Ocular Manifestations of Child Abuse — MCQs
Which of the following is not a differential diagnosis of non-accidental injury?
A subconjunctival hemorrhage occurs in all conditions except which of the following?
Following injury to the right temple region, a patient complains of pain in the right eye and loss of vision. On examination, the eye movements are normal, and the pupil normally reacts to light. The affected eye shows increased intraocular pressure of 32 mmHg (normal: 10-21 mmHg), mild corneal edema, and a small hyphema visible in the anterior chamber. The diagnosis is
All of the following are complications of traumatic hyphema except which of the following?
What is the typical appearance of a subhyaloid hemorrhage in the eye?
A young adult presents 2 days after trauma to the eye with proptosis and pain in the right eye. On examination, he is found to have a bruise on the right eye and forehead. The most likely diagnosis is:
Which of the following is a characteristic feature of Battered Baby Syndrome (Non-Accidental Injury)?
All are manifestation of dengue virus infection in eye except?
Dose of vitamin A for an 18 month old baby, with keratomalacia, weighing 10 kg is?
All are seronegative spondyloarthritides with ocular manifestations, except
Ocular Manifestations of Child Abuse Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not a differential diagnosis of non-accidental injury?
- A. Osteogenesis imperfecta
- B. Scurvy
- C. Caffey's disease
- D. Osteopetrosis (Correct Answer)
Explanation: ***Correct: Osteopetrosis*** - Osteopetrosis is a rare genetic disorder characterized by **increased bone density** due to defective osteoclast function - While it causes bones to be brittle and prone to fracture, it has **distinctive radiological features** including diffuse sclerosis and "bone-within-bone" appearance - The **increased bone density on X-ray** is pathognomonic and readily distinguishes it from NAI, making it **less likely to be confused** with non-accidental injury in clinical practice - Fractures occur but the radiological pattern is diagnostic of the underlying metabolic bone disease *Incorrect: Osteogenesis imperfecta* - This is a **classic differential** for NAI causing **multiple brittle bone fractures** that can be mistaken for abuse - Features include **blue sclera**, **dentinogenesis imperfecta**, **wormian bones**, and **family history** - Often presents with multiple fractures at different stages of healing, mimicking the pattern seen in NAI *Incorrect: Scurvy* - Caused by **vitamin C deficiency**, leads to defective collagen synthesis - Results in **subperiosteal hemorrhages**, **metaphyseal fractures**, and **periosteal elevation** that closely mimic NAI - Additional features include **gingival bleeding**, **petechiae**, **follicular hyperkeratosis**, and **poor wound healing** *Incorrect: Caffey's disease* - Also known as **infantile cortical hyperostosis**, presents in infants under 6 months - Causes **periosteal reactions**, **bone thickening**, and **soft tissue swelling** in long bones, ribs, and mandible - The periosteal new bone formation can be mistaken for healing fractures from NAI, making it an important differential
Question 2: A subconjunctival hemorrhage occurs in all conditions except which of the following?
- A. Pertussis
- B. Trauma
- C. High intraocular tension (Correct Answer)
- D. Passive venous congestion
Explanation: ***High intraocular tension*** - **High intraocular tension** (or glaucoma) is characterized by increased pressure within the eye, which primarily affects the optic nerve. - It does not directly cause subconjunctival hemorrhage; rather, it can lead to vision loss, optic nerve damage, and other ocular complications. *Pertussis* - **Pertussis** (whooping cough) involves severe coughing paroxysms, which can significantly increase intrathoracic and intra-abdominal pressure. - This elevated pressure can rupture small blood vessels in the conjunctiva, leading to a subconjunctival hemorrhage. *Trauma* - **Trauma** to the eye or surrounding area, such as a direct blow, can cause blood vessels in the conjunctiva to rupture. - Even minor trauma like rubbing the eye too vigorously can result in a subconjunctival hemorrhage. *Passive venous congestion* - **Passive venous congestion**, often associated with straining, vomiting, or other activities that increase venous pressure in the head and neck. - This increase in pressure can lead to the extravasation of blood from small conjunctival vessels, resulting in a subconjunctival hemorrhage.
