Ocular Manifestations of Systemic Disorders — MCQs

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

Question 131: What is the most common ocular feature in Reiter Syndrome?

A. Anterior Uveitis
B. Pars planitis
C. Conjunctivitis (Correct Answer)
D. Chorioretinitis

Explanation: **Explanation:** **Reiter Syndrome** (now more commonly referred to as **Reactive Arthritis**) is a classic seronegative spondyloarthropathy characterized by the clinical triad: **"Can't see, can't pee, can't climb a tree"** (Conjunctivitis, Urethritis, and Arthritis). 1. **Why Conjunctivitis is correct:** **Conjunctivitis** is the **most common** ocular manifestation of Reiter Syndrome, occurring in approximately 30–60% of patients. It is typically bilateral, mucopurulent, and often occurs shortly after the onset of urethritis. It is usually self-limiting and does not require aggressive steroid therapy. 2. **Analysis of Incorrect Options:** * **Anterior Uveitis (A):** This is the **second most common** ocular feature (seen in about 10–20% of cases). While it is more clinically significant and potentially sight-threatening due to its association with HLA-B27, it occurs less frequently than conjunctivitis. * **Pars planitis (B):** This is a form of intermediate uveitis. While systemic inflammatory conditions can cause various forms of uveitis, pars planitis is not a characteristic or common feature of Reiter Syndrome. * **Chorioretinitis (D):** This involves the posterior segment (choroid and retina). Reiter Syndrome primarily affects the anterior segment; posterior segment involvement is extremely rare. **High-Yield Clinical Pearls for NEET-PG:** * **HLA Association:** Strongly associated with **HLA-B27** (up to 80% of cases). * **Triggering Infections:** Often follows urogenital (Chlamydia) or gastrointestinal (Shigella, Salmonella, Campylobacter) infections. * **Keratoderma Blennorrhagica:** A pathognomonic skin lesion (vesicular/pustular) found on the palms and soles. * **Circinate Balanitis:** Painless dermatitis of the glans penis. * **Management:** Conjunctivitis is usually managed with lubricants; Uveitis requires topical steroids and cycloplegics.

Question 132: A cherry red spot is seen in the fundus in which of the following conditions?

A. Central retinal vein occlusion
B. Diabetic retinopathy
C. Retinal artery occlusion (Correct Answer)
D. Retinitis pigmentosa

Explanation: **Explanation:** The **Cherry Red Spot** is a classic ophthalmological finding characterized by a bright red fovea surrounded by a pale, edematous retina. **Why Retinal Artery Occlusion (C) is correct:** In Central Retinal Artery Occlusion (CRAO), the blood supply to the inner layers of the retina is blocked, leading to intracellular edema and a "milky white" appearance of the retina. However, the **foveola** is the thinnest part of the retina and derives its blood supply from the underlying **choriocapillaris** (not the retinal artery). Therefore, the foveola remains transparent, allowing the vascularity of the choroid to shine through, creating the appearance of a "cherry red spot" against the surrounding pale, ischemic retina. **Why the other options are incorrect:** * **A. Central Retinal Vein Occlusion (CRVO):** Characterized by a "Blood and Thunder" fundus with extensive flame-shaped hemorrhages, dilated tortuous veins, and disc edema. * **B. Diabetic Retinopathy:** Features microaneurysms, hard exudates, cotton wool spots, and hemorrhages (dot-blot), but not a cherry red spot. * **D. Retinitis Pigmentosa:** A degenerative condition characterized by the triad of bony spicule pigmentation, arteriolar attenuation, and waxy pallor of the optic disc. **NEET-PG High-Yield Pearls:** * **Differential Diagnosis of Cherry Red Spot:** Remember the mnemonic **"Sandwich"** or **"Cherry Trees Never Grow Tall In Mud"**: **S**ialidosis, **T**ay-Sachs, **N**iemann-Pick, **G**aucher (Type 2), **T**rauma (Berlin’s Edema), **I**schemia (CRAO), **M**etachromatic Leukodystrophy. * **CRAO Management:** It is an ocular emergency. Immediate measures include digital ocular massage, anterior chamber paracentesis, and inhaled carbogen to lower IOP and dislodge the embolus. * **Cilioretinal Artery:** In 15-20% of people, this artery (from ciliary circulation) spares a portion of the macula in CRAO, preserving central vision.

