Ophthalmic Surgery — MCQs

Ophthalmic Surgery Indian Medical PG Practice Questions and MCQs

Question 131: Where is the intraocular lens placed during cataract surgery?

A. Surface of iris
B. Capsular bag (Correct Answer)
C. Around the limbus
D. Over the face of vitreous

Explanation: ***Capsular bag*** - The **capsular bag** is the natural anatomical space where the human crystalline lens resides and is the ideal location for an intraocular lens (IOL) to mimic the natural lens's position and function. - Placing the IOL in the capsular bag provides **optimal stability**, centration, and reduces the risk of complications such as glare or secondary glaucoma. *Surface of iris* - Placing an IOL on the surface of the iris (**iris-fixated IOL**) is a less common surgical approach, typically reserved for cases where capsular support is absent or insufficient. - This position can lead to potential complications including **iris chafing**, pigment dispersion, and increased risk of uveitis or secondary glaucoma. *Over the face of vitreous* - Placing an IOL over the face of the vitreous typically occurs in cases of **capsular rupture** with inadequate posterior capsule support, requiring anterior vitrectomy and alternative IOL fixation. - This position is less stable and carries a higher risk of **vitreous prolapse**, retinal detachment, and cystoid macular edema compared to capsular bag placement. *Around the limbus* - The limbus is the **junction between the cornea and sclera** and is an entirely incorrect location for an intraocular lens implant. - An IOL around the limbus would be outside the globe and would serve no optical purpose within the eye, leading to **severe visual impairment** and potentially structural damage.

Question 132: Enucleation of the eyeball is contraindicated in:

A. Endophthalmitis
B. Intraocular tumours
C. Panophthalmitis (Correct Answer)
D. Painful blind eye

Explanation: ***Panophthalmitis*** - Enucleation is **relatively contraindicated** in **panophthalmitis** due to the high risk of spreading infection along the **optic nerve** to the **meninges**, potentially causing **meningitis** or brain abscess. - In panophthalmitis, the inflammatory process extends beyond the globe to involve **orbital tissues**, making enucleation potentially dangerous. - **Evisceration** (removing intraocular contents while preserving the scleral shell) is preferred over enucleation as it reduces the risk of CNS spread. - Medical management with systemic antibiotics is the first-line treatment. *Endophthalmitis* - **Endophthalmitis** is an infection confined to the interior of the eyeball (vitreous and aqueous humors). - Initial treatment is intravitreal antibiotics, but enucleation may be considered in severe, unresponsive cases to control infection and alleviate pain, especially if vision is unsalvageable. - This is an **indication** for enucleation in advanced cases, not a contraindication. *Intraocular tumours* - **Intraocular tumours**, such as retinoblastoma or choroidal melanoma, are common **indications** for enucleation to prevent metastasis and preserve life. - Enucleation is a crucial treatment for eliminating the tumour and preventing its spread. *Painful blind eye* - A **painful blind eye** is a frequent **indication** for enucleation, especially if the pain is severe and unresponsive to medical management. - Removing the eye can provide significant **pain relief** and improve the patient's quality of life.

Question 133: Dacryocystorhinostomy involves?

A. Opening the terminal blocked end of the nasolacrimal duct
B. Complete excision of the lacrimal sac
C. Insertion of a drainage tube in the lacrimal sac
D. Connecting the lacrimal sac to the nose by opening the medial wall (Correct Answer)