Question 3: Following injury to the right temple region, a patient complains of pain in the right eye and loss of vision. On examination, the eye movements are normal, and the pupil normally reacts to light. The affected eye shows increased intraocular pressure of 32 mmHg (normal: 10-21 mmHg), mild corneal edema, and a small hyphema visible in the anterior chamber. The diagnosis is
- A. Traumatic glaucoma (Correct Answer)
- B. Optic nerve atrophy
- C. Sub-arachnoid haemorrhage
- D. Functional loss of vision
Explanation: ***Traumatic glaucoma*** - Increased **intraocular pressure (32 mmHg)** after a **temple injury** with **corneal edema** and **hyphema** are classic signs of traumatic glaucoma. - The hyphema (blood in the anterior chamber) obstructs the **trabecular meshwork**, impeding aqueous humor outflow and leading to elevated IOP. *Optic nerve atrophy* - While optic nerve atrophy can cause **vision loss**, it is a chronic condition and typically not an acute presentation following trauma unless there is direct optic nerve damage. - It would not explain the acute findings of **hyphema**, **corneal edema**, or acutely elevated **intraocular pressure**. *Sub-arachnoid haemorrhage* - A **sub-arachnoid hemorrhage** might present with headache and loss of consciousness, or **papilledema** in severe cases, but typically would not cause such specific eye findings as **hyphema** or **corneal edema** from elevated IOP. - While a blow to the head could cause this, the direct eye findings point to a local ocular issue. *Functional loss of vision* - **Functional vision loss** (or psychogenic vision loss) is a diagnosis of exclusion where no organic cause can be found. - The presence of clear organic signs such as **hyphema**, **corneal edema**, and significantly elevated **intraocular pressure** rules out a functional cause.
Question 4: All of the following are complications of traumatic hyphema except which of the following?
- A. Pupillary Block
- B. Posterior synechiae
- C. Rebleeding
- D. Corneal Ulcer (Correct Answer)
Explanation: ***Corneal Ulcer*** - A **corneal ulcer** is typically caused by infection, trauma, or exposure keratitis and is not a direct complication of blood in the anterior chamber from a **traumatic hyphema**. - While prolonged elevation of **intraocular pressure** from hyphema could theoretically impair corneal health, a direct ulcer is not a typical or primary complication. *Rebleeding* - **Rebleeding** is a common and serious complication of hyphema, usually occurring 2-7 days after the initial injury. - It often results in a more significant bleed and carries a higher risk of complications such as **elevated intraocular pressure** and **blood staining of the cornea**. *Pupillary Block* - **Pupillary block** can occur if the amount of blood from the hyphema prevents the flow of aqueous humor from the posterior to the anterior chamber. - This blockage leads to a buildup of **aqueous humor** in the posterior chamber, causing the iris to bow forward and potentially precipitating **acute angle-closure glaucoma**. *Posterior synechiae* - **Posterior synechiae** can develop due to inflammation (uveitis) associated with the hyphema, where the iris adheres to the anterior lens capsule. - This complication can lead to **irregular pupil shape**, **pupillary block glaucoma**, or other visual disturbances.
Question 5: What is the typical appearance of a subhyaloid hemorrhage in the eye?
- A. Boat shaped (Correct Answer)
- B. Crescent shaped
- C. Round
- D. Flame shaped
Explanation: ***Boat shaped*** - A subhyaloid hemorrhage is located beneath the **hyaloid membrane** (the posterior vitreous cortex), which is attached to the retina. - The collected blood often assumes a **dependent, gravity-influenced shape**, appearing flat on top and curved underneath, resembling a boat. *Crescent shaped* - This shape is not characteristic of a typical subhyaloid hemorrhage; it might be seen in other types of hemorrhages or detachment patterns. - **Crescentic shapes** are more commonly associated with certain types of **retinal detachments** or tears where fluid accumulation takes on a curved boundary. *Round* - While hemorrhages can be round, a subhyaloid hemorrhage typically spreads out due to gravity within the confined space, resulting in a more distinct shape. - A **perfectly round hemorrhage** is less common in the subhyaloid space as blood tends to layer out rather than remain as a sphere. *Flame shaped* - **Flame-shaped hemorrhages** are typically found in the **nerve fiber layer** due to the orientation of nerve fibers. - These hemorrhages are shallower and follow the linear arrangement of nerve fibers, unlike the larger, more globular subhyaloid bleeds.
Question 6: A young adult presents 2 days after trauma to the eye with proptosis and pain in the right eye. On examination, he is found to have a bruise on the right eye and forehead. The most likely diagnosis is:
- A. Cavernous sinus thrombosis
- B. Carotico-cavernous fistula (Correct Answer)
- C. Internal carotid artery aneurysm
- D. Fracture sphenoid bone
Explanation: ***Carotico-cavernous fistula*** - The presentation of **proptosis**, **pain**, and a **bruise on the eye and forehead** following trauma is highly suggestive of a carotico-cavernous fistula. - This condition involves an abnormal connection between the **carotid artery** and the **cavernous sinus**, often resulting from trauma, leading to increased venous pressure and orbital congestion. *Cavernous sinus thrombosis* - This condition is typically associated with **infection** spreading from the face or sinuses, rather than direct trauma. - While it can cause proptosis and pain, the presence of a distinct bruise and forehead involvement post-trauma points away from an infectious etiology. *Internal carotid artery aneurysm* - An aneurysm itself usually does not immediately present with **proptosis** and **ecchymosis** unless it has ruptured or is causing direct compression. - While an aneurysmal rupture could cause hemorrhage, the specific cluster of symptoms post-trauma strongly favors a vascular shunting issue. *Fracture sphenoid bone* - A sphenoid bone fracture can occur with head trauma, but it would typically present with symptoms such as **cranial nerve deficits** (especially optic nerve or oculomotor nerve dysfunction), **CSF leak**, or **hemorrhage** into surrounding structures. - While a fracture could indirectly contribute to other issues, it doesn't directly explain the combination of proptosis, pain, and orbital bruising as a primary diagnosis in this context.