Question 133: Angioid streaks are seen in which of the following conditions?

A. Tendinous xanthoma
B. Pseudoxanthoma elasticum (Correct Answer)
C. Xanthelasma
D. Eruptive xanthoma

Explanation: **Explanation:** **Angioid streaks** are irregular, jagged, radiating lines deep to the retina that resemble blood vessels. They represent **crack-like dehiscences in a thickened, calcified Bruch’s membrane**. **1. Why Pseudoxanthoma Elasticum (PXE) is correct:** PXE (Grönblad-Strandberg syndrome) is the most common systemic association of angioid streaks. It is a genetic disorder characterized by progressive calcification and fragmentation of elastic fibers in the skin, eyes, and cardiovascular system. The calcification makes Bruch’s membrane brittle, leading to the characteristic "streaks." A classic clinical sign in these patients is "plucked chicken skin" appearance on the neck or axilla. **2. Why the other options are incorrect:** * **Options A, C, and D (Xanthomas/Xanthelasma):** These are localized accumulations of lipid-laden macrophages (foam cells) usually associated with hyperlipidemia. While they are important dermatological markers of systemic lipid metabolism disorders, they do not involve the calcification of Bruch’s membrane and are not associated with angioid streaks. **3. High-Yield Clinical Pearls for NEET-PG:** To remember the causes of Angioid Streaks, use the mnemonic **PEPSI**: * **P:** **P**seudoxanthoma elasticum (Most common) * **E:** **E**hlers-Danlos syndrome * **P:** **P**aget’s disease of bone * **S:** **S**ickle cell anemia (and other hemoglobinopathies like Thalassemia) * **I:** **I**diopathic **Key Complication:** The most vision-threatening complication of angioid streaks is **Choroidal Neovascularization (CNV)**, which can lead to subretinal hemorrhage and macular scarring. Patients should be monitored with Amsler grids.

Question 134: Dalen Fuch's nodules are found in which condition?

A. Superficial keratitis
B. Sympathetic ophthalmitis (Correct Answer)
C. Vernal catarrh
D. Trachoma

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"), subsequently affecting the fellow eye (the "sympathizing eye"). **Why Option B is correct:** **Dalen-Fuchs nodules** are the hallmark histopathological feature of Sympathetic Ophthalmitis. They are small, yellowish-white elevated lesions located between the **Bruch’s membrane and the Retinal Pigment Epithelium (RPE)**. Microscopically, these nodules consist of epithelioid cells, lymphocytes, and pigment-laden macrophages. Their presence indicates a granulomatous reaction characteristic of this condition. **Why other options are incorrect:** * **A. Superficial Keratitis:** This involves inflammation of the corneal epithelium (e.g., Thygeson’s) and does not present with deep intraocular granulomatous nodules. * **C. Vernal Catarrh (VKC):** This is an allergic conjunctivitis characterized by **Horner-Trantas dots** (limbal eosinophil collections) and **cobblestone papillae**, not Dalen-Fuchs nodules. * **D. Trachoma:** This chronic keratoconjunctivitis is characterized by **Herbert’s pits** (scarred limbal follicles) and **Arlt’s line** (conjunctival scarring). **High-Yield Clinical Pearls for NEET-PG:** * **Histopathology of SO:** Characterized by non-necrotizing granulomatous inflammation with "sparing of the choriocapillaris." * **Other conditions with Dalen-Fuchs nodules:** While classic for SO, they can also be seen in **Vogt-Koyanagi-Harada (VKH) syndrome** and **Sarcoidosis**. * **Prevention:** Evisceration or enucleation of the injured eye within 10–14 days of injury can prevent the development of SO in the sympathizing eye.