Explanation: ***Connecting the lacrimal sac to the nose by opening the medial wall*** - A **dacryocystorhinostomy (DCR)** is a surgical procedure to create a new drainage pathway between the **lacrimal sac** and the **nasal cavity**. - This bypasses an obstruction in the **nasolacrimal duct**, allowing tears to drain properly into the nose. *Opening the terminal blocked end of the nasolacrimal duct* - This describes a **dacryocystoplasty** or an attempt to probe the existing duct, which is a less invasive procedure than a DCR and often insufficient for complete obstruction. - While it aims to restore tear flow, it specifically addresses the terminal end rather than creating a new anastomosis. *Complete excision of the lacrimal sac* - This procedure is known as a **dacryocystectomy**, which is typically performed for tumors or chronic infections of the lacrimal sac that cannot be resolved otherwise. - It results in permanent dry eye and does not aim to restore tear drainage but rather to remove the problematic sac. *Insertion of a drainage tube in the lacrimal sac* - This describes **intubation** of the lacrimal drainage system, often using silicone tubes, which is usually a temporary measure to keep the duct patent after a procedure or for partial obstructions. - It is not the definitive surgical creation of a new permanent pathway, as achieved with a DCR.

Question 134: Expulsive hemorrhage in cataract surgery is from?

A. Vortex vein
B. Choroidal vein
C. Ciliary artery (Correct Answer)
D. None of the options

Explanation: ***Ciliary artery*** - Expulsive hemorrhage is a rare but devastating complication, typically resulting from the rupture of a **posterior ciliary artery** within the choroid. - This arterial rupture leads to a sudden, massive increase in intraocular pressure and extrusion of intraocular contents. *Vortex vein* - **Vortex veins** drain the choroid, and while their rupture could lead to hemorrhage, it is less likely to cause the highly pressurized, expulsive nature of a choroidal hemorrhage. - Hemorrhage from a vortex vein is generally less severe and less rapid in onset compared to arterial bleeding. *Choroidal vein* - **Choroidal veins** are part of the venous drainage system; bleeding from these vessels would typically be lower pressure and less likely to cause an expulsive hemorrhage. - Venous bleeds are generally slower and do not generate the rapid, violent pressure increase characteristic of expulsive hemorrhage. *None of the options* - This option is incorrect because the rupture of a ciliary artery is the direct cause of expulsive hemorrhage. - The other options are incorrect for the reasons stated above.

Question 135: What is the absolute indication for enucleation?

A. Mutilating ocular injury with infection risk
B. Severe endophthalmitis requiring enucleation
C. None of the options
D. Advanced intraocular retinoblastoma (Group D/E) (Correct Answer)

Explanation: ***Advanced intraocular retinoblastoma (Group D/E)*** - **Advanced retinoblastoma** (Group D/E by International Classification) is an **absolute indication** for enucleation to prevent metastasis and save the child's life. - Group D/E tumors have extensive retinal involvement, vitreous seeding, or are unlikely to respond to globe-salvage therapies. - The goal is to remove the entire tumor, thereby preventing life-threatening spread while preserving overall survival. - Early-stage retinoblastomas (Groups A-C) can often be treated with chemotherapy, laser photocoagulation, or cryotherapy without enucleation. *Mutilating ocular injury with infection risk* - While a severely **mutilated eye** with infection risk may warrant enucleation, it is not always an absolute indication. - Attempts may be made to salvage the globe if there is potential for vision preservation or cosmetic appearance, especially if no active endophthalmitis is present. *Severe endophthalmitis requiring enucleation* - **Severe endophthalmitis** can lead to permanent vision loss, but enucleation is considered a last resort. - Aggressive medical and surgical treatments such as **intravitreal antibiotics** and **vitrectomy** are typically attempted first to control infection and preserve the eye. *None of the options* - This option is incorrect because **advanced intraocular retinoblastoma** (Group D/E) is a clear and well-established absolute indication for enucleation when the tumor is too extensive for globe-salvage treatments.

Question 136: Which muscle is most commonly operated on during squint surgery?

