Ocular Manifestations of Systemic Disorders — MCQs

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

Question 11: Behcet's disease is characterised by all of the following except:

A. Unilateral granulomatous uveitis (Correct Answer)
B. Recurrent hypopyon
C. Aphthous ulceration
D. Genital ulcerations

Explanation: **Explanation:** Behcet’s disease is a chronic, multisystemic, idiopathic inflammatory disorder characterized by a **relapsing systemic vasculitis**. **Why Option A is the Correct Answer:** Behcet’s disease typically presents as **bilateral** (though often asymmetrical) **non-granulomatous** uveitis. The inflammation is characterized by fine Keratic Precipitates (KPs) rather than the large "mutton-fat" KPs seen in granulomatous conditions like Sarcoidosis or TB. Therefore, "Unilateral granulomatous uveitis" is the incorrect statement regarding Behcet’s. **Analysis of Incorrect Options:** * **B. Recurrent hypopyon:** This is a hallmark of Behcet’s. It is classically described as a **"sterile" and "shifting" hypopyon**, meaning the pus moves easily with the patient's head position due to its low fibrin content. * **C & D. Aphthous and Genital ulcerations:** These are part of the classic clinical triad (along with uveitis). Oral aphthous ulcers are usually the first presenting sign and are mandatory for diagnosis under the International Study Group criteria. **High-Yield Clinical Pearls for NEET-PG:** * **HLA Association:** Strongly linked with **HLA-B51**. * **Pathergy Test:** A unique diagnostic feature where a sterile pustule forms 24–48 hours after a skin prick with a needle. * **Ocular Complication:** The most common cause of vision loss in these patients is **obliterative retinal vasculitis** (involving both arteries and veins). * **Gender:** More common and severe in young males (Middle Eastern/Silk Road ancestry).

Question 12: Granulomatous uveitis is seen in all of the following conditions except?

A. Uveitis associated with ankylosing spondylitis (Correct Answer)
B. Sympathetic ophthalmitis
C. Tubercular uveitis
D. Uveitis associated with sarcoidosis

Explanation: **Explanation:** Uveitis is pathologically classified into two types: **Granulomatous** and **Nongranulomatous**. The differentiation is crucial for diagnosing systemic associations. **1. Why Ankylosing Spondylitis (AS) is the correct answer:** Uveitis associated with **Ankylosing Spondylitis** is the classic prototype of **Nongranulomatous uveitis**. It typically presents as an acute, unilateral, recurrent anterior uveitis. It is strongly associated with the **HLA-B27** marker. Pathologically, it lacks the organized collection of macrophages (granulomas) and presents with fine, small keratic precipitates (KPs) on the corneal endothelium. **2. Why the other options are incorrect (Granulomatous causes):** * **Sympathetic Ophthalmitis:** A bilateral granulomatous panuveitis following penetrating ocular trauma. It is characterized by **Dalen-Fuchs nodules** (granulomas between the RPE and Bruch’s membrane). * **Tubercular Uveitis:** Tuberculosis is a chronic infectious granulomatous disease. Ocular involvement typically shows "mutton-fat" KPs and iris nodules (Koeppe and Busacca nodules). * **Sarcoidosis:** A multisystem idiopathic disease characterized by non-caseating granulomas. It frequently causes granulomatous uveitis with a "string of pearls" appearance in the vitreous. **Clinical Pearls for NEET-PG:** * **Mutton-fat KPs:** Large, greasy-looking clusters of epithelioid cells and macrophages; a hallmark of **Granulomatous uveitis**. * **HLA-B27 Triad:** Ankylosing spondylitis, Reiter’s syndrome (Reactive arthritis), and Psoriatic arthritis all cause **Nongranulomatous** uveitis. * **Vogt-Koyanagi-Harada (VKH) syndrome:** Another high-yield cause of bilateral granulomatous panuveitis associated with poliosis and vitiligo.

