Ocular Manifestations of Systemic Disorders Practice Questions

Q: What is seen in the fundus of a patient with disseminated tuberculosis?

Choroid tubercles. **Explanation:** **Choroid Tubercles (Correct Answer):** In disseminated or miliary tuberculosis, the bacilli reach the eye via the **hematogenous route**. The choroid is the most common site of involvement because it is the most vascularized tissue in the eye. Choroid tubercles appear as multiple, small (0.5 to 3.0 mm), yellowish-white, ill-defined nodules, typically located in the posterior pole. Their presence is a pathognomonic sign of miliary TB and often aids in the systemic diagnosis. **Why other options are incorrect:** * **Optic Atrophy:** This is a late-stage sequela of various conditions (like chronic papilledema or TB meningitis) but is not a primary or diagnostic fundus finding of disseminated TB itself. * **Papilledema:** While this can occur in TB patients, it is usually secondary to **Tuberculous Meningitis (TBM)** causing increased intracranial pressure, rather than the direct hematogenous spread of the bacilli to the globe. * **Macular Edema:** This is a non-specific finding seen in various inflammatory conditions (uveitis) or vascular disorders, but it is not the characteristic hallmark of disseminated TB. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ocular lesion in TB:** Anterior uveitis (granulomatous). * **Pathognomonic sign of Miliary TB:** Choroid tubercles. * **Eales’ Disease:** An idiopathic peripheral perivasculitis (often linked to TB hypersensitivity) characterized by peripheral retinal neovascularization and vitreous hemorrhage. * **Treatment:** Standard Anti-Tubercular Therapy (ATT). Note that Ethambutol can cause **optic neuritis** (retrobulbar), a common side effect tested in exams.

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

Conjunctivitis. **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.

Q: In mumps, what is the most common eye lesion?

Dacryoadenitis. **Explanation:** **Mumps** is a viral infection caused by the **Paramyxovirus**, primarily known for causing painful swelling of the parotid glands. However, it is a systemic disease that can affect various glandular tissues and the ocular system. **1. Why Dacryoadenitis is the correct answer:** **Dacryoadenitis** (inflammation of the lacrimal gland) is the **most common** ocular complication of mumps. This occurs because the Paramyxovirus has a high affinity for glandular epithelium. Since the lacrimal gland is structurally and functionally similar to the salivary glands, it is frequently involved. It typically presents as sudden onset of pain, swelling, and redness in the temporal aspect of the upper eyelid, often occurring bilaterally. **2. Analysis of Incorrect Options:** * **B. Uveitis:** While mumps can cause a transient, non-granulomatous anterior uveitis (usually during the recovery phase), it is significantly less common than dacryoadenitis. * **C. Membranous conjunctivitis:** Mumps usually causes a mild follicular conjunctivitis. Membranous conjunctivitis is more classically associated with *Corynebacterium diphtheriae* or Adenovirus (EKC). * **D. Chorioretinitis:** This is a rare posterior segment complication of mumps. It is much more frequently associated with infections like Toxoplasmosis, CMV, or Syphilis. **3. NEET-PG High-Yield Pearls:** * **Most common systemic complication in children:** Aseptic meningitis. * **Most common systemic complication in post-pubertal males:** Orchitis (usually unilateral; rarely leads to sterility). * **Most common cause of sudden onset sensorineural hearing loss (SNHL) in children:** Mumps (typically unilateral and permanent). * **Ocular triad:** Though rare, mumps can present with the triad of dacryoadenitis, keratitis, and optic neuritis.

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

Cranial nerve palsies. **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.

Q: 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:

Von Graefe's sign. **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.

Q: Which of the following indicates activity of anterior uveitis?

Cells in anterior chamber. **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.

Question 1

What is seen in the fundus of a patient with disseminated tuberculosis?

Accepted Answer

Choroid tubercles

Answer

Optic atrophy

Answer

Papilledema

Answer

Macular edema

Question 2

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 3

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 4

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 5

What is the most common ocular feature in Reiter Syndrome?

Accepted Answer

Conjunctivitis

Answer

Anterior Uveitis

Answer

Pars planitis

Answer

Chorioretinitis

Question 6

In mumps, what is the most common eye lesion?

Accepted Answer

Dacryoadenitis

Answer

Uveitis

Answer

Membranous conjunctivitis

Answer

Chorioretinitis

Question 7

Which ocular symptom is NOT seen in Herpes zoster ophthalmicus?

Accepted Answer

Cranial nerve palsies

Answer

Nummular keratitis

Answer

Glaucoma

Answer

Uveitis

Question 8

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:

Accepted Answer

Von Graefe's sign

Answer

Joffroy's sign

Answer

Moebius sign

Answer

Stellwag's sign

Question 9

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

Accepted Answer

Chronic congestive glaucoma

Answer

Candidiasis

Answer

Multiple sclerosis

Answer

Sarcoidosis

Question 10

Which of the following indicates activity of anterior uveitis?

Accepted Answer

Cells in anterior chamber

Answer

Circumcorneal congestion

Answer

Keratic precipitate

Answer

Corneal edema

Ocular Manifestations of Systemic Disorders — MCQs

Ocular Manifestations of Systemic Disorders — MCQs

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