Ocular Manifestations of Systemic Disorders Practice Questions

Q: Granulomatous uveitis is seen in which of the following conditions?

Vogt-Koyanagi-Harada disease. **Explanation:** Uveitis is clinically classified into **Granulomatous** and **Non-granulomatous** based on the type of inflammatory response and the appearance of Keratic Precipitates (KPs). **1. Why Vogt-Koyanagi-Harada (VKH) disease is correct:** VKH is a multisystem autoimmune disorder directed against melanocytes. It typically presents as a **bilateral chronic granulomatous panuveitis**. On examination, it is characterized by "mutton-fat" Keratic Precipitates (KPs), Busacca nodules on the iris, and Dalen-Fuchs nodules in the choroid. Systemic features include poliosis, vitiligo, alopecia, and meningeal signs. **2. Why the other options are incorrect:** * **Fuch’s Heterochromic Iridocyclitis (FHI):** This is a chronic **non-granulomatous** uveitis. It is characterized by fine, stellate KPs distributed over the entire corneal endothelium, iris heterochromia, and an absence of posterior synechiae. * **Behcet’s Syndrome:** This is a multisystem vasculitis that causes a classic **non-granulomatous** uveitis. It is famous for presenting with a "shifting hypopyon" (sterile pus in the anterior chamber) and occlusive retinal vasculitis. **NEET-PG High-Yield Pearls:** * **Granulomatous Uveitis Mnemonic (STLV):** **S**arcoidosis, **T**uberculosis, **L**eprosy, **V**KH (also includes Syphilis and Sympathetic Ophthalmitis). * **Mutton-fat KPs:** Large, greasy-looking clusters of epithelioid cells and macrophages, pathognomonic for granulomatous inflammation. * **HLA Association:** VKH is strongly associated with **HLA-DR4**. * **Behcet’s Association:** Associated with **HLA-B51**.

Q: All of the following are true for anaemic retinopathy except?

Veins are pale and narrow. **Explanation:** Anaemic retinopathy occurs due to retinal hypoxia and increased capillary permeability resulting from low oxygen-carrying capacity. **Why Option C is the correct answer (The False Statement):** In anaemic retinopathy, the retinal **veins are typically dilated and tortuous**, not narrow. This dilation is a compensatory mechanism to improve blood flow in response to systemic hypoxia. While the veins do appear **pale** (due to the reduction in red blood cell concentration), the "narrow" description makes this statement incorrect. **Analysis of Incorrect Options (True Statements):** * **Option A:** Retinopathy is rarely seen unless the anaemia is severe. It typically manifests when haemoglobin levels fall below **5 g/dL** or when the red cell count drops below 1.5 million/mm³. * **Option B:** Both arterioles and veins appear pale or "straw-colored" because the blood contains less oxyhaemoglobin, leading to a loss of the normal bright red color. * **Option C:** Common findings include flame-shaped (superficial) haemorrhages, Roth spots (haemorrhages with white centers), and occasionally subhyaloid haemorrhages. These occur due to endothelial damage from hypoxia. **High-Yield Clinical Pearls for NEET-PG:** * **Roth Spots:** Though classic for Subacute Bacterial Endocarditis (SBE), they are frequently seen in anaemic and leukaemic retinopathy. * **Combined Effect:** Retinopathy is significantly more severe if anaemia is associated with concomitant **thrombocytopenia**. * **Reversibility:** Anaemic retinopathy is generally reversible once the underlying systemic anaemia is corrected. * **Cotton Wool Spots:** These may also be present, representing micro-infarctions of the nerve fiber layer.

Q: A stye is a suppurative inflammation of which glands?

Zeis. **Explanation:** A **Stye (Hordeolum Externum)** is an acute, focal, suppurative (pus-forming) inflammation of the eyelash follicle and its associated glands. 1. **Why Zeis is correct:** The infection typically involves the **Glands of Zeis** (sebaceous glands) or the **Glands of Moll** (modified sweat glands) located at the lid margin. It is most commonly caused by *Staphylococcus aureus*. Because these glands are superficial and associated with the lashes, the lesion points outward on the skin side of the lid margin. 2. **Why other options are incorrect:** * **Meibomian Glands:** Inflammation of these glands leads to a **Hordeolum Internum** (Internal Stye) or a **Chalazion** (chronic granulomatous inflammation). Because these glands are embedded deep within the tarsal plate, the infection points toward the conjunctival side (posteriorly). * **Glands of Wolfring:** These are accessory lacrimal glands located in the upper border of the tarsal plate. They are responsible for basal tear secretion, not the formation of a stye. **High-Yield Clinical Pearls for NEET-PG:** * **Hordeolum Externum (Stye):** Painful, acute, superficial, involves Glands of Zeis/Moll. * **Hordeolum Internum:** Painful, acute, deep, involves Meibomian glands. * **Chalazion:** Painless, chronic, non-infective, involves Meibomian glands. * **Treatment:** Hot compresses are the mainstay of treatment for acute hordeolum to facilitate drainage. If a chalazion is recurrent in elderly patients, always rule out **Sebaceous Cell Carcinoma** via biopsy.