Question 135: Which ocular symptom is NOT seen in Herpes zoster ophthalmicus?

A. Nummular keratitis
B. Glaucoma
C. Uveitis
D. Cranial nerve palsies (Correct Answer)

Explanation: **Explanation:** **Herpes Zoster Ophthalmicus (HZO)** is caused by the reactivation of the Varicella-Zoster Virus (VZV) in the trigeminal ganglion, specifically involving the ophthalmic division ($V_1$). **Why "Cranial nerve palsies" is the correct answer:** While HZO primarily affects the sensory distribution of the trigeminal nerve, cranial nerve palsies (III, IV, and VI) are considered **extraocular complications** rather than "ocular symptoms" or direct manifestations of the ophthalmic infection itself. In the context of standard NEET-PG questions, the ocular involvement focuses on the globe and its immediate structures. While motor palsies can occur due to contiguous inflammation (orbital apex syndrome), they are neurological complications rather than primary ocular symptoms. **Analysis of Incorrect Options:** * **Nummular Keratitis:** This is a classic late manifestation of HZO characterized by multiple granular, "coin-shaped" subepithelial opacities. * **Glaucoma:** Secondary glaucoma is common in HZO, usually resulting from trabeculitis (inflammation of the drainage angle) or as a complication of chronic uveitis. * **Uveitis:** HZO frequently causes a severe, hypertensive anterior uveitis often associated with sectorial iris atrophy due to vasculitis. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Sign:** Vesicles on the tip or side of the nose (involvement of the nasociliary nerve) strongly predict ocular involvement. * **Pseudodendrites:** Unlike the true dendrites of Herpes Simplex (which have terminal bulbs and central ulceration), HZO produces "pseudodendrites" which are elevated, lack central ulceration, and do not stain well with fluorescein. * **Treatment:** Oral Acyclovir (800 mg 5 times daily for 7–10 days) is the gold standard; it must be started within 72 hours of rash onset to be most effective.

Question 136: Which of the following is not part of Hutchinson's triad?

A. Interstitial keratitis
B. Chemical burns (Correct Answer)
C. Deafness
D. Hutchinson teeth

Explanation: **Explanation:** **Hutchinson's Triad** is a classic clinical diagnostic triad used to identify **Late Congenital Syphilis**. It was named after Sir Jonathan Hutchinson, who described these findings as pathognomonic for the condition. **Why "Chemical Burns" is the correct answer:** Chemical burns are acute ocular emergencies caused by external agents (acids or alkalis) and have no pathophysiological association with congenital syphilis. Therefore, they are not part of the triad. **Analysis of the Triad components (Incorrect Options):** 1. **Interstitial Keratitis (Option A):** This is the ocular component. It typically presents in late childhood or adolescence with bilateral corneal inflammation, leading to scarring and "ground-glass" appearance of the cornea. 2. **Sensorineural Deafness (Option C):** This is the vestibulocochlear component. It results from involvement of the 8th cranial nerve (labyrinthitis), often leading to sudden or progressive hearing loss around puberty. 3. **Hutchinson Teeth (Option D):** This is the dental component. It refers to permanent upper central incisors that are peg-shaped, widely spaced, and notched at the biting edge. **High-Yield Clinical Pearls for NEET-PG:** * **Late Congenital Syphilis:** Defined as manifestations appearing after 2 years of age. * **Other Dental Signs:** "Mulberry molars" (first molars with multiple poorly developed cusps). * **Skeletal Signs:** Saber shins (anterior bowing of the tibia) and Clutton’s joints (painless symmetrical hydrarthrosis of the knees). * **Ocular Signs:** Apart from interstitial keratitis, look for "salt and pepper" fundus (chorioretinitis). * **Treatment:** Penicillin G remains the drug of choice for all stages of syphilis.

Question 137: Circumcorneal congestion is not seen in which of the following conditions?

