Ocular Manifestations of Systemic Disorders Practice Questions

Q: Epidemic dropsy is characterised by all EXCEPT:

Hard exudates. **Explanation:** Epidemic dropsy is a clinical condition caused by the ingestion of mustard oil adulterated with **Argemone mexicana** oil. The toxic alkaloid responsible is **Sanguinarine**, which increases capillary permeability and causes widespread vasodilation. **Why "Hard Exudates" is the correct answer:** Hard exudates are composed of lipoprotein deposits resulting from chronic vascular leakage (commonly seen in Diabetic Retinopathy). In Epidemic Dropsy, the ocular pathology is primarily driven by **acute hypervolemia and massive capillary dilation** rather than chronic lipid leakage. Therefore, hard exudates are not a feature of this condition. **Analysis of Incorrect Options:** * **Tortuous retinal vessels & Periretinal hemorrhage:** Sanguinarine inhibits the Na+-K+ ATPase pump, leading to a rise in intracellular calcium and the release of prostaglandins. This causes extreme dilatation and tortuosity of retinal vessels and increased fragility, leading to superficial (periretinal) hemorrhages. * **Disc edema:** The systemic toxicity leads to increased capillary permeability and venous congestion, which manifests as bilateral optic disc edema (papilledema). **High-Yield Clinical Pearls for NEET-PG:** 1. **Glaucoma Type:** It causes a specific type of **Open Angle Glaucoma** characterized by very high Intraocular Pressure (IOP), but notably, there is **no shallowing of the anterior chamber** and **no pain/redness**. 2. **Mechanism of Glaucoma:** Increased production of aqueous humor and increased resistance to outflow due to dilated capillaries in the uveal tract. 3. **Systemic Features:** Bilateral pitting edema of legs, diarrhea, and cardiac failure. 4. **Diagnosis:** The **Nitric Acid Test** or Marquis test is used to detect Argemone oil in mustard oil.

Q: Which of the following is the most common cause of anterior uveitis?

Idiopathic. **Explanation:** Anterior uveitis (comprising iritis and iridocyclitis) is the most common form of intraocular inflammation. Epidemiological studies consistently show that despite extensive diagnostic workups, **Idiopathic** causes remain the most frequent, accounting for approximately **50% or more** of all cases. **Why the other options are incorrect:** * **HLA-B27 associated:** While this is the most common *identifiable* systemic association (linked to Ankylosing Spondylitis, Reiter’s Syndrome, and IBD), it still ranks second to idiopathic cases in overall prevalence. * **Sarcoidosis:** This is a significant cause of granulomatous uveitis (often presenting with "mutton-fat" keratic precipitates), but it is statistically less common than HLA-B27 or idiopathic varieties. * **Tuberculosis:** Though a major cause of infectious uveitis in developing countries like India, it is a specific etiology and does not surpass the frequency of idiopathic presentations. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of uveitis:** Anterior Uveitis. * **Most common systemic association:** HLA-B27 (typically presents as acute, unilateral, recurrent, non-granulomatous inflammation). * **Granulomatous vs. Non-granulomatous:** Idiopathic and HLA-B27 cases are usually non-granulomatous (small KPs), whereas Sarcoidosis and TB are typically granulomatous (large mutton-fat KPs). * **Classic Triad of Symptoms:** Pain, photophobia, and redness (ciliary congestion). * **Gold Standard Treatment:** Topical corticosteroids (e.g., Prednisolone acetate) and cycloplegics (e.g., Homatropine) to prevent synechiae.

Q: What is the most common benign tumor of the eyelids?

Simple papilloma. **Explanation:** **1. Why Simple Papilloma is Correct:** Simple papilloma (specifically the squamous cell papilloma) is the **most common benign tumor of the eyelids**. It is a slow-growing, painless lesion that can be either sessile or pedunculated. These tumors arise from the proliferation of the squamous epithelium and often have a characteristic "raspberry" or "cauliflower" appearance. They are frequently seen in elderly patients or as viral warts (Verruca vulgaris) in younger individuals. **2. Analysis of Incorrect Options:** * **Xanthelasma:** While very common, it is technically a **lipid deposit** (histiocytes containing cholesterol) within the dermis rather than a true neoplastic tumor. It is often associated with hyperlipidemia. * **Capillary Haemangioma:** This is the most common benign orbital/eyelid tumor of **childhood** (infancy), but it is not the most common in the general population. * **Neurofibroma:** These are associated with Neurofibromatosis Type 1 (NF-1). While they can present as a "S-shaped" deformity of the eyelid (Plexiform neurofibroma), they are significantly less common than simple papillomas. **3. NEET-PG High-Yield Pearls:** * **Most common malignant tumor of the eyelid:** Basal Cell Carcinoma (BCC), typically involving the lower lid. * **Most common site for BCC:** Lower eyelid > Inner canthus > Upper eyelid. * **Sebaceous Gland Carcinoma:** A highly malignant tumor that often mimics chronic chalazion or blepharoconjunctivitis (Masquerade syndrome). * **Hutchinson’s Freckle:** A precursor to Lentigo Maligna (Melanoma).

