Lacrimal System Disorders — MCQs
Which of the following findings is typically NOT seen in a patient with allergic conjunctivitis?
A patient presented with gradually progressive painless mass since 10 yrs. It is firm and nodular & variable in consistency at each site. Most probable diagnosis is?
Regarding Sjögren's syndrome, all are true except:
In a child presenting unilateral watering and photophobia which of the following is the least likely disorder?
Identify the investigation being carried out in the image.
Gland that secretes an oily substance is:
Massaging of nasolacrimal duct is done in ?
Surgery of choice for chronic acquired dacryocystitis
Surgery of choice for chronic acquired dacryocystitis
The most common benign tumour of the orbit is
Lacrimal System Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following findings is typically NOT seen in a patient with allergic conjunctivitis?
- A. Watery discharge
- B. Itching
- C. Bilateral eye redness
- D. Purulent discharge (Correct Answer)
Explanation: ***Purulent discharge*** - **Purulent discharge** (thick, yellowish, or greenish) is characteristic of **bacterial conjunctivitis** and is usually absent in allergic conjunctivitis. - Allergic conjunctivitis typically presents with a **clear or watery discharge**. *Watery discharge* - **Watery discharge** is a very common symptom of **allergic conjunctivitis**, often accompanied by itching and redness. - It results from the inflammatory response and increased lacrimation due to allergen exposure. *Itching* - **Ocular itching** is the hallmark symptom of allergic conjunctivitis and is considered its most distinctive feature. - It is caused by the release of **histamine** and other inflammatory mediators from mast cells in response to allergens. *Bilateral eye redness* - **Bilateral conjunctival redness** (hyperemia) is a frequent finding in allergic conjunctivitis. - This is due to **vasodilation** in response to the inflammatory process affecting both eyes, as airborne allergens often affect both simultaneously.
Question 2: A patient presented with gradually progressive painless mass since 10 yrs. It is firm and nodular & variable in consistency at each site. Most probable diagnosis is?
- A. Cystic lesion with central punctum (e.g., sebaceous cyst)
- B. Congenital cystic lesion (e.g., dermoid cyst)
- C. Pleomorphic adenoma (Correct Answer)
- D. Rapidly growing mass with systemic features (e.g., malignancy)
Explanation: **Pleomorphic adenoma** - This benign salivary gland tumor is characterized by **slow, painless growth over many years** and a **variable consistency** (firm to nodular) upon palpation due to its mixed epithelial and mesenchymal components. - The combination of a **long duration (10 years)** and its typical texture makes it the most probable diagnosis for a gradually progressive painless mass. *Cystic lesion with central punctum (e.g., sebaceous cyst)* - While sebaceous cysts are painless and grow slowly, they typically have a **smooth, uniform consistency** and a characteristic **central punctum**, which is not mentioned in the description. - Their growth is usually not described as "variable in consistency at each site." *Congenital cystic lesion (e.g., dermoid cyst)* - Dermoid cysts are present from birth and grow slowly, but they usually have a **consistent, firm, or doughy feel** and are often found in specific developmental fusion planes. - The description of "variable consistency at each site" does not fit the typical presentation of a simple congenital cyst. *Rapidly growing mass with systemic features (e.g., malignancy)* - Malignant masses typically show **rapid growth**, may be associated with **pain**, and can present with **systemic symptoms** like weight loss, which are absent in this case. - A 10-year history of painless, gradual progression makes a rapidly growing malignancy highly unlikely.
Question 3: Regarding Sjögren's syndrome, all are true except:
- A. Rheumatoid arthritis
- B. Keratoconjunctivitis sicca
- C. Epiphora (Correct Answer)
- D. Autoimmune in nature
Explanation: ***Epiphora*** - **Epiphora** refers to excessive tearing or watery eyes, which is not characteristic of Sjögren's syndrome. - Sjögren's syndrome is instead characterized by **dry eyes** due to decreased tear production. *Rheumatoid arthritis* - Sjögren's syndrome can occur as a **secondary condition** associated with other autoimmune diseases, including rheumatoid arthritis [1]. - This association means that individuals with rheumatoid arthritis have an increased risk of developing Sjögren's syndrome [1]. *Keratoconjunctivitis sicca* - **Keratoconjunctivitis sicca** (dry eyes) is a hallmark symptom of Sjögren's syndrome, resulting from inflammation and damage to the lacrimal glands [1]. - Patients experience chronic dryness, foreign body sensation, and irritation due to insufficient tear production [1]. *Autoimmune in nature* - Sjögren's syndrome is an **autoimmune disease** where the immune system mistakenly attacks the body's own moisture-producing glands, primarily the lacrimal and salivary glands. - This autoimmune attack leads to chronic inflammation and dysfunction of these glands, causing symptoms of dryness.