Question 13: Histological changes in lens-induced uveitis include:

A. Ghost cells
B. Giant cell reaction (Correct Answer)
C. Amyloid in the cornea
D. Vasculitis

Explanation: **Explanation:** **Lens-induced uveitis** (specifically **Phacoantigenic Uveitis**) is a granulomatous inflammatory response that occurs when lens proteins leak through a ruptured or compromised lens capsule (e.g., after trauma or cataract surgery). 1. **Why Option B is Correct:** The underlying mechanism is a **Type IV hypersensitivity reaction** (delayed-type) to lens proteins, which the body perceives as "foreign" because they are normally sequestered from the immune system. Histologically, this manifests as a **zonal granulomatous inflammation** surrounding the lens material. This zone characteristically contains polymorphonuclear leukocytes, epithelioid cells, and **multinucleated giant cells**. The presence of these giant cells is the hallmark histological feature. 2. **Why Other Options are Incorrect:** * **A. Ghost cells:** These are empty, degenerated red blood cells seen in **Ghost Cell Glaucoma**, typically following a long-standing vitreous hemorrhage where cells migrate into the anterior chamber and block the trabecular meshwork. * **C. Amyloid in the cornea:** This is associated with Lattice Corneal Dystrophy or secondary systemic amyloidosis, not lens-induced inflammation. * **D. Vasculitis:** While systemic inflammatory conditions (like SLE or Sarcoidosis) can cause retinal vasculitis, lens-induced uveitis is a localized reaction confined to the anterior segment and the lens material itself. **High-Yield Clinical Pearls for NEET-PG:** * **Phacolytic Glaucoma:** Unlike phacoantigenic uveitis, this is a non-specific inflammatory response where **macrophages** (not giant cells) ingest leaked lens protein and block the trabecular meshwork. * **Phacomorphic Glaucoma:** An acute secondary angle-closure glaucoma caused by an intumescent (swollen) lens. * **Key Distinction:** Phacoantigenic = Granulomatous/Giant Cells; Phacolytic = Macrophages/Heavy protein leak.

Question 14: What is the most common adverse effect on the eye associated with contraceptive usage?

A. Colour blindness
B. Ring scotoma
C. Optic neuritis (Correct Answer)
D. Nystagmus

Explanation: **Explanation:** The correct answer is **Optic neuritis**. Oral contraceptive pills (OCPs) are known to induce a hypercoagulable state and cause vascular changes. While rare, the most significant and frequently cited ocular complication in medical literature and examinations regarding OCP usage is **Optic neuritis** (or papillitis). This is thought to occur due to thromboembolic phenomena or inflammatory changes affecting the microvasculature of the optic nerve. Patients may present with sudden blurring of vision, retrobulbar pain, and a relative afferent pupillary defect (RAPD). Other documented OCP-related ocular issues include retinal vascular occlusions (CRAO/CRVO) and contact lens intolerance due to corneal edema. **Analysis of Incorrect Options:** * **A. Colour blindness:** This is typically a congenital condition (X-linked recessive) or acquired through toxicity (e.g., Ethambutol) or chronic optic nerve disease, but it is not a primary side effect of OCPs. * **B. Ring scotoma:** This is a classic visual field defect associated with **Retinitis Pigmentosa** or the toxic effects of **Chloroquine/Hydroxychloroquine** (bull’s eye maculopathy). * **D. Nystagmus:** This is an involuntary rhythmic oscillation of the eyes usually caused by vestibular dysfunction, cerebellar lesions, or certain drugs like Phenytoin and Alcohol, rather than hormonal contraceptives. **High-Yield Clinical Pearls for NEET-PG:** * **OCPs and the Eye:** The most common "minor" complaint is **contact lens intolerance** (due to changes in tear film and corneal curvature), but **Optic neuritis** is the classic "major" association tested. * **Pseudotumor Cerebri:** OCPs are a known risk factor for Idiopathic Intracranial Hypertension (IIH), which presents with bilateral papilledema. * **Vascular Risks:** Always consider OCP use in young females presenting with Retinal Vein Occlusion (RVO).

Question 15: What is the ocular symptom of Von Recklinghausen disease?

