmentosa**. - The initial pathology in pericentral RP is the degeneration of **photoreceptors and retinal pigment epithelium in the central retina**, not the choroid.

Q: What is the immediate management approach for severe vitreous hemorrhage in the eye?

Conservative management (observation). ***Correct: Conservative management (observation)*** - **Conservative management with observation** is the immediate approach for severe vitreous hemorrhage, as most cases resolve spontaneously over 2-3 months - Initial management includes **bed rest with head elevation** to allow blood to settle inferiorly and **bilateral eye patching** to reduce eye movement - This approach allows time for **spontaneous resorption** of blood while monitoring for complications like retinal detachment - **Vitrectomy is reserved for later** if there's no improvement after 2-3 months, or if there are urgent indications like retinal detachment *Incorrect: Vitrectomy* - While vitrectomy is definitive treatment, it is **not immediate management** for uncomplicated vitreous hemorrhage - **Indications for vitrectomy** include: failure to clear after 2-3 months of observation, bilateral hemorrhage in diabetics, suspected retinal detachment, or ghost cell glaucoma - Immediate vitrectomy would expose patients to **unnecessary surgical risks** when most cases resolve spontaneously *Incorrect: Steroids* - **Steroids** reduce inflammation but do not address the blood in the vitreous cavity - They have **no role** in managing vitreous hemorrhage itself, though they may be used for associated inflammatory conditions *Incorrect: Antibiotics* - **Antibiotics** treat bacterial infections and have **no role** in vitreous hemorrhage management, which is a bleeding issue, not an infection - Inappropriate antibiotic use contributes to resistance without providing benefit for this condition

Question 1

A young man presented with night blindness and tubular vision. On examination, the findings include an intraocular pressure of 18 mm, a normal anterior segment, and fundus examination reveals waxy pallor of the disc, attenuation of arterioles, and bony corpuscles resembling spicules of pigmentation in the midperipheral retina. Perimetry testing shows a ring scotoma with subnormal electroretinography. What is your most likely diagnosis?

Accepted Answer

Pigmented retinal dystrophy

Answer

Primary angle-closure glaucoma

Answer

Retinal lattice degeneration

Answer

Retinal paving stone degeneration

Question 2

Which of the following treatments is not suitable for advanced proliferative diabetic retinopathy with extensive vitreoretinal fibrosis and tractional retinal detachment?

Accepted Answer

Photocoagulation

Answer

Removal of epiretinal membrane

Answer

Vitrectomy

Answer

Reattachment of detached or torn retina

Question 3

Which of the following is not a feature in diabetic retinopathy on fundus examination?

Accepted Answer

Arteriolar dilatation

Answer

Microaneurysms

Answer

Retinal hemorrhages

Answer

Neovascularisation

Question 4

A 25-year-old male presents with a history of sudden, painless loss of vision in one eye for the past two weeks, with no history of trauma. On examination, the anterior segment is normal, but there is no fundal glow. Which one of the following is the most likely cause?

Accepted Answer

Vitreous haemorrhage

Answer

Optic atrophy

Answer

Acute attack of angle closure glaucoma

Answer

Developmental cataract

Question 5

What type of laser is primarily used in confocal scanning laser ophthalmoscopy?

Accepted Answer

Infrared laser

Answer

Diode laser

Answer

YAG laser

Answer

Excimer laser

Question 6

All of the following are true about the incidence of retinoblastoma except:

Accepted Answer

More common in African children than Caucasian children

Answer

Is the most common intraocular tumour of childhood

Answer

No sex predisposition

Answer

Occurs in 1 in 14000-34000 live births

Question 7

Endophthalmitis involves inflammation of all of the following, except:

Accepted Answer

Sclera

Answer

Retina

Answer

Vitreous

Answer

Uvea

Question 8

Not a common cause of night blindness is:

Accepted Answer

Pathological myopia

Answer

Oguchi disease

Answer

Cataract

Answer

RP

Question 9

Which of the following is true about pericentral retinitis pigmentosa?

Accepted Answer

Central vision loss occurs first

Answer

Progressive Choroid degeneration

Answer

Bony spicule in the peripheral retina

Answer

Bony spicule in the fovea

Question 10

What is the immediate management approach for severe vitreous hemorrhage in the eye?

Accepted Answer

Conservative management (observation)

Answer

Steroids

Answer

Antibiotics

Answer

Vitrectomy

Diseases of the Retina — MCQs

Diseases of the Retina — MCQs

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