Ocular Manifestations of Systemic Disorders — MCQs

Ocular Manifestations of Systemic Disorders Indian Medical PG Practice Questions and MCQs

Question 121: Which of the following is a feature of Fuch's heterochromic iridocyclitis?

A. Heterochromia of iris
B. Keratic precipitates
C. Posterior subcapsular cataract
D. All the above (Correct Answer)

Explanation: **Explanation:** **Fuchs’ Heterochromic Iridocyclitis (FHI)**, also known as Fuchs’ Uveitis Syndrome, is a chronic, typically unilateral, non-granulomatous low-grade uveitis. It is a high-yield topic for NEET-PG due to its unique clinical presentation and lack of typical inflammatory signs. **Why "All the above" is correct:** * **Heterochromia of Iris (Option A):** This is the hallmark feature. Due to iris stromal atrophy, the affected eye usually becomes lighter (hypochromic). In patients with light-colored irides, the eye may paradoxically appear darker due to the visibility of the posterior pigment epithelium. * **Keratic Precipitates (Option B):** FHI is characterized by **small, round, or stellate (star-shaped) white KPs** that are distributed diffusely over the entire corneal endothelium (unlike the typical Arlt’s triangle seen in other uveitis). * **Posterior Subcapsular Cataract (Option C):** This is the most common complication of FHI, occurring in nearly 75-85% of cases. Glaucoma is the second most common complication. **Clinical Pearls for NEET-PG:** 1. **The "Silent" Uveitis:** FHI is typically asymptomatic. There is **no redness, no pain, and no photophobia** (ciliary congestion is absent). 2. **Amsler’s Sign:** This is a diagnostic feature where filiform hemorrhage occurs at the chamber angle following paracentesis or minor trauma during surgery. 3. **Treatment Paradox:** Unlike other forms of uveitis, FHI **does not respond to topical steroids**, and they should generally be avoided as they accelerate cataract and glaucoma formation. 4. **No Posterior Synechiae:** Despite chronic inflammation, the formation of posterior synechiae is characteristically absent in FHI.

Question 122: What is the commonest ocular sign of hypothyroidism?

A. Cataract (Correct Answer)
B. Glaucoma
C. Band-shaped keratopathy
D. Uveitis

Explanation: **Explanation:** The correct answer is **A. Cataract**. **Why Cataract is the Correct Answer:** In hypothyroidism, the metabolic rate of the lens is significantly reduced. This leads to a decrease in the activity of enzymes responsible for maintaining lens transparency and osmotic balance. The most characteristic ocular finding is the development of **punctate subcapsular opacities**, which can eventually progress to a mature cataract. While Graves' ophthalmopathy (hyperthyroidism) is more frequently discussed in exams, hypothyroidism is clinically associated with early-onset lenticular changes due to altered protein metabolism. **Analysis of Incorrect Options:** * **B. Glaucoma:** While some studies suggest a weak association between hypothyroidism and increased intraocular pressure (due to glycosaminoglycan deposition in the trabecular meshwork), it is not as common or characteristic as cataract. * **C. Band-shaped keratopathy:** This is typically associated with **hypercalcemia** (often due to hyperparathyroidism), chronic uveitis, or silicone oil in the vitreous, rather than thyroid dysfunction. * **D. Uveitis:** This is an inflammatory condition usually linked to HLA-B27 associated systemic diseases (like Ankylosing Spondylitis) or infections, not primary thyroid hormone deficiency. **High-Yield Clinical Pearls for NEET-PG:** * **Commonest Ocular Sign of Hypothyroidism:** Cataract (Punctate opacities). * **Other Hypothyroid Signs:** Loss of the outer one-third of eyebrows (**Madarosis/Queen Anne’s sign**), non-pitting edema of the eyelids, and dry eye syndrome. * **Hyperthyroidism (Graves'):** The most common sign is **Lid Retraction** (Dalrymple’s sign); the most common cause of both unilateral and bilateral proptosis in adults. * **Stellwag’s Sign:** Infrequent blinking seen in thyrotoxicosis.

Question 123: Unilateral ptosis is NOT seen in which of the following conditions?

