Sports-Related Eye Injuries — MCQs
A boy presents with diplopia and restriction of eye movements following blunt trauma to his eye. X-ray reveals blow out fracture of orbit. Which part of orbit is most likely damaged?
Which of the following is NOT a characteristic of a blowout fracture of the orbit?
Which drug is generally contraindicated in the management of traumatic hyphema in a patient with sickle cell disease?
Most serious injury to the eye is caused by:
A 20-year-old man is hit on the eye with a ball, and on examination, there is restriction of upward gaze and diplopia, with no obvious visible signs of injury to the eye ball, but with some enophthalmos. What is the likely diagnosis?
A young adult presents with proptosis and pain in eye after 4 days of trauma to eye. Chemosis, conjunctival congestion and extraocular muscle palsy with inability to move eye are seen.Investigation of choice -
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:
Vossius ring occurs in
A young 23-year-old black African man presents with a hyphema in the right eye after blunt injury. All of the following are acceptable initial treatments except?
Berlin's edema is due to
Sports-Related Eye Injuries Indian Medical PG Practice Questions and MCQs
Question 1: A boy presents with diplopia and restriction of eye movements following blunt trauma to his eye. X-ray reveals blow out fracture of orbit. Which part of orbit is most likely damaged?
- A. Inferior wall (Correct Answer)
- B. Medial wall
- C. Lateral wall
- D. Superior wall
Explanation: ***Inferior wall*** - The **inferior wall** (orbital floor) is the most common site for **blowout fractures** because it is the weakest and thinnest part of the orbital bone. - A fracture here often causes **entrapment** of the inferior rectus muscle and/or periorbital tissues, leading to **diplopia** and **restricted eye movements**, especially on upward gaze. *Medial wall* - While relatively thin, the medial wall is less commonly fractured in isolation than the inferior wall in typical blowout injuries. - Fractures here might involve the **ethmoid sinuses** and can lead to **subcutaneous emphysema** or **epistaxis**, which are not reported as primary symptoms in this case. *Lateral wall* - The lateral wall is the **thickest and strongest** part of the orbit, making fractures of this wall less common in isolated blowout injuries. - Fractures here typically require significant force and are often associated with other facial bone trauma. *Superior wall* - The superior wall (orbital roof) is made of the **frontal bone** and is relatively thick, making fractures here uncommon. - Fractures of the superior wall carry a risk of **intracranial injury** due to proximity to the brain, which is not suggested by the patient's presentation.
Question 2: Which of the following is NOT a characteristic of a blowout fracture of the orbit?
- A. Orbital floor and medial wall involvement are common
- B. Exophthalmos (Correct Answer)
- C. Tear drop sign on CT scan
- D. Diplopia due to muscle entrapment
Explanation: ***Exophthalmos*** - A **blowout fracture** typically causes the orbital contents to herniate into adjacent sinuses (maxillary or ethmoid), leading to an **increase in orbital volume**. - This increased orbital volume, combined with swelling and potential hemorrhage, usually results in **enophthalmos** (recession of the eyeball), not exophthalmos (protrusion of the eyeball). *Orbital floor and medial wall involvement are common* - The **orbital floor** (paper-thin bone separating the orbit from the maxillary sinus) and **medial wall** (separating the orbit from the ethmoid sinus) are the weakest structures of the orbit and are most commonly fractured in a blowout injury. - These areas are susceptible to fracture due to the force transmitted to the orbital contents, causing a sudden increase in intraorbital pressure. *Tear drop sign on CT scan* - The **tear drop sign** on a CT scan is a classic finding in orbital blowout fractures, representing the **herniation of orbital fat** or inferior rectus muscle into the maxillary sinus. - This sign indicates the displacement of soft tissue through the fractured orbital floor. *Diplopia due to muscle entrapment* - **Diplopia** (double vision) is a common symptom in blowout fractures, often caused by the **entrapment of extraocular muscles** (most commonly the inferior rectus or medial rectus) within the fracture site. - Muscle entrapment restricts ocular motility, particularly on upward or sideways gaze, leading to double vision.
Question 3: Which drug is generally contraindicated in the management of traumatic hyphema in a patient with sickle cell disease?
