Assessment of Low Vision Patients — MCQs
All of the following conditions are immediate priorities in the WHO's "Vision -2020: The Right to sight" except:
A child presents with night blindness, delayed dark adaptation. Which investigation is to be done further to confirm the diagnosis?
In infants of diabetic mothers (IDM), when is ophthalmologic evaluation indicated?
Patient was in an accident and put on mechanical ventilation. He is opening his eyes on verbal command and follows motor commands with all four limbs. What is his GCS score?
Campimetry is used to measure:
Minimum visual acuity below which a person is called Blind
Steps in review of patient's history during secondary survey of trauma care can be summarised as
A diabetic patient presents to you with visual acuity of 6/9 in one eye. Further investigations revealed preretinal hemorrhages with neovascularization at the optic disc. What is the next step in management?
A Patient in medical intensive care unit who is intubated, suddenly removes the endotracheal tube. What should be done next?
A 40-year-old woman presents with double vision, difficulty swallowing, and drooping eyelids that worsen as the day progresses. Which class of medications is the most appropriate initial treatment?
Assessment of Low Vision Patients Indian Medical PG Practice Questions and MCQs
Question 1: All of the following conditions are immediate priorities in the WHO's "Vision -2020: The Right to sight" except:
- A. Cataract
- B. Epidemic conjunctivitis (Correct Answer)
- C. Onchocerciasis
- D. Trachoma
Explanation: ***Epidemic conjunctivitis*** - While **epidemic conjunctivitis** can cause significant discomfort and temporary vision impairment, it is generally **self-limiting** and rarely leads to permanent blindness. - It was not identified as one of the top five global causes of avoidable blindness targeted by the Vision 2020 initiative. *Cataract* - **Cataract** is the **leading cause of blindness** globally, accounting for approximately half of all cases. - It is a highly treatable condition through surgery, making it a critical priority for Vision 2020. *Onchocerciasis* - Also known as **river blindness**, onchocerciasis is a parasitic disease that causes severe visual impairment and blindness. - It is a significant public health problem in several regions, particularly in Africa, and was a key focus of Vision 2020 due to its widespread impact and the availability of preventive chemotherapy. *Trachoma* - **Trachoma** is the **leading infectious cause of blindness** worldwide, caused by *Chlamydia trachomatis*. - Given its preventable and treatable nature, and its prevalence in many impoverished areas, it was designated as one of the priority diseases under Vision 2020.
Question 2: A child presents with night blindness, delayed dark adaptation. Which investigation is to be done further to confirm the diagnosis?
- A. ERG (Correct Answer)
- B. Retinoscopy
- C. Dark adaptometry
- D. EOG
Explanation: ***ERG*** - **Electroretinography (ERG)** measures the electrical responses of various retinal cells, including **rods** and **cones**, to light stimuli. - In conditions like **retinitis pigmentosa** which cause night blindness and delayed dark adaptation, ERG will show characteristic abnormal or extinguished responses, confirming retinal dysfunction. *Retinoscopy* - **Retinoscopy** is an objective method to assess the refractive error of the eye by observing the light reflex from the retina. - It does not directly evaluate the functional integrity of photoreceptors or diagnose conditions causing **night blindness**. *Dark adaptometry* - **Dark adaptometry** measures the time it takes for the eye to adapt to dim light after exposure to bright light, quantifying the function of **rod photoreceptors**. - While it can *detect* delayed dark adaptation, it is a functional test that assesses the symptom, not the underlying cause provided by ERG. *EOG* - **Electrooculography (EOG)** measures the potential difference between the cornea and the retina, primarily assessing the function of the **retinal pigment epithelium (RPE)**. - While useful for conditions like **Best's disease**, it is less direct for evaluating generalized rod dysfunction causing night blindness compared to ERG.
Question 3: In infants of diabetic mothers (IDM), when is ophthalmologic evaluation indicated?
- A. At the time of diagnosis
- B. Only if visual symptoms develop (Correct Answer)
- C. After 5 years routinely
- D. After developing diabetes
Explanation: ***Only if visual symptoms develop*** - Unlike **retinopathy of prematurity**, infants of diabetic mothers (IDMs) do not have a higher incidence of **retinopathy** or other **ocular abnormalities** at birth or in early infancy. - **Ophthalmologic evaluation** is generally reserved for IDMs who develop specific **visual symptoms** or signs of ocular pathology. *At the time of diagnosis* - Routine ophthalmologic screening at the time of diagnosis of IDM is **not standard practice**, as the risk of **congenital ocular anomalies** is not substantially elevated to warrant universal screening. - Initial management focuses on metabolic stability, especially **glucose control**, and screening for other common IDM-related complications like **cardiac defects** or **respiratory distress**. *After 5 years routinely* - There is **no evidence or recommendation** for routine ophthalmologic screening of IDMs specifically at the age of 5 years. - Regular **well-child check-ups** include basic vision screening, which would identify significant refractive errors or strabismus, but not specifically for diabetes-related ocular issues. *After developing diabetes* - While it is true that individuals with **type 1 or type 2 diabetes** require regular **ophthalmologic evaluations** for **diabetic retinopathy**, this refers to the child developing diabetes later in life, not being an IDM. - Being an IDM is a **risk factor for developing diabetes** later in life, but it doesn't automatically mean they have diabetes-related ocular issues from birth.