A. Deformed anterior chamber with reduced angle of AC
B. Glaucoma (Correct Answer)
C. Choroidal hemangioma
D. Subretinal neovascularization

Explanation: **Explanation:** **Von Recklinghausen disease**, also known as **Neurofibromatosis Type 1 (NF1)**, is an autosomal dominant multisystem disorder. **Glaucoma** is a well-recognized ocular complication of NF1, occurring in approximately 1/300 cases. It is almost always **unilateral and congenital/infantile** in presentation. **Why Glaucoma is the correct answer:** The pathophysiology of glaucoma in NF1 is multifactorial: 1. **Infiltration of the angle:** Neurofibromatous tissue can directly infiltrate the anterior chamber angle, obstructing aqueous outflow. 2. **Ciliary body involvement:** Thickening of the ciliary body or choroid can displace the iris-lens diaphragm forward, causing secondary angle closure. 3. **Developmental anomalies:** It is frequently associated with **ipsilateral plexiform neuroma of the upper eyelid** (S-shaped deformity), which leads to malformation of the angle structures. **Analysis of Incorrect Options:** * **Option A:** While the angle may be abnormal, "deformed anterior chamber" is a vague description. The specific clinical entity associated with NF1 is glaucoma. * **Option C:** Choroidal hemangiomas are classic features of **Sturge-Weber Syndrome**, not NF1. NF1 is instead associated with **Lisch nodules** (iris hamartomas) and **choroidal nevi/hamartomas**. * **Option D:** Subretinal neovascularization is not a primary feature of NF1; it is more commonly seen in conditions like Exudative AMD or High Myopia. **High-Yield Clinical Pearls for NEET-PG:** * **Lisch Nodules:** The most common ocular finding in NF1 (melanocytic hamartomas of the iris). * **Optic Nerve Glioma:** The most serious primary orbital tumor associated with NF1. * **Plexiform Neurofibroma:** Gives the characteristic **"bag of worms"** feel and **S-shaped ptosis**. * **Sphenoid Wing Dysplasia:** A skeletal diagnostic criterion for NF1 that can cause pulsating exophthalmos.

Question 16: All of the following viruses can involve the eye except?

A. Herpes zoster
B. Herpes simplex
C. Echo virus (Correct Answer)
D. Adenovirus type 8

Explanation: **Explanation:** The correct answer is **Echo virus**. While many systemic viruses have ocular manifestations, Enteroviruses (like Echo virus) are rarely associated with primary ocular infections. In contrast, the other listed viruses are classic causes of significant ophthalmic disease. * **Echo virus (Correct Answer):** Part of the Enterovirus family, these primarily cause gastrointestinal and respiratory infections, aseptic meningitis, or exanthems. They do not typically target ocular tissues. (Note: **Enterovirus 70** and **Coxsackievirus A24** are exceptions that cause Acute Hemorrhagic Conjunctivitis, but Echo virus specifically is not a standard ocular pathogen). * **Herpes zoster (Incorrect):** Causes **Herpes Zoster Ophthalmicus (HZO)** via the reactivation of the Varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a painful vesicular rash, pseudodendrites, and uveitis. * **Herpes simplex (Incorrect):** A leading cause of corneal blindness. HSV-1 typically causes **Dendritic Keratitis** (true ulcers with terminal bulbs) and geographic ulcers. * **Adenovirus type 8 (Incorrect):** A major cause of **Epidemic Keratoconjunctivitis (EKC)**. It is highly contagious and characterized by "follicular conjunctivitis" followed by "subepithelial corneal infiltrates." **High-Yield Clinical Pearls for NEET-PG:** 1. **Hutchinson’s Sign:** Vesicles on the tip of the nose in Herpes Zoster indicate involvement of the nasociliary nerve and a high risk of ocular involvement. 2. **Adenovirus Serotypes:** Types 8, 19, and 37 cause EKC; Types 3, 4, and 7 cause Pharyngoconjunctival Fever (PCF). 3. **Dendrites:** HSV causes *true* dendrites (terminal bulbs, stains with Fluorescein); HZ causes *pseudodendrites* (no bulbs, stains poorly).