A. Myasthenia Gravis
B. Thyroid Ophthalmopathy (Correct Answer)
C. Marfan Syndrome
D. Pancoast Tumor

Explanation: **Explanation:** The correct answer is **Thyroid Ophthalmopathy (TED)** because it typically presents with **lid retraction** (Dalrymple sign) rather than ptosis. In TED, sympathetic overactivity of Müller’s muscle and fibrotic changes in the levator palpebrae superioris (LPS) lead to an abnormally high position of the upper eyelid, making it the "opposite" of ptosis. **Analysis of Options:** * **Myasthenia Gravis:** Characteristically presents with fluctuating, asymmetric ptosis that worsens with fatigue (Cogan’s twitch sign). While it can be bilateral, it often starts or remains significantly **unilateral**. * **Marfan Syndrome:** While primarily known for ectopia lentis, it is associated with structural connective tissue weaknesses that can result in **simple myogenic ptosis**, which can be unilateral. * **Pancoast Tumor:** This apical lung tumor can compress the cervical sympathetic chain, leading to **ipsilateral Horner’s Syndrome**. A classic feature of Horner’s is "pseudo-ptosis" or mild ptosis due to paralysis of Müller’s muscle. **High-Yield Clinical Pearls for NEET-PG:** * **Thyroid Eye Disease:** The most common cause of both unilateral and bilateral proptosis in adults. Look for "Lid Lag" (Von Graefe's sign) in exams. * **Horner’s Syndrome Triad:** Ptosis, Miosis, and Anhidrosis. * **Myasthenia Gravis Test:** The **Ice Pack Test** improves ptosis in MG by inhibiting acetylcholinesterase, a common bedside diagnostic pearl. * **Rule of Thumb:** If a question mentions "lid retraction," think Thyroid; if it mentions "ptosis," rule Thyroid out.

Question 124: Which of the following causes uveitis with vitiligo and deafness?

A. Sturge Weber syndrome
B. Centurion syndrome
C. Alezzandrini syndrome
D. Vogt Koyanagi Harada syndrome (Correct Answer)

Explanation: **Explanation:** **Vogt-Koyanagi-Harada (VKH) Syndrome** is a multisystem autoimmune disorder characterized by T-cell mediated destruction of melanocytes. It typically affects individuals with darker skin pigmentation. The syndrome presents in four clinical stages: 1. **Prodromal:** Flu-like symptoms and meningismus. 2. **Uveitic:** Bilateral granulomatous panuveitis with exudative retinal detachments. 3. **Chronic (Convalescent):** Depigmentation of the choroid (Sunset glow fundus) and skin. 4. **Chronic Recurrent:** Smoldering anterior uveitis. The classic triad/tetrad includes **bilateral uveitis**, **cutaneous signs** (vitiligo, poliosis, alopecia), and **neurological/auditory signs** (meningismus, tinnitus, and sensorineural deafness). **Analysis of Incorrect Options:** * **Sturge-Weber Syndrome:** A phakomatosis characterized by a Port-wine stain (Nevus Flammeus), leptomeningeal angiomas, and ocular involvement (glaucoma and tomato-sauce fundus/choroidal hemangioma). It does not cause uveitis or deafness. * **Centurion Syndrome:** A rare condition where the anterior displacement of the medial canthus leads to epiphora (overflow of tears) because the puncta are not in contact with the globe. * **Alezzandrini Syndrome:** A very rare syndrome featuring **unilateral** facial vitiligo, poliosis, and ipsilateral retinal degeneration. While it shares skin findings with VKH, it is typically unilateral and lacks the systemic/auditory features of VKH. **High-Yield Clinical Pearls for NEET-PG:** * **Sunset Glow Fundus:** A hallmark of the convalescent stage of VKH due to choroidal depigmentation. * **Sugiura’s Sign:** Perilimbal vitiligo (depigmentation) seen in VKH. * **Treatment:** High-dose systemic corticosteroids are the mainstay of therapy. * **Dalen-Fuchs Nodules:** Small, yellow-white granulomatous lesions between the RPE and Bruch’s membrane (also seen in Sympathetic Ophthalmitis).

Question 125: All the following are true regarding acute anterior uveitis in ankylosing spondylitis EXCEPT?