Question 4: Patient was in an accident and put on mechanical ventilation. He is opening his eyes on verbal command and follows motor commands with all four limbs. What is his GCS score?
- A. 12
- B. 11
- C. 9
- D. 10 (Correct Answer)
Explanation: ***10*** - **Eye-opening on verbal command scores 3 points** on the GCS (E3). - **Following motor commands with all four limbs scores 6 points** on the GCS (M6). - The patient is on **mechanical ventilation, meaning verbal response is untestable** and scores **1 point (V1T)** for intubated patients. - **Total GCS score: E3 + V1T + M6 = 10T** *12* - This score would incorrectly assume a verbal response of 5 (oriented), which is impossible for an intubated patient. - Would require: E3 + V5 + M4 or similar incorrect combinations that don't match the clinical presentation. *11* - This score would result from incorrect component assignment. - For example, E3 + V2 + M6 = 11, but verbal response cannot be 2 in an intubated patient (must be 1T). - Does not align with the untestable verbal response due to mechanical ventilation. *9* - This score underestimates the patient's neurological status. - Would require: E2 + V1 + M6 = 9, which contradicts the finding that the patient opens eyes on verbal command (E3, not E2). - Incorrectly assigns lower eye-opening score than the clinical presentation indicates.
Question 5: Campimetry is used to measure:
- A. Squint
- B. Field of Vision (Correct Answer)
- C. Pattern of retina
- D. Malignant melanoma
Explanation: ***Field of Vision*** - **Campimetry** is a diagnostic test specifically designed to map and assess a person's **field of vision**, identifying blind spots or areas of diminished sight. - This technique is crucial for detecting and monitoring conditions that affect the optic nerve or visual pathways, such as **glaucoma** or neurological disorders. *Squint* - A **squint**, also known as strabismus, refers to a misalignment of the eyes. - Its assessment primarily involves tests of **ocular motility** and alignment, such as the cover test, rather than perimetry. *Pattern of retina* - The **pattern of the retina** is evaluated through direct visualization using an **ophthalmoscope** or other retinal imaging techniques like fundus photography or optical coherence tomography (OCT). - These methods provide structural information about the retina, not its functional visual field. *Malignant melanoma* - **Malignant melanoma** (in the context of the eye) is a tumor that can affect various parts of the eye, including the choroid, iris, or conjunctiva. - Its diagnosis involves clinical examination, imaging studies (**ultrasound**, OCT, **fluorescein angiography**), and sometimes biopsy, not primarily visual field testing.
Question 6: Minimum visual acuity below which a person is called Blind
- A. 6/60
- B. 2/60
- C. 4/60
- D. 3/60 (Correct Answer)
Explanation: ***3/60*** - This is the **WHO and Indian definition threshold for legal blindness** - visual acuity of 3/60 or worse in the better eye with best possible correction - This means seeing at 3 meters what a person with normal vision sees at 60 meters - Visual acuity **below 3/60** (i.e., 3/60 or worse) qualifies as blind - This is the internationally recognized standard used in **NEET-PG and Indian ophthalmology practice** *6/60* - Visual acuity of 6/60 represents **severe visual impairment** but NOT blindness - This is above the 3/60 threshold, so does not meet criteria for legal blindness - Classified as "severely visually impaired" rather than blind *2/60* - While 2/60 is definitely blindness (being worse than 3/60), it is NOT the **minimum threshold** - The question asks for the cutoff point, which is 3/60 - This represents a more severe degree of blindness beyond the defining threshold *4/60* - Like 2/60, this is also below the 3/60 threshold and qualifies as blindness - However, it is NOT the standard defining threshold - The established cutoff remains **3/60** per WHO/Indian guidelines
Question 7: Steps in review of patient's history during secondary survey of trauma care can be summarised as
- A. TRIAGE
- B. ABCDE
- C. AMPLE (Correct Answer)
- D. None of the options
Explanation: ***AMPLE*** - The **AMPLE history** is a mnemonic used during the **secondary survey** in trauma care to gather crucial patient information - It stands for **Allergies, Medications, Past medical history/Pregnancy, Last meal, and Events** surrounding the injury. *TRIAGE* - **Triage** is the process of prioritizing patients based on the severity of their condition and the likelihood of benefit from immediate treatment. - It is an initial assessment done to determine the urgency of care, not a detailed historical review for a single patient. *ABCDE* - The **ABCDE approach** (**Airway, Breathing, Circulation, Disability, Exposure**) is part of the **primary survey** in trauma care. - It focuses on identifying and managing immediate life-threatening conditions. *None of the options* - This option is incorrect because **AMPLE** specifically describes the historical review process during the secondary survey.