A. Acute bacterial conjunctivitis (Correct Answer)
B. Acute iritis
C. Acute glaucoma
D. Scleritis

Explanation: **Explanation:** The key to answering this question lies in distinguishing between **superficial (conjunctival)** and **deep (ciliary/circumcorneal)** congestion. **1. Why Acute Bacterial Conjunctivitis is the correct answer:** In acute bacterial conjunctivitis, the inflammation is limited to the conjunctiva. The congestion is **superficial**, meaning the redness is most intense in the fornices and periphery, fading toward the limbus. The vessels are bright red, move with the conjunctiva, and blanch with 0.1% adrenaline. **Circumcorneal congestion (ciliary flush)**, however, involves the deep episcleral vessels surrounding the limbus and is a hallmark of intraocular or deep-seated inflammation. **2. Why the other options are incorrect:** * **Acute Iritis:** Inflammation of the iris involves the ciliary body. The ciliary vessels (branches of anterior ciliary arteries) become engorged, leading to a characteristic dusky-red circumcorneal flush. * **Acute Glaucoma:** A sudden rise in intraocular pressure causes significant ocular ischemia and inflammation, leading to intense ciliary congestion. * **Scleritis:** This is a deep-seated inflammation of the sclera. Because the deep episcleral plexus is involved, circumcorneal congestion is a prominent feature. **Clinical Pearls for NEET-PG:** * **Ciliary Flush:** Characterized by a violaceous/purplish hue, vessels do not move with the conjunctiva and do **not** blanch with adrenaline. * **The "Big Three" of Red Eye:** Always differentiate Acute Conjunctivitis (superficial) from Acute Iridocyclitis and Acute Angle Closure Glaucoma (deep/circumcorneal). * **Discharge:** Presence of mucopurulent discharge strongly points toward conjunctivitis, whereas its absence suggests deeper pathology.

Question 138: When a patient is asked to look down, the upper eyelid fails to follow the rotation of the eyeball and lags behind. This eye sign is known as:

A. Von Graefe's sign (Correct Answer)
B. Joffroy's sign
C. Moebius sign
D. Stellwag's sign

Explanation: **Explanation:** The clinical sign described is **Von Graefe’s sign**, which is the most specific physical finding in **Thyroid Eye Disease (TED)** or Graves' Ophthalmopathy. It occurs due to the overactivation of the sympathetic nervous system and the contraction of the levator palpebrae superioris (LPS) and Müller’s muscle. When the patient looks down, the upper eyelid remains abnormally high, exposing the superior sclera. **Analysis of Options:** * **Von Graefe’s sign (Correct):** Defined as **lid lag** on downgaze. It is caused by the failure of the LPS muscle to relax as the eye moves inferiorly. * **Joffroy’s sign:** Refers to the **absence of forehead wrinkling** when the patient looks upward. This occurs because the frontalis muscle is unable to compensate for the restricted upward gaze. * **Moebius sign:** Refers to the **inability to maintain convergence** of the eyeballs, leading to diplopia during near-work. * **Stellwag’s sign:** Characterized by **infrequent or incomplete blinking**, which contributes to the "staring look" often seen in thyrotoxicosis. **High-Yield Clinical Pearls for NEET-PG:** * **Dalrymple sign:** Widening of the palpebral fissure (staring look) in the primary position. * **Enroth sign:** Edema of the eyelids (especially the upper lid). * **Pathogenesis:** TED is primarily caused by the activation of orbital fibroblasts by TSH-receptor antibodies, leading to glycosaminoglycan (GAG) deposition and extraocular muscle enlargement. * **Sequence of Muscle Involvement (IMSLO):** Inferior Rectus > Medial Rectus > Superior Rectus > Lateral Rectus > Obliques.

Question 139: Snow banking is not a feature of which of the following conditions?