A. More common in females (Correct Answer)
B. Recurrent attacks occur
C. Fibrous reaction in anterior chambers
D. Narrowing of joint spaces and sclerosis of the sacroiliac joints

Explanation: **Explanation:** **Ankylosing Spondylitis (AS)** is a chronic inflammatory seronegative spondyloarthropathy strongly associated with the **HLA-B27** antigen. Acute Anterior Uveitis (AAU) is the most common extra-articular manifestation, occurring in approximately 25-40% of patients. **1. Why Option A is the Correct Answer (The False Statement):** Ankylosing spondylitis is significantly **more common in males** (ratio approx. 3:1). Consequently, the associated acute anterior uveitis also shows a strong male predilection. Therefore, the statement "More common in females" is incorrect. **2. Analysis of Other Options:** * **Option B (Recurrent attacks):** AAU in AS is typically **unilateral, acute, and recurrent**. While it affects one eye at a time, it frequently alternates between the two eyes over several years. * **Option C (Fibrous reaction):** The inflammation in AS is often "plastic" or exudative. Intense flare and cells in the anterior chamber can lead to a heavy **fibrinous exudate**, which increases the risk of forming posterior synechiae. * **Option D (Joint changes):** Sacroiliitis is the hallmark of AS. Radiographic findings include **narrowing of joint spaces**, subchondral sclerosis, and eventual bony ankylosis ("Bamboo spine"). **Clinical Pearls for NEET-PG:** * **HLA-B27 Association:** Found in >90% of AS patients. * **Presentation:** Sudden onset of pain, redness, photophobia, and "ciliary flush." * **Management:** Topical corticosteroids and cycloplegics (to prevent synechiae). Systemic NSAIDs or TNF-alpha inhibitors may be needed for the underlying joint disease. * **Mnemonic:** Remember the **"Seronegative"** group (PAIR: Psoriatic arthritis, Ankylosing spondylitis, Inflammatory bowel disease, Reactive arthritis)—all are HLA-B27 positive and cause similar uveitis.

Question 126: A patient develops red eye two days after an episode of malaria. What is the probable cause?

A. Conjunctivitis
B. Anterior uveitis
C. Viral keratitis (Correct Answer)
D. Endophthalmitis

Explanation: **Explanation:** The correct answer is **Viral Keratitis**, specifically **Herpes Simplex Keratitis (HSK)**. **Why Viral Keratitis is the correct answer:** Malaria is characterized by high-grade, intermittent fever (febrile episodes). High fever acts as a potent trigger for the reactivation of the latent **Herpes Simplex Virus (HSV)** residing in the trigeminal ganglion. Once reactivated, the virus travels down the ophthalmic nerve to the cornea, leading to the development of dendritic ulcers. In medical literature, these are often referred to as "fever blisters" or "cold sores" when occurring on the lips, but they manifest as viral keratitis in the eye. **Analysis of Incorrect Options:** * **A. Conjunctivitis:** While common, it is not specifically triggered by the high-fever episodes characteristic of malaria. * **B. Anterior Uveitis:** Though it can be associated with systemic infections, it is not the classic post-malarial ocular presentation. * **D. Endophthalmitis:** This is a severe intraocular inflammation usually following trauma or surgery; it is not a recognized complication of a febrile malarial episode. **NEET-PG High-Yield Pearls:** * **The "Fever" Connection:** Any systemic condition causing high fever (Malaria, Typhoid, Influenza) can trigger **Dendritic Keratitis**. * **Clinical Sign:** The hallmark of HSV keratitis is a **dendritic ulcer** with terminal bulbs, which stains with Rose Bengal (devitalized cells at the margin) and Fluorescein (central ulceration). * **Treatment Contraindication:** Never use topical steroids in active dendritic keratitis, as it can lead to a "geographic ulcer." * **Other Ocular Malarial Signs:** While keratitis is a post-febrile complication, acute malarial retinopathy (hemorrhages, whitening) is a key prognostic indicator in Cerebral Malaria.

Question 127: CRAO may be seen in which of the following conditions?