Q: What is the cause of acute vision loss in a patient with alcoholic pancreatitis?

Puscher's retinopathy. **Explanation:** **Purtscher’s Retinopathy** is the correct answer. It is a rare but well-recognized microvascular occlusive syndrome characterized by sudden, painless vision loss. While classically associated with severe head trauma or chest compression, it is a known complication of **acute pancreatitis**. The underlying pathophysiology involves the activation of the complement cascade (specifically C5a), leading to leukocyte aggregation and the formation of microemboli (granulocyte/platelet/fibrin clumps). These emboli cause infarction of the retinal nerve fiber layer, manifesting clinically as multiple **Purtscher flecken** (areas of retinal whitening) and cotton-wool spots surrounding the optic nerve. **Why other options are incorrect:** * **Sudden alcohol withdrawal:** Typically presents with systemic neurological symptoms (tremors, seizures, delirium tremens) rather than acute structural retinal pathology or vision loss. * **Acute congestive glaucoma:** Presents with a painful red eye, corneal edema, and a mid-dilated pupil, rather than the painless retinal findings associated with pancreatitis. * **Central retinal artery occlusion (CRAO):** While it causes sudden vision loss, it is usually due to an embolus from the heart or carotid arteries. In CRAO, the entire retina is pale with a "cherry-red spot," whereas Purtscher’s shows localized patches of whitening (flecken). **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Purtscher’s:** Sudden vision loss + Purtscher flecken + Cotton-wool spots. * **Common Causes:** Trauma (most common), Acute Pancreatitis, Fat Embolism Syndrome, and Systemic Lupus Erythematosus (SLE). * **Diagnosis:** Primarily clinical; Fundus Fluorescein Angiography (FFA) shows areas of capillary non-perfusion. * **Management:** Observation and treatment of the underlying systemic condition (e.g., managing the pancreatitis).

Q: Heterochromia iridis is a feature of:

All of the above. **Explanation:** **Heterochromia iridis** refers to a difference in the color of the iris between the two eyes (complete) or within a single iris (sectoral). It occurs due to an alteration in the density or distribution of melanocytes within the iris stroma. **Why "All of the above" is correct:** 1. **Malignant Melanoma of Iris:** This is a neoplastic cause of **hyperchromic** heterochromia. The proliferation of malignant melanocytes increases the pigment density, making the affected iris appear darker than the normal side. 2. **Sympathetic Paralysis (Horner’s Syndrome):** The sympathetic nervous system is essential for the development and maintenance of iris pigmentation. Congenital Horner’s syndrome leads to **hypochromic** heterochromia (the affected eye is lighter) because the melanocytes fail to mature without sympathetic stimulation. 3. **Glaucomatocyclitis Crisis (Posner-Schlossman Syndrome):** Recurrent episodes of acute intraocular pressure spikes and mild anterior uveitis can lead to iris atrophy over time. This loss of iris stroma and pigment results in a lighter-colored iris (**hypochromic** heterochromia) in the affected eye. **High-Yield Clinical Pearls for NEET-PG:** * **Fuchs’ Heterochromic Iridocyclitis (FHI):** The most common cause of heterochromia in clinical practice. It typically presents as a lighter-colored iris (hypochromic) with fine, stellate Keratic Precipitates (KPs) and a high risk of cataract and glaucoma. * **Siderosis Bulbi:** A retained iron intraocular foreign body can cause the iris to turn rusty brown (**hyperchromic**). * **Latanoprost (Prostaglandin analogues):** A common pharmacological cause of increased iris pigmentation (**hyperchromic**). * **Waardenburg Syndrome:** A systemic cause featuring heterochromia, white forelock, and sensorineural deafness.