Question 17: Which of the following is NOT true about Behçet's disease?

A. It is characterized by the presence of aphthous ulceration, genital ulceration, and uveitis.
B. Uveitis is typically bilateral, acute, recurrent iridocyclitis with hypopyon.
C. It generally has a good visual prognosis. (Correct Answer)
D. Chlorambucil can be used as a treatment to control the disease.

Explanation: **Explanation:** Behçet's disease is a chronic, multisystem idiopathic occlusive vasculitis. The correct answer is **Option C** because Behçet's disease typically has a **poor visual prognosis**. It is characterized by recurrent inflammatory episodes that lead to cumulative damage, including retinal vasculitis, macular edema, and optic atrophy, often resulting in legal blindness if not aggressively managed. **Analysis of Options:** * **Option A:** This describes the classic **Behçet’s Triad**. The disease is clinically diagnosed based on recurrent oral aphthous ulcers (most common), genital ulcers, and ocular involvement. * **Option B:** Ocular involvement occurs in about 70% of patients. It typically presents as a **bilateral, non-granulomatous uveitis**. A hallmark is the "transient" or "shifting" **hypopyon**, which disappears quickly as the inflammation subsides. * **Option D:** Since the disease is an autoimmune vasculitis, systemic immunosuppression is mandatory. **Chlorambucil** and Cyclophosphamide (alkylating agents) are historically used for sight-threatening posterior uveitis to induce remission. **High-Yield Clinical Pearls for NEET-PG:** * **HLA Association:** Strongly associated with **HLA-B51**. * **Pathergy Test:** A unique diagnostic feature where a sterile pustule forms 24-48 hours after a skin prick with a needle. * **Ocular Hallmark:** Recurrent hypopyon and **obliterative retinal vasculitis** (leading to a "bloodless" retina in late stages). * **Treatment:** Biologicals like **Infliximab** (anti-TNFα) are now considered first-line for severe ocular Behçet's.

Question 18: Herpes zoster ophthalmicus is defined as:

A. Reactivation of herpes simplex virus in the optic nerve.
B. Reactivation of herpes zoster virus in the trigeminal nerve. (Correct Answer)
C. Reactivation of herpes simplex virus in the oculomotor nerve.
D. Herpes infection in an immunocompromised patient.

Explanation: ### Explanation **1. Why Option B is Correct:** Herpes Zoster Ophthalmicus (HZO) is caused by the reactivation of the **Varicella-Zoster Virus (VZV)**, which remains latent in the sensory ganglia after a primary infection (chickenpox). Specifically, HZO occurs when the virus reactivates in the **Trigeminal Ganglion (Gasserian ganglion)** and travels down the **Ophthalmic division (V1)** of the trigeminal nerve. This results in a characteristic painful, unilateral vesicular rash along the dermatome supplied by the V1 nerve. **2. Why the Other Options are Incorrect:** * **Option A & C:** These options incorrectly identify the causative agent as *Herpes Simplex Virus (HSV)*. HSV typically causes primary or recurrent keratitis (dendritic ulcers) but is not the cause of "Zoster." Furthermore, the oculomotor nerve (CN III) is a motor nerve; HZO primarily involves sensory pathways. * **Option D:** While HZO is more common and severe in immunocompromised patients (e.g., HIV, elderly), the *definition* of the disease is based on the specific virus and nerve involved, not the immune status of the host. **3. High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Sign:** Vesicles on the tip, side, or root of the nose indicate involvement of the **nasociliary nerve** (a branch of V1). This is a strong predictor of ocular involvement (keratitis, uveitis). * **Ocular Complications:** The most common is epithelial keratitis (pseudodendrites), followed by stromal keratitis, anterior uveitis, and secondary glaucoma. * **Treatment:** Oral antivirals (Acyclovir 800mg 5x/day, Famciclovir, or Valacyclovir) started within 72 hours of rash onset. * **Post-Herpetic Neuralgia:** The most common chronic complication, characterized by persistent pain after the rash heals.