Question 7: Which of the following is a characteristic feature of Battered Baby Syndrome (Non-Accidental Injury)?
- A. Stab injury
- B. Firearm injury
- C. Bruises of varying ages (Correct Answer)
- D. None of the options
Explanation: ***Bruises of varying ages*** - The presence of bruises at **different stages of healing** is a hallmark indicator of **non-accidental trauma** or Battered Baby Syndrome, as it suggests repeated injuries occurring over time rather than a single incident. - **Forensic significance**: Fresh bruises (red/purple) alongside older bruises (yellow/green/brown) indicate multiple episodes of trauma, which is inconsistent with the caregiver's explanation of a single accidental event. - Other classic features include fractures (especially metaphyseal/corner fractures, rib fractures), subdural hematomas, retinal hemorrhages, and injuries in protected body areas. *Stab injury* - While a stab injury represents severe trauma requiring forensic investigation, it is **not characteristic** of the typical presentation pattern of Battered Baby Syndrome. - Stab wounds indicate a specific violent act rather than the pattern of **repeated blunt force trauma** that defines the syndrome. - Battered Baby Syndrome classically involves injuries from shaking, hitting, or blunt trauma rather than penetrating injuries. *Firearm injury* - A firearm injury is a distinct acute traumatic event that does not represent the **chronic, repetitive abuse pattern** seen in Battered Baby Syndrome. - Such injuries are typically isolated incidents rather than part of ongoing physical abuse with varied injury ages. - The syndrome is characterized by multiple injuries at different healing stages from repeated episodes, not single penetrating trauma. *None of the options* - This option is incorrect because "bruises of varying ages" is a **well-established forensic indicator** for diagnosing Battered Baby Syndrome in medical literature and practice. - The presence of injuries at multiple stages of healing is one of the most important diagnostic features that raises suspicion for non-accidental injury in pediatric forensic medicine.
Question 8: All are manifestation of dengue virus infection in eye except?
- A. Cataract (Correct Answer)
- B. Vitreous hemorrhage
- C. Maculopathy
- D. Optic neuritis
Explanation: ***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.
Question 9: Dose of vitamin A for an 18 month old baby, with keratomalacia, weighing 10 kg is?
- A. 1,00,000 IU
- B. 50,000 IU
- C. 5,00,000 IU
- D. 2,00,000 IU (Correct Answer)
Explanation: **2,00,000 IU** - For children 12 months of age and older with **keratomalacia** due to vitamin A deficiency, the recommended dose is **200,000 IU** orally, given immediately. - This dose should be repeated the next day and again after four weeks to replenish stores and prevent recurrence. *1,00,000 IU* - This dose is typically recommended for infants **aged 6 to 11 months** with **clinical vitamin A deficiency**, including keratomalacia. - It is insufficient for an 18-month-old child with active keratomalacia. *50,000 IU* - This dose is usually given to infants **under 6 months** of age with clinical signs of **vitamin A deficiency**. - It is too low for an 18-month-old baby with keratomalacia. *5,00,000 IU* - This dose is excessively high and potentially toxic for an 18-month-old child. - Vitamin A toxicity can lead to adverse effects, including **increased intracranial pressure** and liver damage.
Question 10: All are seronegative spondyloarthritides with ocular manifestations, except
- A. Psoriatic arthritis
- B. Rheumatoid arthritis (Correct Answer)
- C. Ankylospondylitis
- D. Reiter's disease
Explanation: ***Rheumatoid arthritis*** - While rheumatoid arthritis can have **ocular manifestations** (e.g., **scleritis**, **keratoconjunctivitis sicca**) [1], it is categorized as a **seropositive** arthritis due to the presence of **rheumatoid factor** and **anti-CCP antibodies** in most cases. - The question specifically asks for a condition that is *not* a seronegative spondyloarthritide. *Psoriatic arthritis* - This is a **seronegative spondyloarthritide** and can present with various **ocular manifestations**, including **conjunctivitis** and **uveitis**. - It lacks **rheumatoid factor** and typically involves the skin and joints. *Ankylospondylitis* - This is a classic example of a **seronegative spondyloarthritide**, strongly associated with **HLA-B27** [2]. - **Acute anterior uveitis** is a common ocular complication, affecting up to 40% of patients [2]. *Reiter's disease* - Now more commonly referred to as **reactive arthritis**, it is a **seronegative spondyloarthritide** by definition. - Ocular manifestations are prominent and include **conjunctivitis** and **anterior uveitis**, often part of the classic triad (arthritis, urethritis, conjunctivitis) [2].
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