- A. Timolol
- B. Steroids
- C. Acetazolamide (Correct Answer)
- D. Atropine
Explanation: ***Acetazolamide*** - **Acetazolamide** is a **carbonic anhydrase inhibitor** that is **generally contraindicated** in patients with **sickle cell disease or trait**. - It causes **systemic acidosis** by increasing renal bicarbonate excretion, which lowers blood pH. - **Acidosis promotes sickling** of red blood cells, which can lead to **vaso-occlusion**, increased blood viscosity, and potential complications including **anterior chamber obstruction** and **secondary glaucoma**. - Despite its usefulness in lowering intraocular pressure in other settings, this risk makes it contraindicated in sickle cell patients with hyphema. *Timolol* - **Timolol** is a **beta-blocker** that reduces aqueous humor production and is generally **safe and effective** for reducing **intraocular pressure** in traumatic hyphema. - It does not cause systemic acidosis or affect red blood cell sickling. - Commonly used in hyphema management regardless of sickle cell status. *Steroids* - **Topical or systemic steroids** are often used to reduce **inflammation** and anterior chamber reaction in traumatic hyphema. - They help prevent **secondary hemorrhage** and reduce complications. - They do not contribute to red blood cell sickling or systemic acidosis and are safe in sickle cell disease. *Atropine* - **Atropine** is a **cycloplegic agent** used to paralyze the ciliary body and dilate the pupil, which helps **relieve pain** and prevent **posterior synechiae** in hyphema. - It has no adverse effects related to **sickle cell disease** or red blood cell sickling. - Routinely used in hyphema management.
Question 4: Most serious injury to the eye is caused by:
- A. Nitric acid
- B. Hydrochloric acid
- C. Lime (Correct Answer)
- D. Sulphuric acid
Explanation: ***Lime*** - **Lime (calcium hydroxide)** is an **alkali** that causes **liquefactive necrosis** of ocular tissues, leading to deep penetration and severe, progressive damage. - Alkaline burns saponify cell membranes, resulting in continuous tissue destruction and potentially **corneal opacification**, **limbal ischemia**, and **perforation**. *Nitric acid* - **Nitric acid** is a strong acid that causes **coagulation necrosis**, which tends to create a protective barrier on the tissue. - While serious, this barrier often limits deeper penetration and tissue destruction compared to alkalis. *Hydrochloric acid* - **Hydrochloric acid** is also a strong acid and causes **coagulation necrosis**, similar to nitric acid. - This type of injury typically results in superficial damage to the eye, as the denatured proteins form a physical barrier. *Sulphuric acid* - **Sulphuric acid**, another strong acid, also primarily causes **coagulation necrosis**. - Although it can dehydrate tissues and cause significant superficial damage, its effect is generally less severe and penetrating than strong alkalis.
Question 5: A 20-year-old man is hit on the eye with a ball, and on examination, there is restriction of upward gaze and diplopia, with no obvious visible signs of injury to the eye ball, but with some enophthalmos. What is the likely diagnosis?
- A. Zygoma fracture
- B. Maxillary fracture
- C. Blow out fracture of the orbit (Correct Answer)
- D. Injury to lateral rectus
Explanation: ***Blow out fracture of the orbit*** - This fracture typically involves the **orbital floor** or medial wall, leading to prolapse of orbital contents into the maxillary or ethmoid sinus. - Symptoms like **diplopia** (due to muscle entrapment), **restricted gaze** (especially upward gaze if the inferior rectus is trapped), and **enophthalmos** (due to increased orbital volume) are classic signs. *Zygoma fracture* - A zygoma fracture primarily affects the cheekbone and can cause facial flattening, trismus (difficulty opening the mouth), and numbness in the distribution of the infraorbital nerve. - While it can indirectly affect orbital integrity, the specific combination of restricted gaze and enophthalmos points more directly to an orbital blow-out. *Maxillary fracture* - Maxillary fractures often present with midfacial pain, swelling, malocclusion, and sometimes epistaxis. - While some maxillary fractures can involve the orbital floor, the isolated presentation of restricted gaze, diplopia, and enophthalmos without other prominent midfacial signs makes a specific blow-out fracture diagnosis more probable. *Injury to lateral rectus* - Isolated injury to the lateral rectus muscle would primarily cause **restricted lateral gaze** and horizontal diplopia due to impaired abduction of the eye. - It would not typically explain **restricted upward gaze** or **enophthalmos**, which are more indicative of structural damage and entrapment within the orbit.
Question 6: A young adult presents with proptosis and pain in eye after 4 days of trauma to eye. Chemosis, conjunctival congestion and extraocular muscle palsy with inability to move eye are seen.Investigation of choice -
- A. MR angiography
- B. CT
- C. MRI
- D. Digital subtraction angiography (Correct Answer)
Explanation: ***Digital subtraction angiography*** - The combination of **proptosis**, **pain**, **chemosis**, **conjunctival congestion**, and **extraocular muscle palsy** following trauma strongly suggests a **carotid-cavernous fistula (CCF)**. - **Digital subtraction angiography (DSA)** is the **gold standard** for diagnosing and characterizing CCFs, providing detailed visualization of arterial and venous flow. *MR angiography* - While MRA can provide information about vascular structures, it is less sensitive and specific than DSA for detecting and characterizing subtle shunts in **carotid-cavernous fistulas**. - It might miss smaller fistulas or provide insufficient detail for therapeutic planning. *CT* - **Computed tomography (CT)** is useful for assessing orbital bony structures, but it offers limited information regarding the dynamic blood flow and shunt characteristics crucial for diagnosing **carotid-cavernous fistulas**. - **CT angiography** can provide some vascular detail, but it is generally less comprehensive than DSA for this specific condition. *MRI* - **Magnetic Resonance Imaging (MRI)** can show orbital soft tissue changes and identify potential vascular abnormalities, but it lacks the real-time, high-resolution vascular detail of DSA, especially for depicting the exact location and flow dynamics of an **arteriovenous shunt**. - It is often used as a preliminary imaging modality but is not the definitive diagnostic tool for **carotid-cavernous fistulas**.
