Ocular Manifestations of Systemic Disorders Practice Questions

Q: Consider the following : 1. Night blindness 2. Corneal xerosis 3. Conjunctival xerosis 4. Keratomalacia What is the correct sequence of the above in the progress of clinical presentation of vitamin A deficiency blindness?

1-3-2-4. ***1-3-2-4*** - This is the **correct sequence** according to WHO classification of xerophthalmia in vitamin A deficiency. - **Night blindness (XN)** is typically the **earliest clinical manifestation**, resulting from impaired rod photoreceptor function due to insufficient rhodopsin synthesis. - This is followed by **conjunctival xerosis (X1A)**, characterized by dryness and thickening of the bulbar conjunctiva, often accompanied by Bitot's spots (X1B) - foamy triangular patches of keratinized epithelium. - As deficiency progresses, **corneal xerosis (X2)** develops, with dryness extending to the corneal surface, creating a hazy, lusterless appearance. - The final and most severe stage is **keratomalacia (X3)**, involving corneal softening, ulceration, and potential perforation leading to irreversible blindness. *2-1-4-3* - This sequence incorrectly places **corneal xerosis** before **night blindness**. - Night blindness is a functional symptom that appears early, while corneal xerosis is a later structural change. - The progression also illogically places keratomalacia before conjunctival xerosis. *1-2-3-4* - This sequence incorrectly suggests **corneal xerosis** precedes **conjunctival xerosis**. - In vitamin A deficiency, xerosis (dryness) affects the **conjunctiva first**, then progresses to involve the **cornea**. - The conjunctiva is more susceptible to early changes than the cornea. *1-3-4-2* - This sequence incorrectly places **keratomalacia** before **corneal xerosis**. - Keratomalacia represents corneal softening and melting, which cannot occur before the cornea becomes xerotic (dry). - Corneal xerosis is a **prerequisite** for the development of keratomalacia.

Q: A patient presented with dryness in the eye with a gritty sensation along with corneal softening. What is the most probable cause?

Vitamin A deficiency. Vitamin A deficiency - **Dry eyes** with a **gritty sensation (xerophthalmia)** and **corneal softening (keratomalacia)** are classic signs of severe vitamin A deficiency [1], [2]. - This condition can lead to blindness if not treated promptly, as vitamin A is crucial for the health of the **cornea** and **retina** [1], [2]. *Follicular conjunctivitis* - Characterized by the presence of **lymphoid follicles** on the conjunctiva, often due to viral infections like **adenovirus** or **chlamydia**. - While it can cause dryness, it does not typically lead to **corneal softening** or the severe vision-threatening complications seen with vitamin A deficiency. *Viral Keratitis* - Involves inflammation of the **cornea** due to a viral infection, commonly by **herpes simplex virus**. - Symptoms include pain, redness, blurred vision, and sensitivity to light, but **generalized dryness** and **corneal softening** as the primary presentation are less characteristic. *Riboflavin Deficiency* - Also known as **ariboflavinosis**, this deficiency can cause ocular symptoms like **photophobia**, **corneal vascularization**, and **conjunctivitis**. - However, it typically does not present with **severe dry eyes** or **corneal softening (keratomalacia)** as seen in vitamin A deficiency.

Q: All of the following are false about eye lid signs in GRAVES DISEASE except?