Q: What is the commonest cause of fungal uveitis?

Candida. **Explanation:** **Candida albicans** is the most common cause of fungal uveitis (specifically endogenous endophthalmitis). This occurs primarily via **hematogenous spread** from a distant site. The underlying medical concept involves the seeding of the highly vascular choroid during episodes of fungemia. It is most frequently seen in immunocompromised patients, intravenous drug users (IVDU), or those on long-term indwelling catheters or parenteral nutrition. **Analysis of Options:** * **Candida (Correct):** It typically presents as "fluffy white cotton-ball" colonies in the vitreous and multifocal chorioretinitis. It is the leading cause of endogenous fungal infections of the eye. * **Aspergillus:** While it is the second most common cause of endogenous fungal endophthalmitis, it is less frequent than Candida. It tends to be more aggressive, often causing rapid vision loss and vascular occlusion. * **Fusarium:** This is the most common cause of **fungal keratitis** (exogenous infection) worldwide, particularly following trauma with vegetative matter, but it is a rare cause of uveitis. * **Mucormycosis:** This typically causes **Rhino-oculo-cerebral mucormycosis**, characterized by orbital cellulitis and apex syndrome in diabetic ketoacidosis patients, rather than isolated uveitis. **High-Yield Clinical Pearls for NEET-PG:** * **Endogenous Fungal Endophthalmitis:** Most common organism is *Candida*. * **Exogenous Fungal Keratitis:** Most common organism is *Fusarium* (filamentous fungi). * **Classic Sign:** "String of pearls" or "Cotton ball" opacities in the vitreous are pathognomonic for Candidal endophthalmitis. * **Treatment:** Intravitreal Amphotericin B or Voriconazole are the drugs of choice.

Q: Lisch nodule is seen in which of the following conditions?

Neurofibromatosis. **Explanation:** **Lisch nodules** are the most common ocular finding in **Neurofibromatosis Type 1 (NF-1)**, also known as von Recklinghausen’s disease. They are melanocytic hamartomas of the iris stroma, appearing as well-defined, dome-shaped, yellowish-brown elevations. While they do not affect vision, they are a critical diagnostic criterion for NF-1, present in over 95% of affected individuals by age 20. **Analysis of Options:** * **Neurofibromatosis (Correct):** Lisch nodules are pathognomonic for NF-1. They are typically bilateral and increase in frequency with age. * **Sympathetic Ophthalmitis:** This is a bilateral granulomatous panuveitis following trauma to one eye. The characteristic findings are **Dalen-Fuchs nodules** (small, white inflammatory nodules between the RPE and Bruch’s membrane), not Lisch nodules. * **Chronic Iridocyclitis:** This condition is associated with inflammatory nodules such as **Koeppe nodules** (at the pupillary margin) and **Busacca nodules** (on the iris surface), which are composed of inflammatory cells, unlike the hamartomatous nature of Lisch nodules. * **Trachoma:** This is a chronic keratoconjunctivitis caused by *Chlamydia trachomatis*. Key findings include **Herbert’s pits**, Arlt’s line, and follicles, but it does not involve the iris. **High-Yield Clinical Pearls for NEET-PG:** * **NF-1 Diagnostic Ocular Signs:** Lisch nodules (most common) and Optic Nerve Glioma (most serious). * **NF-2 Ocular Sign:** Posterior subcapsular lens opacities (cataract). * **Differentiating Nodules:** * *Lisch:* NF-1 (Hamartoma) * *Koeppe/Busacca:* Granulomatous Uveitis (Inflammatory) * *Dalen-Fuchs:* Sympathetic Ophthalmitis/Vogt-Koyanagi-Harada (VKH) * *Brushfield Spots:* Down Syndrome (Connective tissue hyperplasia)

Q: Uveitis is caused by all of the following microorganisms except:

Klebsiella. **Explanation:** The question focuses on the distinction between **infectious uveitis** (caused by direct invasion of microorganisms) and **immune-mediated uveitis** (associated with systemic inflammatory conditions). **Why Klebsiella is the correct answer:** *Klebsiella pneumoniae* does not typically cause direct infectious uveitis. Instead, it is famously associated with **HLA-B27-related acute anterior uveitis**. In this context, the uveitis is a sterile, autoimmune inflammatory response triggered by molecular mimicry or cross-reactivity, rather than a direct infection of the uveal tissue by the bacteria itself. While *Klebsiella* is a leading cause of endogenous endophthalmitis (a more severe, global ocular infection), it is not classified as a primary causative agent of infectious uveitis. **Analysis of Incorrect Options:** * **Mycobacterium tuberculosis (A):** A classic cause of granulomatous uveitis. It can involve the eye via direct hematogenous spread, leading to choroidal tubercles or disseminated posterior uveitis. * **Staphylococcus (B) and Streptococcus (C):** These are common pyogenic bacteria that can cause exogenous infectious uveitis (following trauma or surgery) or endogenous uveitis via hematogenous spread from a distant focus (e.g., endocarditis). **High-Yield Clinical Pearls for NEET-PG:** * **HLA-B27 Association:** Remember the mnemonic **PEAR** (Psoriatic arthritis, Enteropathic arthritis, Ankylosing spondylitis, and Reactive arthritis). These are associated with *Klebsiella* and present as non-granulomatous acute anterior uveitis. * **Endogenous Endophthalmitis:** If a patient has a liver abscess and sudden vision loss, suspect *Klebsiella pneumoniae*. * **Granulomatous vs. Non-granulomatous:** TB, Sarcoidosis, and Syphilis cause granulomatous uveitis (large "mutton-fat" KPs), while most acute bacterial/viral cases are non-granulomatous.

Q: A 30-year-old male patient presented with anterior granulomatous uveitis, arthralgia, and respiratory difficulties. What is the probable diagnosis?

Ocular sarcoidosis. **Explanation:** The clinical triad of **granulomatous uveitis, arthralgia, and respiratory symptoms** in a young adult is a classic presentation of **Sarcoidosis**. 1. **Why Sarcoidosis is correct:** Sarcoidosis is a multisystem idiopathic disorder characterized by non-caseating granulomas. Ocular involvement occurs in about 25–50% of cases, most commonly presenting as **bilateral granulomatous anterior uveitis** (characterized by "mutton-fat" keratic precipitates and Iris nodules like Koeppe and Bussaca nodules). The systemic association with hilar lymphadenopathy or interstitial lung disease explains the respiratory difficulty, while joint involvement causes arthralgia. 2. **Why other options are incorrect:** * **Tuberculosis:** While it causes granulomatous uveitis and respiratory issues, it is usually associated with weight loss, night sweats, and fever. The specific combination with arthralgia (Lofgren’s syndrome) is more characteristic of Sarcoidosis. * **Behcet’s Syndrome:** This typically presents with **non-granulomatous** uveitis (often with a shifting hypopyon) and is characterized by the triad of oral ulcers, genital ulcers, and uveitis, rather than respiratory distress. * **HLA-B27 associated uveitis:** This is the most common cause of **acute non-granulomatous** anterior uveitis. While associated with Ankylosing Spondylitis (back pain), it does not typically present with granulomatous features or primary respiratory distress. **High-Yield Clinical Pearls for NEET-PG:** * **Lofgren’s Syndrome:** An acute form of sarcoidosis consisting of Erythema nodosum, bilateral hilar lymphadenopathy, and arthralgia. * **Heerfordt’s Syndrome (Uveoparotid fever):** Uveitis, Parotid swelling, and Facial nerve palsy. * **Investigation of Choice:** Chest X-ray (Bilateral hilar lymphadenopathy) and Serum ACE levels (elevated). * **Definitive Diagnosis:** Biopsy showing non-caseating granulomas.

Q: Which of the following is NOT a cause of Roth spots?

Hypersensitivity pneumonitis. **Explanation:** **Roth spots** are retinal hemorrhages characterized by a pale or white center. Pathophysiologically, they represent a **fibrin-platelet thrombus** at the site of a ruptured capillary wall. The white center is composed of fibrin, platelets, and focal ischemia, rather than inflammatory cells. **Why Hypersensitivity Pneumonitis is the correct answer:** Hypersensitivity pneumonitis is an immunologically mediated inflammation of the lung parenchyma (Type III and IV hypersensitivity). It does not typically cause the systemic hematological disturbances or microvascular damage required to produce retinal hemorrhages. Therefore, it is not associated with Roth spots. **Why the other options are incorrect:** * **Leukemia:** This is a classic cause. Hyperviscosity and abnormal white blood cell counts lead to capillary fragility and hemorrhage. * **Severe Anemia:** Low hemoglobin levels lead to retinal hypoxia and increased capillary permeability, resulting in flame-shaped hemorrhages with pale centers. * **Systemic Lupus Erythematosus (SLE):** SLE causes a systemic vasculitis. Immune complex deposition in the retinal vessels leads to micro-infarctions and hemorrhages. **Clinical Pearls for NEET-PG:** * **Mnemonic for Roth Spots:** "**L**ads **S**hould **B**e **D**oing **H**omework" (**L**eukemia, **S**ubacute Bacterial Endocarditis (SBE), **B**lastomycosis, **D**iabetes, **H**ypertension/HIV). * **Most Common Association:** While classically taught with **Subacute Bacterial Endocarditis (SBE)**, they are actually more frequently seen in **Leukemia** and **Diabetes Mellitus**. * **Differential Diagnosis:** Other causes include Carbon Monoxide poisoning, Preeclampsia, and Vitamin B12 deficiency.