Question 7: 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 8: Vossius ring occurs in
- A. Lens dislocation
- B. Concussion injury (Correct Answer)
- C. Penetrating injury
- D. Extra capsular extraction
Explanation: ***Concussion injury*** - A Vossius ring is a circular deposit of **iris pigment** on the anterior lens capsule, formed by direct contact between the iris and the lens following **blunt ocular trauma**. - This typically occurs during a **concussion injury** to the eye, where the force temporarily compresses the iris against the lens. *Lens dislocation* - While lens dislocation is also a traumatic injury, a Vossius ring is not a direct consequence but rather a separate finding. - Lens dislocation involves the displacement of the **lens from its normal position**, often due to rupture of zonular fibers. *Penetrating injury* - A penetrating injury involves a **breach of the globe's integrity**, often by a sharp object, leading to different sequelae such as uveal prolapse or traumatic cataract. - Vossius rings are characteristic of **blunt trauma**, not penetrating trauma. *Extra capsular extraction* - Extracapsular extraction is a surgical procedure for **cataract removal**, not a type of injury. - This procedure involves removing the lens nucleus and cortex while leaving the posterior capsule intact.
Question 9: A young 23-year-old black African man presents with a hyphema in the right eye after blunt injury. All of the following are acceptable initial treatments except?
- A. Sleep with the head elevated
- B. Cyclopentolate dilating drops
- C. Carbonic anhydrase inhibitor pressure drops (Correct Answer)
- D. Prednisolone steroid eye drops
Explanation: ***Carbonic anhydrase inhibitor pressure drops*** - **Carbonic anhydrase inhibitors** are generally avoided in patients with **sickle cell trait or disease** because they can cause **acidosis**, which may induce RBC sickling within the anterior chamber and worsen secondary hemorrhage or complications like **increased intraocular pressure (IOP)**. - The patient's presentation as a **young black African man** increases the suspicion for **sickle cell trait/disease**, making this treatment potentially harmful. *Sleep with the head elevated* - Elevating the head of the bed helps to settle red blood cells and debris inferiorly in the anterior chamber, which can prevent them from obstructing vision and potentially **reduce rebleeding rates**. - This position can also contribute to **reducing intraocular pressure** by promoting aqueous outflow and preventing pooling of blood. *Cyclopentolate dilating drops* - **Cyclopentolate** is a **cycloplegic agent** that helps to relieve ciliary spasm and pain associated with trauma. - It also dilates the pupil, which helps to prevent **posterior synechiae formation** (adhesions between the iris and lens) and allows for better examination of the fundus. *Prednisolone steroid eye drops* - **Topical corticosteroids** like prednisolone are used to reduce intraocular inflammation that often accompanies a hyphema. - Anti-inflammatory effects help to decrease the risk of **secondary hemorrhage** and improve overall healing by stabilizing damaged blood vessels.
Question 10: Berlin's edema is due to
- A. Blunt trauma to eye (Correct Answer)
- B. Choroidal melanoma
- C. Pars planitis
- D. Extradural hemorrhage
Explanation: ***Blunt trauma to eye*** - **Berlin's edema**, also known as **commotio retinae**, is a form of **retinal edema** that occurs after **blunt trauma to the eye**. - The trauma causes a disruption of the photoreceptor outer segments and retinal pigment epithelium, leading to extracellular and intracellular fluid accumulation. *Choroidal melanoma* - This is a **malignant tumor** arising from the melanocytes in the choroid, not caused by trauma. - Presents as a pigmented mass in the choroid and can lead to **retinal detachment** or **vision loss** due to tumor growth. *Pars planitis* - This is a form of **intermediate uveitis**, characterized by inflammation of the pars plana, ciliary body, and peripheral retina. - It is an **inflammatory condition**, not directly caused by acute trauma, and often presents with **floaters** and **blurred vision**. *Extradural hemorrhage* - This refers to bleeding between the inner surface of the skull and the dura mater, typically in the brain. - It is a **neurological emergency** usually caused by head injury, and its direct effect is not Berlin's edema in the eye.
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