Stellwag's sign: Incomplete and infrequent blinking. **⚠️ QUESTION ISSUE: All four options are TRUE statements about Graves' disease, making this question technically flawed.** ***Stellwag's sign: Incomplete and infrequent blinking*** ✓ - **Stellwag's sign** is correctly defined as **incomplete and infrequent blinking**, causing a characteristic staring appearance. - This is a **TRUE** sign of **Graves' ophthalmopathy** due to sympathetic overactivity. - **Marked as correct answer**, but all options are actually true. *Mobius sign: convergence insufficiency* ✓ - **Moebius sign** is correctly defined as **convergence insufficiency** (inability to converge eyes for near vision). - This is a **TRUE** sign of **Graves' disease**. - Statement is medically accurate. *Dalrymple sign: lid retraction* ✓ - **Dalrymple's sign** is correctly defined as **lid retraction** (upper eyelid retraction exposing sclera above iris). - This is a **TRUE** and classic sign of **Graves' ophthalmopathy**. - Statement is medically accurate. *Von Graefe's sign: lid lag on downgaze* ✓ - **Von Graefe's sign** is correctly defined as **lid lag on downgaze** (upper eyelid lags behind eyeball during downward gaze). - This is a **TRUE** sign of **Graves' disease**. - Statement is medically accurate. **Educational Note:** This FMGE-2017 question is problematic because all four eyelid sign descriptions are medically accurate. In the actual exam, Stellwag's sign was likely considered the "best" answer, possibly because it's the most specific or commonly tested.

Q: Sarcoidosis is associated with

Anterior uveitis. ***Anterior uveitis*** - **Anterior uveitis**, particularly chronic granulomatous anterior uveitis, is the most common ocular manifestation of **sarcoidosis**. - It results from **non-caseating granulomas** affecting the iris and ciliary body. - Sarcoidosis can also cause intermediate uveitis, posterior uveitis, and panuveitis, but anterior uveitis is most frequently seen. - Characteristic findings include mutton-fat keratic precipitates and iris nodules (Koeppe and Busacca nodules). *Keratitis* - **Keratitis** (inflammation of the cornea) is less commonly associated with sarcoidosis compared to uveitis. - While ocular sarcoidosis can rarely cause interstitial keratitis or band keratopathy, direct corneal inflammation is not a hallmark feature. *Cataract* - **Cataracts** are not directly caused by sarcoidosis itself, but can be a complication of chronic uveitis or prolonged corticosteroid treatment. - The disease process of sarcoidosis does not primarily involve cataract formation. *Ectopia lentis* - **Ectopia lentis** (lens dislocation) is a rare condition usually associated with genetic disorders like **Marfan syndrome** or homocystinuria. - It is not a recognized ocular manifestation of sarcoidosis.

Q: All are manifestation of dengue virus infection in eye except?

Cataract. ***Cataract*** - **Cataracts** are primarily associated with aging, congenital factors, trauma, or long-term steroid use, not directly with acute dengue virus infection. - While dengue can cause various ocular manifestations, the formation of cataracts is a **chronic process** that does not fit the typical acute or subacute presentation of dengue-related eye complications. *Vitreous hemorrhage* - **Vitreous hemorrhage** can occur in dengue due to associated **thrombocytopenia** and coagulation abnormalities, leading to bleeding in the eye. - Severe dengue can induce systemic vasculopathy and bleeding tendencies, which may manifest as intraocular hemorrhage. *Maculopathy* - **Dengue maculopathy** is a recognized complication, often presenting as macular edema, hemorrhage, or foveolitis, leading to visual impairment. - This is thought to be due to direct viral effects, immune-mediated responses, or vasculitis affecting the retinal microvasculature. *Optic neuritis* - **Optic neuritis** following dengue infection has been reported, characterized by inflammation of the optic nerve, causing acute vision loss. - This is considered to be an **immune-mediated post-infectious complication** rather than a direct viral cytopathic effect on the nerve.

Q: Which type of uveitis is most commonly associated with systemic autoimmune diseases such as ankylosing spondylitis and reactive arthritis?