Q: Nodules seen near the collarette are called?

Busacca nodules. **Explanation:** The question refers to the clinical features of **Granulomatous Uveitis**. In this condition, inflammatory cells (lymphocytes and epithelioid cells) aggregate on the iris surface to form nodules. 1. **Busacca Nodules (Correct Answer):** These are inflammatory nodules located on the **anterior surface of the iris stroma**, typically near the **collarette**. They are pathognomonic for granulomatous uveitis (e.g., Sarcoidosis, Tuberculosis). 2. **Koeppe’s Nodules:** These are also seen in granulomatous uveitis but are located specifically at the **pupillary margin**. They are smaller than Busacca nodules and can lead to the formation of posterior synechiae. 3. **Lisch Nodules:** These are melanocytic hamartomas of the iris. They appear as well-defined, dome-shaped, light brown elevations. They are a hallmark diagnostic feature of **Neurofibromatosis Type 1 (NF-1)** and are not inflammatory. 4. **Dalén-Fuchs Nodules:** These are small, yellowish-white spots seen in the **chorioretinal periphery**. They represent aggregates of epithelioid cells between the retinal pigment epithelium (RPE) and Bruch’s membrane, typically seen in **Vogt-Koyanagi-Harada (VKH) syndrome** and **Sympathetic Ophthalmitis**. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic:** **K**oeppe = **K**orner (Pupillary margin); **B**usacca = **B**ody (Iris stroma/collarette). * **Mutton-fat Keratic Precipitates (KPs):** Large, greasy inflammatory deposits on the corneal endothelium, also characteristic of granulomatous uveitis. * **Berlin’s Nodules:** Inflammatory nodules found in the angle of the anterior chamber (seen on gonioscopy).

Question 1

Granulomatous uveitis is seen in which of the following conditions?

Accepted Answer

Vogt-Koyanagi-Harada disease

Answer

Fuch's disease

Answer

Behcet's syndrome

Answer

All of the above

Question 2

All of the following are true for anaemic retinopathy except?

Accepted Answer

Veins are pale and narrow

Answer

Occurs when haemoglobin level falls below 5 gm%

Answer

Arterioles become pale

Answer

Superficial retinal and subhyaloid haemorrhage are seen

Question 3

A stye is a suppurative inflammation of which glands?

Accepted Answer

Zeis

Answer

Meibomian

Answer

Wolfring

Answer

All the above

Question 4

What is the commonest cause of fungal uveitis?

Accepted Answer

Candida

Answer

Aspergillus

Answer

Fusarium

Answer

Mucor mycosis

Question 5

Lisch nodule is seen in which of the following conditions?

Accepted Answer

Neurofibromatosis

Answer

Sympathetic ophthalmitis

Answer

Chronic iridocyclitis

Answer

Trachoma

Question 6

Uveitis is caused by all of the following microorganisms except:

Accepted Answer

Klebsiella

Answer

Mycobacterium tuberculosis

Answer

Staphylococcus

Answer

Streptococcus

Question 7

A 30-year-old male patient presented with anterior granulomatous uveitis, arthralgia, and respiratory difficulties. What is the probable diagnosis?

Accepted Answer

Ocular sarcoidosis

Answer

Tuberculosis

Answer

Behcet's syndrome

Answer

HLA B27 associated uveitis

Question 8

Which of the following is NOT a cause of Roth spots?

Accepted Answer

Hypersensitivity pneumonitis

Answer

Leukemia

Answer

Severe anemia

Answer

Systemic lupus erythematosus

Question 9

Nodules seen near the collarette are called?

Accepted Answer

Busacca nodules

Answer

Koeppe's nodules

Answer

Lisch nodules

Answer

Dalén-Fuchs nodules

Question 10

A 12-year-old girl presents with mood and emotional lability and a golden brown discoloration in Descemet's membrane. What is the most likely diagnosis?

Accepted Answer

Wilson's disease

Answer

Fabry's disease

Answer

Glycogen storage disease

Answer

Acute rheumatic fever

Ocular Manifestations of Systemic Disorders — MCQs

Ocular Manifestations of Systemic Disorders — MCQs

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