Question 4: In a child presenting unilateral watering and photophobia which of the following is the least likely disorder?
- A. Congenital entropion
- B. Congenital glaucoma
- C. Congenital NLDO (Correct Answer)
- D. Congenital dacryocystitis
Explanation: **Congenital NLDO** - **Congenital nasolacrimal duct obstruction (NLDO)** typically presents with **unilateral watering** (epiphora) due to blockage of tear drainage. - While it causes watering, **photophobia** is not a characteristic symptom of isolated NLDO, making it less likely given the combined presentation. *Congenital entropion* - **Congenital entropion** involves the inward turning of the eyelid margin, causing eyelashes to rub against the cornea. - This irritation can lead to **unilateral watering** and **photophobia** due to corneal abrasion and discomfort. *Congenital glaucoma* - **Congenital glaucoma** is characterized by elevated intraocular pressure, which can cause corneal edema and stretching. - These changes commonly result in **unilateral watering** (epiphora) and marked **photophobia**, often accompanied by **buphthalmos** (enlarged eye). *Congenital dacryocystitis* - **Congenital dacryocystitis** is an infection of the lacrimal sac, often secondary to NLDO. - It presents with **unilateral watering**, discharge, and inflammation of the lacrimal sac, and the associated irritation can induce **photophobia**.
Question 5: Identify the investigation being carried out in the image.
- A. Fluoroscopy
- B. X-ray after alkali ingestion
- C. X-ray after acid ingestion
- D. Barium Swallow (Correct Answer)
Explanation: ***Barium Swallow*** - The image shows a contrast material, characteristic of **barium**, flowing through the esophagus, captured as a sequence of X-ray images, which is the definition of a barium swallow study. - This **dynamic imaging** allows for evaluation of swallowing function and esophageal motility. *Fluoroscopy* - While a barium swallow uses **fluoroscopy** to visualize the movement of barium, fluoroscopy itself is the technique, not the specific investigation being performed. The image depicts the result of a specific type of fluoroscopic examination. - Fluoroscopy is a general term for real-time X-ray imaging, whereas "Barium Swallow" specifies the type of study being done on the upper GI tract. *X-ray after alkali ingestion* - This scenario would typically involve viewing the effects of **corrosive injury** to the esophagus, which would appear as mucosal damage, narrowing, or perforation. The image does not show these features; instead, it shows smooth passage of contrast. - There is no visible evidence of an acute or chronic injury pattern consistent with **alkali ingestion**, which often leads to severe burns or strictures. *X-ray after acid ingestion* - Similar to alkali ingestion, acid ingestion also causes **corrosive injury**, typically affecting the stomach more severely than the esophagus. The image does not demonstrate these pathological changes. - The smooth, unobstructed flow of contrast in multiple frames is indicative of normal esophageal function rather than the sequelae of corrosive ingestion.
Question 6: Gland that secretes an oily substance is:
- A. Meibomian gland (Correct Answer)
- B. Sweat gland
- C. Lacrimal gland
- D. Salivary gland
Explanation: ***Meibomian gland*** - These glands secrete **oily lipids** (meibum) that form the outermost layer of the tear film, preventing evaporation. - They are a type of **sebaceous gland** located within the eyelids. *Sweat gland* - Sweat glands produce a watery solution of electrolytes and metabolic waste products, primarily for **thermoregulation**. - They do not secrete an **oily substance**, but rather a clear, aqueous fluid. *Lacrimal gland* - The lacrimal gland produces the **aqueous layer of tears**, primarily for lubrication, washing away debris, and providing oxygen to the cornea. - Its secretion is predominantly **watery**, not oily. *Salivary gland* - Salivary glands produce **saliva**, a fluid containing enzymes (like amylase), mucins, and antibodies, important for digestion, lubrication, and oral hygiene. - Saliva is a **mucoserous or aqueous substance**, not an oily secretion.
Question 7: Massaging of nasolacrimal duct is done in ?
- A. Acute dacryocystitis
- B. Congenital dacryocystitis (Correct Answer)
- C. Conjunctivitis
- D. None of the options
Explanation: ***Congenital dacryocystitis*** - **Massaging the nasolacrimal duct** (Crigler massage) is a primary treatment for congenital dacryocystitis to promote the opening of the **valve of Hasner**. - This condition is due to incomplete canalization of the nasolacrimal duct, leading to tearing and discharge in infants. *Acute dacryocystitis* - This is an **acute infection of the lacrimal sac**, and massaging can worsen the condition by spreading the infection. - Treatment typically involves **antibiotics** and, if necessary, incision and drainage of any abscess. *Conjunctivitis* - **Conjunctivitis** is inflammation of the conjunctiva and is not related to obstruction of the nasolacrimal duct. - Massaging the nasolacrimal duct has no therapeutic role in treating conjunctivitis. *None of the options* - This option is incorrect because **congenital dacryocystitis** is a condition where nasolacrimal duct massage is a standard and effective treatment.