Anterior uveitis. ***Anterior uveitis*** - **Anterior uveitis**, particularly acute anterior uveitis, is the type most frequently associated with **HLA-B27 positive spondyloarthropathies**, such as **ankylosing spondylitis** and **reactive arthritis**. - It often presents with sudden onset of **redness**, **pain**, and **photophobia** in one or both eyes. *Intermediate uveitis* - This type of uveitis primarily affects the **vitreous** and **pars plana**, often presenting with **floaters** and **blurred vision**. - It is typically associated with conditions like **multiple sclerosis** or is idiopathic, rather than spondyloarthropathies. *Posterior uveitis* - **Posterior uveitis** involves the **retina** and **choroid**, leading to symptoms like **decreased vision** and **scotomas**. - It is more commonly linked to infectious causes (e.g., **toxoplasmosis**, **tuberculosis**) or systemic diseases like **sarcoidosis**, not spondyloarthropathies. *Panuveitis* - **Panuveitis** involves inflammation of all parts of the uvea: **iris**, **ciliary body**, and **choroid**. - While it can occur in severe cases, it is not the initial or most common presentation of uveitis associated with spondyloarthropathies; **anterior uveitis** is the characteristic form.

Q: Which of the following ocular findings is not associated with diabetes?

Blepharophimosis. ***Blepharophimosis*** - This is a **congenital disorder** characterized by small palpebral fissures, ptosis, and epicanthus inversus, which is **not associated with diabetes**. - It is a **developmental anomaly** of the eyelids, with no known link to metabolic conditions like diabetes. *Retinopathy* - **Diabetic retinopathy** is a common and serious complication of diabetes, caused by damage to the blood vessels in the retina. - It can lead to vision loss if not managed, and is directly linked to **poor glycemic control**. *Early senile cataract* - Diabetes is a significant risk factor for the **earlier development and progression of cataracts**, including senile cataracts. - High blood sugar levels can cause changes in the lens, leading to **opacification** and impaired vision. *Neovascular glaucoma* - This severe form of **secondary glaucoma** is often a complication of advanced **diabetic retinopathy**. - Ischemia in the retina triggers the growth of **new blood vessels** on the iris and in the angle of the eye, obstructing aqueous outflow and raising intraocular pressure.

Q: What is the most common eye lesion in HIV?

Cotton wool spots. ***Cotton wool spots*** - These are the most common ocular manifestation in HIV-positive individuals, resulting from **ischemic retinal nerve fiber layer damage**. - While not vision-threatening themselves, their presence indicates **microvascular damage** and can be a sign of systemic disease progression. *Kaposi Sarcoma of Lid* - While Kaposi sarcoma can affect the eyelids in HIV patients, it is **not the most common ocular lesion**. - It presents as a **reddish-purple nodule** or plaque and is an indicator of advanced immunosuppression. *CMV Retinitis* - Cytomegalovirus (CMV) retinitis is a significant and **vision-threatening opportunistic infection** in advanced HIV. - However, it occurs in patients with **severe immunosuppression** (low CD4 counts) and is less common overall than cotton wool spots. *Choroiditis* - Choroiditis, an inflammation of the choroid, can occur in HIV patients due to various opportunistic infections or directly from the virus. - It is **less prevalent** than cotton wool spots and typically requires specific etiologies beyond HIV itself.

Q: Which of the following is a specific sign of albinism?

Iris transillumination. ***Iris transillumination*** - This is a highly **specific sign** of albinism, resulting from the severe reduction or absence of pigment in the iris. - When light shines through the pupil, it passes through the unpigmented iris, creating a visible red reflex, indicating the lack of pigment that normally blocks the light. *Sensitivity to light (photophobia)* - While common in albinism due to the lack of pigment in the iris and retina allowing more light to enter the eye, **photophobia is not specific** to albinism. - It can be a symptom of various other ocular conditions like uveitis, corneal abrasions, or migraines. *Involuntary eye movements (nystagmus)* - **Nystagmus is frequently associated with albinism** due to foveal hypoplasia and impaired visual development but is **not specific**. - It can also be caused by neurological disorders, inner ear problems, or other ocular conditions. *Decreased visual acuity* - **Reduced vision is a characteristic feature of albinism** resulting from foveal hypoplasia and abnormal optic nerve pathways, but it is **not specific** to the condition. - Numerous eye conditions, such as refractive errors, cataracts, and retinal diseases, can lead to decreased visual acuity.