Q: Which syndrome is characterized by the following ocular finding?

Goldenhar's syndrome. ***Goldenhar's syndrome*** - Characterized by **epibulbar (limbal) dermoids**, typically located at the **inferotemporal limbus** as shown in the image. - Part of the **oculo-auriculo-vertebral spectrum** with associated **microtia**, **preauricular tags**, and **vertebral anomalies**. *Moebius syndrome* - Primary feature is **congenital facial paralysis** due to **cranial nerve VI and VII palsy**, not limbal dermoids. - Ocular findings include **limited horizontal eye movements** and **lagophthalmos**, but no epibulbar masses. *Alagille syndrome* - Characterized by **posterior embryotoxon** (prominent Schwalbe's line) and **retinal pigmentary changes**. - Associated with **liver disease**, **cardiac defects**, and **butterfly vertebrae**, but no limbal dermoids. *Treacher Collins syndrome* - Ocular findings include **downslanting palpebral fissures**, **lower eyelid colobomas**, and **absent lower eyelashes**. - Features **mandibular hypoplasia** and **external ear malformations**, but epibulbar dermoids are not characteristic.

Q: All are causes of chronic granulomatous uveitis EXCEPT:

Fuchs heterochromic iridocyclitis. **Explanation:** Uveitis is clinically classified into **granulomatous** and **nongranulomatous** types based on the nature of the inflammatory infiltrate. Granulomatous uveitis is typically chronic and characterized by large, "mutton-fat" keratic precipitates (KPs), Koeppe and Busacca nodules, and is usually associated with systemic infections or autoimmune conditions. **Why Fuchs Heterochromic Iridocyclitis (FHI) is the correct answer:** FHI is a chronic, low-grade, typically unilateral **nongranulomatous** uveitis. Despite its chronic nature, it presents with fine, stellate, diffuse KPs distributed over the entire corneal endothelium, rather than the large, greasy mutton-fat KPs seen in granulomatous disease. It is unique because it lacks typical signs of inflammation like synechiae or redness. **Analysis of Incorrect Options:** * **Sarcoidosis:** A classic cause of bilateral granulomatous uveitis. It presents with mutton-fat KPs, iris nodules, and "string of pearls" vitreous opacities. * **Tuberculosis:** A common infectious cause of granulomatous uveitis in India. It can present as disseminated choroiditis or focal granulomas (tuberculomas). * **Brucellosis:** A zoonotic infection known to cause chronic granulomatous inflammation affecting the posterior segment (multifocal choroiditis) and anterior segment. **NEET-PG High-Yield Pearls:** * **FHI Triad:** Heterochromia iris (affected eye is usually lighter), cataract, and glaucoma. * **Mutton-fat KPs:** Composed of epithelioid cells and macrophages (pathognomonic for granulomatous uveitis). * **Vogt-Koyanagi-Harada (VKH) Syndrome:** Another high-yield cause of bilateral chronic granulomatous uveitis associated with poliosis and vitiligo. * **Syphilis:** Known as the "Great Mimicker," it can cause both granulomatous and nongranulomatous uveitis.

Q: Which of the following can cause lid retraction?

All of the above. **Explanation:** Lid retraction (Dalrymple’s sign) occurs when the upper eyelid rests at or above the superior limbus, exposing the sclera. This can result from myogenic, neurogenic, or mechanical causes. 1. **Graves’ Ophthalmopathy:** This is the most common cause of lid retraction. It occurs due to **sympathetic overactivity** of Müller’s muscle and inflammatory fibrosis/contraction of the Levator Palpebrae Superioris (LPS) muscle. 2. **Hypokalemic Periodic Paralysis:** During an attack, patients may exhibit lid retraction. This is thought to be due to a **hyper-excitable state** of the muscle membrane or a compensatory over-action of the levator muscle during periods of generalized muscle weakness. 3. **Cirrhosis of the Liver:** This is a classic systemic association known as **Summerskill’s sign**. The exact mechanism is not fully understood but is attributed to increased sympathetic activity and high levels of circulating amines (like tyramine) that the cirrhotic liver fails to metabolize. **Clinical Pearls for NEET-PG:** * **Collier’s Sign:** Lid retraction due to a lesion in the midbrain (Parinaud’s Syndrome). * **Pseudo-lid retraction:** Can occur in contralateral ptosis (Hering’s Law of equal innervation) or in unilateral high myopia/buphthalmos. * **Kocher’s Sign:** Staring look on fixed gaze. * **Von Graefe’s Sign:** Lid lag on downgaze (characteristic of thyroid eye disease). Since all three conditions listed are documented causes of lid retraction, the correct answer is **D**.