A. Diabetes mellitus
B. CMV retinitis
C. Panophthalmitis
D. Orbital mucormycosis (Correct Answer)

Explanation: **Explanation:** **Central Retinal Artery Occlusion (CRAO)** occurs when the main blood supply to the retina is obstructed. In the context of **Orbital Mucormycosis**, the mechanism is twofold: direct angioinvasion by the fungal hyphae into the vessel walls (leading to thrombosis) and mechanical compression due to orbital apex syndrome. Mucor has a strong predilection for internal elastic lamina of arteries, causing necrotizing vasculitis and subsequent ischemic infarction of the retina. **Analysis of Options:** * **Orbital Mucormycosis (Correct):** This is a fulminant fungal infection (often in diabetic or immunocompromised patients) that spreads from the sinuses to the orbit. It frequently causes CRAO via direct vascular invasion or compression at the orbital apex. * **Diabetes Mellitus:** While DM is a major risk factor for atherosclerosis and systemic vascular disease (which can lead to CRAO), it typically causes **Diabetic Retinopathy** (microangiopathy) rather than acute CRAO directly. * **CMV Retinitis:** This is a viral opportunistic infection (common in AIDS) that causes a "pizza-pie" appearance due to full-thickness retinal necrosis and hemorrhage, but it does not typically present as a primary CRAO. * **Panophthalmitis:** This is an intense inflammation of all coats of the eye, including the Tenon’s capsule. While it causes global ocular destruction, it is not a classic cause of isolated CRAO. **Clinical Pearls for NEET-PG:** * **Cherry Red Spot:** A classic sign of CRAO (the fovea remains red due to the underlying choroidal supply, while the surrounding retina turns milky white due to edema). * **Orbital Apex Syndrome:** Characterized by involvement of CN II, III, IV, VI, and the ophthalmic branch of V, often seen in Mucormycosis. * **Management:** CRAO is an ocular emergency. Immediate measures include digital ocular massage, anterior chamber paracentesis, and inhalation of Carbogen to induce vasodilation.

Question 128: Which of the following are ocular manifestations seen in patients with AIDS?

A. Kaposi sarcoma
B. Retinitis
C. Lymphoma
D. All of the above (Correct Answer)

Explanation: **Explanation:** Ocular manifestations occur in approximately **70-80% of HIV-infected patients**, primarily due to severe immunosuppression (typically when CD4 counts drop below 200 cells/µL). **Why "All of the above" is correct:** HIV/AIDS affects the eye through opportunistic infections, vascular changes, and neoplasms. * **Kaposi Sarcoma (Option A):** This is the most common vascular neoplasm in AIDS, caused by Human Herpesvirus 8 (HHV-8). It typically presents as a painless, reddish-purple mass on the conjunctiva or eyelids. * **Retinitis (Option B):** CMV (Cytomegalovirus) retinitis is the most common vision-threatening opportunistic infection in AIDS (CD4 < 50). It presents with the classic "Pizza-pie" or "Crumbled cheese and ketchup" appearance on fundoscopy. * **Lymphoma (Option C):** Non-Hodgkin Lymphoma (NHL), particularly B-cell lymphomas, can manifest in the orbit or as intraocular lymphoma in advanced AIDS cases. **Clinical Pearls for NEET-PG:** 1. **HIV Microangiopathy:** The most common overall ocular finding, characterized by **Cotton Wool Spots** (CWS) without hemorrhage. Unlike diabetic retinopathy, these CWS are transient. 2. **CMV Retinitis:** The leading cause of blindness in AIDS patients. Treatment of choice is **Ganciclovir** (Intravitreal/Systemic) or Valganciclovir. 3. **ARN vs. PORN:** Acute Retinal Necrosis (ARN) occurs in immunocompetent/mildly suppressed patients, while **Progressive Outer Retinal Necrosis (PORN)** is a rapidly progressing necrotizing retinitis seen specifically in severe AIDS (caused by Varicella Zoster). 4. **Dry Eye (Keratoconjunctivitis Sicca):** A very common non-infectious manifestation.

Question 129: What is an important feature of sympathetic ophthalmitis?