Question 8: Surgery of choice for chronic acquired dacryocystitis
- A. Probing and syringing
- B. Conjunctivo-dacryocystorhinostomy
- C. Dacryocystorhinostomy (Correct Answer)
- D. Dacryocystectomy
Explanation: ***Dacryocystorhinostomy*** - **Dacryocystorhinostomy (DCR)** is the surgical creation of a new drainage pathway between the **lacrimal sac** and the **nasal cavity**, bypassing the obstructed nasolacrimal duct. - It is the standard and most effective treatment for **chronic acquired dacryocystitis** because it permanently resolves the obstruction and restores tear flow. - Both external and endonasal approaches are highly successful, with success rates exceeding 90%. *Dacryocystectomy* - **Dacryocystectomy** involves the surgical **removal of the lacrimal sac**, which eliminates the source of infection but also prevents any tear drainage through that system. - This procedure is typically reserved for cases where preservation of the lacrimal drainage system is not possible, such as in cases of **tumors of the lacrimal sac** or recurrent severe infections unresponsive to DCR, and is not the first choice for restoring tear flow. *Conjunctivo-dacryocystorhinostomy* - **Conjunctivo-dacryocystorhinostomy (CDCR)** is performed when the obstruction is at the level of the **common canaliculus** or beyond, indicating involvement of the canalicular system. - This procedure usually involves placing a **Jones tube** to create a direct bypass from the conjunctiva to the nasal cavity and is reserved for proximal obstructions, not typical nasolacrimal duct obstruction. *Probing and syringing* - **Probing and syringing** are primarily diagnostic procedures used to assess patency of the lacrimal drainage system. - While therapeutic in **congenital dacryocystitis** in infants, they are ineffective for chronic acquired dacryocystitis in adults where established fibrosis and obstruction require definitive surgical bypass.
Question 9: Surgery of choice for chronic acquired dacryocystitis
- A. Dacryocystorhinostomy (Correct Answer)
- B. Dacryocystectomy
- C. Conjunctivo-cystorhinostomy
- D. None of the options
Explanation: ***Dacryocystorhinostomy*** - This procedure creates a new connection between the **lacrimal sac** and the **nasal cavity**, bypassing the obstructed nasolacrimal duct. - It is the **surgery of choice** for chronic acquired dacryocystitis as it provides a permanent solution for tear drainage. *Dacryocystectomy* - This involves **excision of the lacrimal sac**, which can relieve symptoms of infection but eliminates the sac's function. - It is generally reserved for cases where dacryocystorhinostomy is contraindicated or has failed, and is **not the primary choice** for restoring tear flow. *Conjunctivo-cystorhinostomy* - This procedure creates a bypass from the **conjunctiva** directly to the **nasal cavity**, typically used when the canaliculi are also obstructed. - It is a more complex surgery indicated for **proximal lacrimal system obstruction** (e.g., canalicular block) rather than isolated nasolacrimal duct obstruction. *None of the options* - **Dacryocystorhinostomy** is the well-established and most effective surgical intervention for chronic acquired dacryocystitis. - Therefore, this option is incorrect as there is a suitable surgical choice available.
Question 10: The most common benign tumour of the orbit is
- A. Optic nerve glioma
- B. Meningioma
- C. Benign-mixed tumour
- D. Haemangioma (Correct Answer)
Explanation: ***Haemangioma*** - **Cavernous haemangiomas** are the most frequently encountered benign tumors of the orbit in adults. - They are typically well-circumscribed, slow-growing vascular malformations that can cause **proptosis** and visual disturbances. *Optic nerve glioma* - While optic nerve gliomas are a benign tumor, they are less common than cavernous haemangiomas in the general orbital pathology. - These tumors specifically arise from the **optic nerve** and are more prevalent in children with **neurofibromatosis type 1 (NF1)**. *Meningioma* - **Orbital meningiomas** originate from the meninges surrounding the optic nerve or within the cranial cavity, extending into the orbit. - They are considered less common than haemangiomas and often present with a slower progression of symptoms like **proptosis** and **vision loss**. *Benign-mixed tumour* - This term usually refers to a **pleomorphic adenoma of the lacrimal gland**, which is the most common epithelial tumor of the lacrimal gland, but not the overall most common benign orbital tumor. - While benign, these tumors have a potential for malignant transformation and present with distinct symptoms related to the **lacrimal gland**.
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