Q: Vascular invasion is commonly seen in which of the following ocular tumors?

Malignant melanoma. **Explanation:** **Malignant Melanoma** of the uvea is the most common primary intraocular malignancy in adults. Its hallmark feature is its high propensity for **hematogenous spread** (vascular invasion). Unlike many other tumors, uveal melanoma lacks a lymphatic drainage system; therefore, it spreads primarily through the bloodstream. The tumor cells invade the rich vascular network of the choroid, frequently metastasizing to the **liver** (the most common site of distant metastasis). Histologically, the presence of "vascular loops" or high microvascular density is a significant prognostic indicator for metastasis. **Why other options are incorrect:** * **Retinoblastoma:** While it is the most common intraocular tumor in children, it primarily spreads via **direct extension** through the optic nerve to the CNS or via the subarachnoid space. Hematogenous spread occurs late and is less characteristic than direct neural invasion. * **Optic Nerve Gliomas:** These are benign, slow-growing tumors (usually pilocytic astrocytomas) associated with Neurofibromatosis Type 1. They spread by local expansion along the nerve sheath rather than vascular invasion. * **Medullo-epitheliomas (Diktyoma):** These are rare congenital tumors arising from the ciliary body epithelium. They are usually locally invasive but rarely exhibit systemic vascular metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of metastasis for Uveal Melanoma:** Liver (>90% of cases). * **Callender Classification:** Used for prognosis in melanoma (Spindle A, Spindle B, Mixed, and Epithelioid; Epithelioid has the worst prognosis). * **Genetic Marker:** Monosomy 3 is a strong predictor of metastatic potential in uveal melanoma. * **Treatment of choice:** Plaque radiotherapy (Brachytherapy) for medium-sized tumors; Enucleation for large tumors.

Question 1

Epidemic dropsy is characterised by all EXCEPT:

Accepted Answer

Hard exudates

Answer

Disc edema

Answer

Peri retinal haemorrhage

Answer

Tortuous retinal vessels

Question 2

Which of the following is the most common cause of anterior uveitis?

Accepted Answer

Idiopathic

Answer

HLA-B27 associated

Answer

Sarcoidosis

Answer

Tuberculosis

Question 3

What is the most common benign tumor of the eyelids?

Accepted Answer

Simple papilloma

Answer

Xanthelasma

Answer

Capillary haemangioma

Answer

Neurofibroma

Question 4

What is the cause of acute vision loss in a patient with alcoholic pancreatitis?

Accepted Answer

Puscher's retinopathy

Answer

Sudden alcohol withdrawal

Answer

Acute congestive glaucoma

Answer

Central retinal artery occlusion (CRAO)

Question 5

Heterochromia iridis is a feature of:

Accepted Answer

All of the above

Answer

Malignant melanoma of iris

Answer

Sympathetic paralysis

Answer

Glaucomatocyclitis crisis

Question 6

Which syndrome is characterized by the following ocular finding?

Accepted Answer

Goldenhar's syndrome

Answer

Moebius syndrome

Answer

Alagille syndrome

Answer

Treacher Collins syndrome

Question 7

All are causes of chronic granulomatous uveitis EXCEPT:

Accepted Answer

Fuchs heterochromic iridocyclitis

Answer

Sarcoidosis

Answer

Tuberculosis

Answer

Brucellosis

Question 8

Which of the following statements is not true regarding uveitis?

Accepted Answer

Arlt's line is a triangle-shaped aggregation of Keratic precipitates.

Answer

Intermediate uveitis involves the pars plana.

Answer

Festooned pupil is associated with posterior synechiae.

Answer

Polychromatic luster is a complication of uveitis.

Question 9

Which of the following can cause lid retraction?

Accepted Answer

All of the above

Answer

Graves' ophthalmopathy

Answer

Hypokalemic periodic paralysis

Answer

Cirrhosis of the liver

Question 10

Vascular invasion is commonly seen in which of the following ocular tumors?

Accepted Answer

Malignant melanoma

Answer

Retinoblastoma

Answer

Optic nerve gliomas

Answer

Medullo-epitheliomas

Ocular Manifestations of Systemic Disorders — MCQs

Ocular Manifestations of Systemic Disorders — MCQs

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