A. Candidiasis
B. Multiple sclerosis
C. Chronic congestive glaucoma (Correct Answer)
D. Sarcoidosis

Explanation: **Explanation:** **Snow banking** refers to the accumulation of white, exudative inflammatory material (organized vitreous and inflammatory cells) over the **pars plana** and the inferior ora serrata. It is the hallmark clinical feature of **Intermediate Uveitis (Pars Planitis)**. **Why Chronic Congestive Glaucoma is the correct answer:** Chronic congestive glaucoma (a form of Angle Closure Glaucoma) is a mechanical and vascular disorder characterized by increased intraocular pressure, optic nerve damage, and visual field defects. It is **not an inflammatory condition** of the uveal tract and, therefore, does not present with vitreous exudates or snow banking. **Analysis of Incorrect Options:** * **Multiple Sclerosis (MS):** There is a strong systemic association between MS and intermediate uveitis. Approximately 10–15% of patients with intermediate uveitis may develop MS, making snow banking a potential finding. * **Sarcoidosis:** This multisystem granulomatous disease is a common cause of "granulomatous uveitis." It can involve any part of the uveal tract, including the pars plana, leading to snow banking and "string of pearls" vitreous opacities. * **Candidiasis:** Fungal endophthalmitis (often caused by *Candida albicans*) presents with fluffy white "cotton ball" or "snowball" opacities in the vitreous. While distinct from idiopathic pars planitis, these inflammatory aggregates are often grouped under the clinical umbrella of snow banking/snowballing in systemic infection contexts. **NEET-PG High-Yield Pearls:** * **Snow banking:** Found on the pars plana (requires indirect ophthalmoscopy with scleral depression). * **Snowball opacities:** Floating inflammatory aggregates in the vitreous humor. * **Most common cause of Intermediate Uveitis:** Idiopathic (Pars Planitis). * **Most common systemic association:** Multiple Sclerosis and Sarcoidosis. * **Treatment of choice:** Topical or periocular steroids; if recalcitrant, consider cryotherapy or vitrectomy.

Question 140: Which of the following indicates activity of anterior uveitis?

A. Cells in anterior chamber (Correct Answer)
B. Circumcorneal congestion
C. Keratic precipitate
D. Corneal edema

Explanation: **Explanation:** In Ophthalmology, distinguishing between **activity** (active inflammation) and **sequelae** (signs of past inflammation) is crucial for management. **Why "Cells in anterior chamber" is correct:** The presence of **aqueous cells** is the most reliable and sensitive indicator of **active** anterior uveitis. These are inflammatory cells (leukocytes) floating in the aqueous humor due to the breakdown of the blood-aqueous barrier. According to the **SUN (Standardization of Uveitis Nomenclature) criteria**, the grading of uveitis activity is primarily based on the number of cells seen in a 1x1 mm slit-lamp beam. **Analysis of Incorrect Options:** * **Circumcorneal congestion (Ciliary flush):** While a sign of acute inflammation, it is non-specific and can be seen in acute glaucoma or keratitis. It indicates the *presence* of a problem but is not the standardized measure of *activity* or severity of the uveitis itself. * **Keratic precipitates (KPs):** These are inflammatory deposits on the corneal endothelium. While they indicate uveitis has occurred, "old" KPs (shrunken, pigmented, or "mutton-fat" appearing) can persist long after the active inflammation has subsided. * **Corneal edema:** This is a complication resulting from endothelial dysfunction or secondary glaucoma (high IOP) associated with uveitis, rather than a direct measure of the inflammatory activity. **High-Yield Clinical Pearls for NEET-PG:** * **Aqueous Flare:** Indicates protein leakage due to blood-aqueous barrier breakdown; it signifies chronicity rather than acute activity. * **Mutton-fat KPs:** Characteristic of **Granulomatous uveitis** (e.g., Sarcoidosis, TB). * **Hypopyon:** A sterile collection of inflammatory cells settling inferiorly in the AC; commonly seen in **HLA-B27** associated uveitis and **Behçet’s disease**. * **Gold Standard for Activity:** Slit-lamp biomicroscopy to count cells.

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Diabetes Mellitus

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Hypertension

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Autoimmune Disorders

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Thyroid Disease

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HIV and AIDS

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Hematological Disorders

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Neurological Disorders

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Dermatological Conditions

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Metabolic Disorders

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Ocular Toxicity of Systemic Medications

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Infectious Systemic Diseases

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