A. Medial rectus (MR) (Correct Answer)
B. Lateral rectus (LR)
C. Superior rectus (SR)
D. Superior oblique (SO)

Explanation: ***MR*** - The **medial rectus (MR)** muscle is the most frequently operated on during squint (strabismus) surgery, especially in cases of **esotropia** (inward turning of the eye). - This is because esotropia is a common form of strabismus, and weakening the medial rectus muscle (recession) helps to correct the inward deviation. *LR* - The **lateral rectus (LR)** muscle is operated on less frequently than the medial rectus, primarily in cases of **exotropia** (outward turning of the eye). - While it can be strengthened (resection) or weakened (recession), esotropia is generally more prevalent, making the MR more commonly targeted. *SR* - The **superior rectus (SR)** muscle primarily elevates the eye and is typically involved in vertical strabismus or cyclovertical deviations. - Surgery on the superior rectus is less common than on the horizontal recti (MR and LR) because horizontal deviations are more prevalent. *SO* - The **superior oblique (SO)** muscle is responsible for intorsion, depression, and abduction of the eye; it is often involved in cyclovertical strabismus. - Surgery on the superior oblique is complex and less frequently performed than on the horizontal recti due to the lower incidence of isolated superior oblique dysfunction requiring surgical correction.

Question 137: Which of the following is the most devastating complication of cataract surgery?

A. Endophthalmitis (Correct Answer)
B. Optic neuropathy
C. Retinal detachment
D. Vitreous loss

Explanation: ***Endophthalmitis*** - **Endophthalmitis** is a severe intraocular infection following cataract surgery that can rapidly lead to irreversible vision loss or even loss of the eye if not promptly treated. - It is considered the most devastating complication due to its acute onset and high potential for **permanent vision impairment**. *Optic neuropathy* - While optic neuropathy can cause visual loss, it is a less common direct complication of cataract surgery compared to endophthalmitis. - It typically results from processes like **ischemia** or severe orbital inflammation, which are rare occurrences immediately post-cataract surgery. *Retinal detachment* - **Retinal detachment** is a serious complication, but generally occurs at a lower rate than endophthalmitis and often has a better visual prognosis with timely surgical repair. - It is a known risk, particularly in patients with pre-existing **myopia** or prior posterior capsular rupture, but not necessarily the *most* devastating. *Vitreous loss* - **Vitreous loss** is an intraoperative complication that increases the risk of other issues like retinal detachment, cystoid macular edema, and endophthalmitis but is not, in itself, the most devastating. - Proper surgical technique and management during the procedure can mitigate many of its long-term sequelae.

Question 138: Which of the following statements about direct ophthalmoscopy is false?

A. There is no stereopsis
B. The retinal periphery cannot be examined
C. Can be used in cases of hazy ocular media (Correct Answer)
D. It can be done with the patient being in any position

Explanation: ***Can be used in cases of hazy ocular media*** - **Direct ophthalmoscopy** relies on clear optical media to transmit light and visualize the fundus. - **Hazy media** such as **corneal opacity**, **cataracts**, **anterior chamber inflammation**, or **vitreous hemorrhage** significantly obstruct the light path and prevent adequate visualization of the retina. - When media opacity is present, **indirect ophthalmoscopy** or imaging modalities like **ultrasound B-scan** are preferred alternatives. - This statement is **FALSE** because direct ophthalmoscopy cannot be effectively used with hazy ocular media. *It can be done with the patient being in any position* - Direct ophthalmoscopy offers flexibility in **patient positioning** - it can be performed with the patient **sitting**, **standing**, **supine**, or even **lateral**. - This versatility is one of the advantages of direct ophthalmoscopy, particularly useful for **bedridden patients** or those who cannot sit upright. - While optimal views may require the patient to look in specific directions, the examination itself is not restricted to one position. *There is no stereopsis* - Direct ophthalmoscopy provides a **monocular view** through a single optical pathway, lacking the binocular vision needed for **stereopsis** (depth perception). - The examiner views the fundus with one eye at a time, preventing the brain from fusing two slightly different images into three-dimensional perception. - For **stereoscopic viewing** of the fundus, **indirect ophthalmoscopy** or **slit-lamp biomicroscopy with fundus lenses** is required. *The retinal periphery cannot be examined* - Direct ophthalmoscopy has a **limited field of view** (approximately **5-10 degrees** or 2 disc diameters), primarily showing the **posterior pole** including the optic disc and macula. - To examine the **retinal periphery**, **indirect ophthalmoscopy** with **scleral indentation** is the standard technique. - The small field of view is a recognized limitation of direct ophthalmoscopy.