Question 19: All of the following are histopathologic features of sympathetic ophthalmia except?

A. Necrosis (Correct Answer)
B. Giant cells located within the choroid
C. T lymphocytes
D. Eosinophils

Explanation: **Explanation:** Sympathetic Ophthalmia (SO) is a rare, bilateral, non-necrotizing granulomatous panuveitis that occurs following a penetrating injury or intraocular surgery in one eye (the "exciting" eye), leading to inflammation in the fellow eye (the "sympathizing" eye). **Why Necrosis is the correct answer:** The hallmark of Sympathetic Ophthalmia is **non-necrotizing** granulomatous inflammation. Unlike other granulomatous conditions like tuberculosis or fungal infections, SO is characterized by a diffuse infiltration of the uveal tract without any tissue necrosis. Therefore, the presence of necrosis is inconsistent with this diagnosis. **Analysis of other options:** * **Giant cells (Option B):** Histology typically shows multinucleated giant cells (Langhans or foreign body type) within the choroid, often containing phagocytosed uveal pigment (Dalen-Fuchs nodules). * **T lymphocytes (Option C):** SO is a T-cell mediated autoimmune response against uveal antigens (likely melanin-related). The uveal infiltrate is predominantly composed of T lymphocytes. * **Eosinophils (Option D):** While less common than lymphocytes, eosinophils are frequently found in the early stages of the inflammatory infiltrate in SO. **High-Yield Clinical Pearls for NEET-PG:** * **Sparing of the Choriocapillaris:** A classic histopathologic feature of SO is that the choriocapillaris and the retina are typically spared from the inflammatory process. * **Dalen-Fuchs Nodules:** These are pathognomonic clusters of epithelioid cells and pigment-laden macrophages located between the RPE and Bruch’s membrane. * **Latent Period:** Most cases occur within 3 months of injury, but the risk remains lifelong. * **Management:** Immediate enucleation of the injured eye (within 2 weeks) can prevent SO, but once inflammation starts in the sympathizing eye, systemic steroids and immunosuppressants are the mainstay of treatment.

Question 20: Mutton fat keratic precipitate is seen in which condition?

A. Posterior uveitis
B. Granulomatous uveitis (Correct Answer)
C. Non-granulomatous uveitis
D. Choroiditis

Explanation: **Explanation:** Keratic precipitates (KPs) are inflammatory cell deposits on the corneal endothelium, typically seen in the lower part of the cornea (Arlt’s triangle). Their morphology provides a crucial diagnostic clue to the underlying etiology of uveitis. **Why Option B is Correct:** **Mutton-fat KPs** are the hallmark of **Granulomatous Uveitis**. These are large, greasy-looking, yellowish-white deposits composed primarily of **epithelioid cells and macrophages**. They are characteristic of chronic granulomatous conditions such as Sarcoidosis, Tuberculosis, Syphilis, and Sympathetic Ophthalmitis. **Why Other Options are Incorrect:** * **Option C (Non-granulomatous uveitis):** This condition typically presents with **small, fine, white KPs** composed of neutrophils and lymphocytes. They lack the "greasy" appearance of mutton-fat KPs. * **Option A & D (Posterior uveitis/Choroiditis):** While these involve inflammation of the posterior segment, KPs are an **anterior segment finding** (iridocyclitis). While panuveitis can show both, the specific morphology of "mutton-fat" is a descriptor for the *type* of inflammation (granulomatous) rather than the *location*. **NEET-PG High-Yield Pearls:** * **Arlt’s Triangle:** The triangular distribution of KPs on the inferior cornea due to convection currents in the aqueous humor. * **Koeppe Nodules:** Small nodules at the pupillary border (seen in both types, but common in granulomatous). * **Busacca Nodules:** Nodules on the iris surface (pathognomonic for granulomatous uveitis). * **Stellate KPs:** Fine, star-shaped KPs distributed over the entire endothelium; characteristic of **Fuchs’ Heterochromic Iridocyclitis** and Viral uveitis (CMV/Herpes).

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