A. Visual field defects
B. Keratic precipitates at the back of the cornea (Correct Answer)
C. Fundus changes
D. Development of lenticular opacities

Explanation: **Explanation:** **Sympathetic Ophthalmitis (SO)** is a rare, bilateral granulomatous panuveitis that occurs following a penetrating ocular injury or intraocular surgery in one eye (the **exciting eye**), which subsequently leads to inflammation in the fellow, non-injured eye (the **sympathizing eye**). **Why Option B is Correct:** The hallmark of SO is a **granulomatous uveitis**. This is clinically characterized by the presence of **large, "mutton-fat" Keratic Precipitates (KPs)** on the corneal endothelium. These KPs are composed of epithelioid cells and macrophages, reflecting the underlying chronic granulomatous inflammatory process. This is a classic diagnostic sign in the sympathizing eye. **Analysis of Incorrect Options:** * **Option A (Visual field defects):** While severe inflammation or secondary glaucoma can eventually affect the field of vision, it is not a primary or diagnostic feature of SO. * **Option C (Fundus changes):** Although SO involves the posterior segment (e.g., Dalen-Fuchs nodules), "fundus changes" is a vague term. The presence of mutton-fat KPs is a more specific, classic clinical sign of the granulomatous nature of the disease. * **Option D (Lenticular opacities):** Cataracts (lenticular opacities) are a common *complication* of chronic uveitis or long-term steroid therapy, but they are not a primary feature used to identify SO. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Characterized by non-necrotizing granulomatous inflammation. A pathognomonic histological feature is **Dalen-Fuchs nodules** (clusters of epithelioid cells between the RPE and Bruch’s membrane). * **Sparing of Choriocapillaris:** Unlike many other uveitic conditions, the choriocapillaris is typically spared in SO. * **Prevention:** The most effective way to prevent SO in a severely injured eye with no visual potential is **enucleation** within 10–14 days of the injury. * **Incubation Period:** Most cases occur within 2 weeks to 3 months after injury, though it can occur years later.

Question 130: Keratoconus is seen in which of the following conditions?

A. Patau syndrome
B. Down syndrome (Correct Answer)
C. Turner syndrome
D. Weber syndrome

Explanation: **Explanation:** **Keratoconus** is a progressive, non-inflammatory ectatic corneal dystrophy characterized by thinning and cone-like protrusion of the cornea. **1. Why Down Syndrome (Trisomy 21) is correct:** Down syndrome is the most common chromosomal disorder associated with Keratoconus, occurring in approximately 5–15% of patients. The association is attributed to structural collagen abnormalities and a high incidence of chronic eye rubbing due to associated blepharitis and atopy, which mechanically weakens the corneal stroma. **2. Analysis of Incorrect Options:** * **Patau Syndrome (Trisomy 13):** Characterized by severe ocular malformations like microphthalmia, colobomas, and cyclopia, but not typically Keratoconus. * **Turner Syndrome (45, XO):** Associated with ocular findings like ptosis, strabismus, and blue sclera, but Keratoconus is not a classic feature. * **Weber Syndrome:** This is a midbrain stroke syndrome (CN III palsy with contralateral hemiplegia) and does not involve structural corneal pathologies. **3. Clinical Pearls for NEET-PG:** * **Mnemonics for Keratoconus Associations:** Remember **"T-DOME"** * **T:** Turner syndrome (Rarely, but Down is much more common) * **D:** **Down Syndrome** (Highest yield) * **O:** Osteogenesis Imperfecta * **M:** Marfan Syndrome * **E:** Ehlers-Danlos Syndrome / Atopic Dermatitis * **Key Signs:** Munson’s sign (V-shaped lower lid on downgaze), Vogt’s striae (vertical stress lines), and Fleischer’s ring (iron deposition at the base of the cone). * **Management:** RGP (Rigid Gas Permeable) lenses for vision; C3R (Corneal Collagen Cross-linking) to stop progression; Penetrating Keratoplasty for advanced cases.

Practice by Chapter

Diabetes Mellitus

Practice Questions

Hypertension

Practice Questions

Autoimmune Disorders

Practice Questions

Thyroid Disease

Practice Questions

HIV and AIDS

Practice Questions

Hematological Disorders

Practice Questions

Neurological Disorders

Practice Questions

Dermatological Conditions

Practice Questions

Pregnancy-Related Eye Changes

Practice Questions

Metabolic Disorders

Practice Questions

Ocular Toxicity of Systemic Medications

Practice Questions

Infectious Systemic Diseases

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