Question 139: The term enucleation means:

A. Removal of eyeball contents
B. Removal of the eyeball along with surrounding orbital tissue
C. Removal of the eyeball along with extraocular muscles and part of skull
D. Removal of eyeball along with a portion of optic nerve (Correct Answer)

Explanation: ***Removal of eyeball along with a portion of optic nerve*** - **Enucleation** specifically refers to the surgical removal of the entire eyeball, typically including a portion of the **optic nerve**. - The extraocular muscles are detached from the globe but remain in the orbit, along with orbital fat and other structures. - This procedure is commonly performed for conditions such as severe trauma, intraocular tumors, or a blind, painful eye. *Removal of eyeball contents* - This describes **evisceration**, a procedure where the contents of the eyeball are removed, leaving the scleral shell and extraocular muscles intact. - Evisceration is often chosen to maintain orbital volume and allow for better prosthetic motility. *Removal of the eyeball along with surrounding orbital tissue* - This would represent a more extensive procedure than enucleation alone. - In enucleation, the globe is removed but the extraocular muscles, orbital fat, and other orbital structures are preserved to maintain orbital volume and support prosthetic fitting. - Removal of orbital tissue beyond the globe itself would describe **orbital exenteration**. *Removal of the eyeball along with extraocular muscles and part of skull* - This extensive procedure is known as **orbital exenteration**, which involves removal of the entire orbital contents, including the eyeball, extraocular muscles, fat, and sometimes bone. - **Exenteration** is reserved for aggressive malignancies that have extended beyond the globe into the orbit.

Question 140: Expulsive hemorrhage in cataract surgery is primarily caused by rupture of which vessels?

A. Ciliary artery
B. Choroidal vessels (Correct Answer)
C. Ciliary body vessels
D. None of the options

Explanation: ***Choroidal vessels*** - **Expulsive (suprachoroidal) hemorrhage** in cataract surgery is caused by rupture of **choroidal vessels**, particularly the **posterior ciliary arteries** and the rich vascular network in the **choroid**. - This rupture leads to sudden accumulation of blood in the **suprachoroidal space**, causing rapid expansion that can extrude intraocular contents through the surgical wound. - Risk factors include **sudden hypotony**, **hypertension**, **atherosclerosis**, and increased venous pressure. *Ciliary body vessels* - While the **ciliary body** has rich vasculature and is part of the uveal tract, the primary source of **expulsive hemorrhage** is the **posterior choroidal circulation**, not the ciliary body vessels. - The ciliary body is located more anteriorly, whereas expulsive hemorrhage typically originates from the **posterior segment** choroidal vessels. *Ciliary artery* - The **posterior ciliary arteries** do supply the choroid and are involved in the vascular supply, but the specific term for the site of rupture is the **choroidal vessels** (which includes the ciliary arterial branches and choroidal capillary network). - The term "ciliary artery" alone is less specific than "choroidal vessels" for describing the anatomical site of hemorrhage. *None of the options* - This option is incorrect because rupture of **choroidal vessels** is the well-established cause of expulsive hemorrhage in cataract surgery. - This is a recognized and preventable complication with specific risk factors and management protocols.

Practice by Chapter

Surgical Anatomy of Eye

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Asepsis and Sterilization in Eye Surgery

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Anesthesia in Ophthalmic Surgery

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Cataract Surgery Techniques

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Corneal Surgeries

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Glaucoma Surgeries

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Oculoplastic Surgeries

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Vitreoretinal Surgeries

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Strabismus Surgery

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Refractive Surgery

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Ocular Oncology Surgeries

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Management of Surgical Complications

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