Ocular Manifestations of Systemic Disorders Practice Questions

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

All the above. **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.

Q: What is the commonest ocular sign of hypothyroidism?

Cataract. **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.

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

Thyroid Ophthalmopathy. **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.

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

Vogt Koyanagi Harada syndrome. **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).

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

More common in females. **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.

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

Viral keratitis. **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.

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

Orbital mucormycosis. **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.

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

All of the above. **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.

Q: Keratoconus is seen in which of the following conditions?

Down syndrome. **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.

Question 1

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

Accepted Answer

All the above

Answer

Heterochromia of iris

Answer

Keratic precipitates

Answer

Posterior subcapsular cataract

Question 2

What is the commonest ocular sign of hypothyroidism?

Accepted Answer

Cataract

Answer

Glaucoma

Answer

Band-shaped keratopathy

Answer

Uveitis

Question 3

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

Accepted Answer

Thyroid Ophthalmopathy

Answer

Myasthenia Gravis

Answer

Marfan Syndrome

Answer

Pancoast Tumor

Question 4

Which of the following causes uveitis with vitiligo and deafness?

Accepted Answer

Vogt Koyanagi Harada syndrome

Answer

Sturge Weber syndrome

Answer

Centurion syndrome

Answer

Alezzandrini syndrome

Question 5

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

Accepted Answer

More common in females

Answer

Recurrent attacks occur

Answer

Fibrous reaction in anterior chambers

Answer

Narrowing of joint spaces and sclerosis of the sacroiliac joints

Question 6

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

Accepted Answer

Viral keratitis

Answer

Conjunctivitis

Answer

Anterior uveitis

Answer

Endophthalmitis

Question 7

CRAO may be seen in which of the following conditions?

Accepted Answer

Orbital mucormycosis

Answer

Diabetes mellitus

Answer

CMV retinitis

Answer

Panophthalmitis

Question 8

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

Accepted Answer

All of the above

Answer

Kaposi sarcoma

Answer

Retinitis

Answer

Lymphoma

Question 9

What is an important feature of sympathetic ophthalmitis?

Accepted Answer

Keratic precipitates at the back of the cornea

Answer

Visual field defects

Answer

Fundus changes

Answer

Development of lenticular opacities

Question 10

Keratoconus is seen in which of the following conditions?

Accepted Answer

Down syndrome

Answer

Patau syndrome

Answer

Turner syndrome

Answer

Weber syndrome

Ocular Manifestations of Systemic Disorders — MCQs

Ocular Manifestations of Systemic Disorders — MCQs

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