Q: What condition is characterized by a salt and pepper fundus appearance in the retina?

Congenital syphilis. ***Congenital syphilis*** - The **"salt and pepper" fundus** appearance is a classic ophthalmologic finding in congenital syphilis, resulting from diffuse pigmentary retinopathy. - This condition is caused by widespread pigmentary changes in the retina, affecting both the retinal pigment epithelium and neurosensory retina. - It represents chronic, bilateral, and symmetric chorioretinitis that is pathognomonic for congenital syphilis. *Congenital toxoplasmosis* - While it can cause chorioretinitis, congenital toxoplasmosis typically presents with **focal, destructive lesions** rather than diffuse "salt and pepper" pigmentary changes. - Classic ocular lesions are often described as a **"headlight in the fog"** or inactive, pigmented chorioretinal scars. *Congenital histoplasmosis* - Ocular histoplasmosis syndrome (OHS) is usually acquired, not congenital, and causes **discrete chorioretinal scars** ("histo spots") often in the macula or peripapillary region. - It does not result in a diffuse **"salt and pepper" fundus** appearance. *Congenital rubella* - Congenital rubella syndrome can cause pigmentary retinopathy, but the pattern is typically **patchy or mottled** rather than the classic "salt and pepper" appearance. - Other ocular findings include cataract, microphthalmos, and glaucoma.

Question 1

Consider the following :

1. Night blindness

2. Corneal xerosis

3. Conjunctival xerosis

4. Keratomalacia
What is the correct sequence of the above in the progress of clinical presentation of vitamin A deficiency blindness?

Accepted Answer

1-3-2-4

Answer

2-1-4-3

Answer

1-2-3-4

Answer

1-3-4-2

Question 2

A patient presented with dryness in the eye with a gritty sensation along with corneal softening. What is the most probable cause?

Accepted Answer

Vitamin A deficiency

Answer

Follicular conjunctivitis

Answer

Viral Keratitis

Answer

Riboflavin Deficiency

Question 3

All of the following are false about eye lid signs in GRAVES DISEASE except?

Accepted Answer

Stellwag's sign: Incomplete and infrequent blinking

Answer

Mobius sign: convergence insufficiency

Answer

Dalrymple sign: lid retraction

Answer

Von Graefe's sign: lid lag on downgaze

Question 4

Sarcoidosis is associated with

Accepted Answer

Anterior uveitis

Answer

Keratitis

Answer

Cataract

Answer

Ectopia lentis

Question 5

All are manifestation of dengue virus infection in eye except?

Accepted Answer

Cataract

Answer

Vitreous hemorrhage

Answer

Maculopathy

Answer

Optic neuritis

Question 6

Which type of uveitis is most commonly associated with systemic autoimmune diseases such as ankylosing spondylitis and reactive arthritis?

Accepted Answer

Anterior uveitis

Answer

Intermediate uveitis

Answer

Posterior uveitis

Answer

Panuveitis

Question 7

Which of the following ocular findings is not associated with diabetes?

Accepted Answer

Blepharophimosis

Answer

Retinopathy

Answer

Early senile cataract

Answer

Neovascular glaucoma

Question 8

What is the most common eye lesion in HIV?

Accepted Answer

Cotton wool spots

Answer

Kaposi Sarcoma of Lid

Answer

CMV Retinitis

Answer

Choroiditis

Question 9

Which of the following is a specific sign of albinism?

Accepted Answer

Iris transillumination

Answer

Sensitivity to light (photophobia)

Answer

Involuntary eye movements (nystagmus)

Answer

Decreased visual acuity

Question 10

What condition is characterized by a salt and pepper fundus appearance in the retina?

Accepted Answer

Congenital syphilis

Answer

Congenital rubella

Answer

Congenital toxoplasmosis

Answer

Congenital histoplasmosis

Ocular Manifestations of Systemic Disorders — MCQs

Ocular Manifestations of Systemic Disorders — MCQs

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