Question 8: A diabetic patient presents to you with visual acuity of 6/9 in one eye. Further investigations revealed preretinal hemorrhages with neovascularization at the optic disc. What is the next step in management?
- A. Focal laser photocoagulation
- B. Pan-retinal photocoagulation (Correct Answer)
- C. Grid laser photocoagulation
- D. Scleral buckling
Explanation: ***Pan-retinal photocoagulation*** - The presence of **preretinal hemorrhages** and **neovascularization at the optic disc (NVD)** indicates **high-risk proliferative diabetic retinopathy (PDR)**. - **NVD is a high-risk characteristic** for severe vision loss and requires urgent treatment with **pan-retinal photocoagulation (PRP)**. - PRP aims to ablate ischemic peripheral retina, which reduces the production of **VEGF** and other angiogenic factors that stimulate neovascularization. *Focal laser photocoagulation* - This treatment targets discrete leaking microaneurysms in cases of **clinically significant macular edema (CSME)**, which is not the primary issue here. - It is used for **non-proliferative diabetic retinopathy** with macular involvement, not for neovascularization. *Grid laser photocoagulation* - Grid laser is a type of focal laser used for **diffuse macular edema** where specific leaking microaneurysms cannot be identified. - It is not indicated for **neovascularization** or **preretinal hemorrhages**, which are signs of PDR. *Scleral buckling* - **Scleral buckling** is a surgical procedure primarily used to treat **retinal detachment** by indenting the sclera to relieve vitreoretinal traction. - It is not the initial or primary treatment for **proliferative diabetic retinopathy** or **neovascularization**.
Question 9: A Patient in medical intensive care unit who is intubated, suddenly removes the endotracheal tube. What should be done next?
- A. Sedate and reintubate
- B. Make him sit and do physiotherapy
- C. Assess the patient and give bag and mask ventilation and look for spontaneous breathing (Correct Answer)
- D. Give bag and mask ventilation and intubate
Explanation: ***Assess the patient and give bag and mask ventilation and look for spontaneous breathing*** - Upon accidental extubation, the immediate priority is to **assess the patient's airway, breathing, and circulation (ABCs)** and ensure oxygenation via **bag-mask ventilation** if needed, while observing for spontaneous breathing efforts. - This step allows for a controlled re-evaluation of the patient's respiratory status and provides time to plan for reintubation if indicated, without rushing into sedating or reintubating a potentially stable patient. *Sedate and reintubate* - While reintubation may ultimately be necessary, sedating and immediately attempting reintubation without prior assessment can be dangerous if the patient has **stable spontaneous breathing** or if there are other contributing factors like **airway swelling** that need to be addressed first. - Rushing to sedate and intubate could lead to complications if the patient's physiology is not fully understood post-extubation. *Make him sit and do physiotherapy* - This option is inappropriate for an intubated patient who has just accidentally self-extubated, as their airway and breathing status are of immediate concern. - Positioning for physiotherapy or performing chest physiotherapy is a secondary concern after ensuring **adequate oxygenation and ventilation** and confirming a stable airway. *Give bag and mask ventilation and intubate* - While bag-mask ventilation is an appropriate immediate step to maintain oxygenation, automatically proceeding to intubation without fully **assessing the patient's spontaneous breathing status** and overall stability is premature. - Some patients might tolerate extubation and breathe adequately on their own, negating the need for immediate reintubation.
Question 10: A 40-year-old woman presents with double vision, difficulty swallowing, and drooping eyelids that worsen as the day progresses. Which class of medications is the most appropriate initial treatment?
- A. Calcium channel blockers
- B. Acetylcholinesterase inhibitors (Correct Answer)
- C. Dopamine agonists
- D. Beta blockers
Explanation: The patient's symptoms (double vision, difficulty swallowing, drooping eyelids, worsening with activity) are classic for **myasthenia gravis** [1, 2], a disorder affecting the **neuromuscular junction**. **Acetylcholinesterase inhibitors** (e.g., pyridostigmine) increase the amount of **acetylcholine** in the synaptic cleft, improving muscle strength and function [1]. *Calcium channel blockers* - These medications affect **calcium influx** into cells and are primarily used for cardiovascular conditions or certain neurological disorders like migraine. - They do not directly address the underlying pathophysiology of **myasthenia gravis**. *Dopamine agonists* - **Dopamine agonists** are used to treat conditions like **Parkinson's disease**, which involves a deficiency of dopamine in the brain. - They have no role in treating the autoantibody-mediated neuromuscular blockade seen in **myasthenia gravis**. *Beta blockers* - **Beta blockers** primarily act on **adrenergic receptors** and are used for conditions like hypertension, angina, and anxiety. - They do not target the acetylcholine receptor dysfunction characteristic of **myasthenia gravis** and can potentially worsen muscle weakness in some patients.
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