Ophthalmic Surgery — MCQs

Ophthalmic Surgery Indian Medical PG Practice Questions and MCQs

Question 81: What is phacoanaphylactic uveitis?

A. Uveitis as a result of lens tissue-induced inflammation following cataract surgery (Correct Answer)
B. Uveitis following cataract extraction in autoimmune diseases like rheumatoid arthritis
C. Uveitis seen with phacoemulsification cataract surgery
D. Uveitis associated with fungal corneal ulcer

Explanation: **Explanation:** **Phacoanaphylactic uveitis** (also known as Lens-Induced Uveitis) is a rare, sterile, granulomatous inflammatory response triggered by the exposure of lens proteins to the systemic circulation. **Why Option A is Correct:** The lens is an immunologically privileged site. During cataract surgery (or trauma), if lens cortical material is left behind or the lens capsule is ruptured, the immune system recognizes these sequestered lens proteins as "foreign" antigens. This triggers a **Type III (Immune-complex mediated)** and **Type IV (Delayed-type)** hypersensitivity reaction, leading to severe granulomatous inflammation. **Analysis of Incorrect Options:** * **Option B:** While patients with RA are prone to post-operative scleritis or peripheral ulcerative keratitis, the specific term "phacoanaphylactic" refers strictly to the immune reaction against lens proteins, not a systemic autoimmune flare-up. * **Option C:** Although it can occur after phacoemulsification, the term is not synonymous with the surgical technique itself. It is a specific pathological reaction to retained lens matter, regardless of the surgery type (ECCE or Phaco). * **Option D:** Uveitis associated with fungal ulcers is typically a reactive "hypopyon uveitis" due to toxins or direct fungal invasion, not an anaphylactic reaction to lens proteins. **High-Yield Clinical Pearls for NEET-PG:** * **Pathology:** Characterized by **granulomatous inflammation** (Zonal granuloma) around the lens material, featuring multinucleated giant cells, epithelioid cells, and neutrophils. * **Clinical Presentation:** Typically occurs 1–14 days after surgery/trauma. Presents with "mutton-fat" Keratic Precipitates (KPs) and high intraocular pressure. * **Management:** The definitive treatment is the **surgical removal of the residual lens material** along with topical/systemic steroids. * **Differential Diagnosis:** Must be distinguished from **Sympathetic Ophthalmitis** (which involves the contralateral eye) and **Endophthalmitis** (which is infective).

Question 82: Plication of inferior lid retractors is indicated in which of the following conditions?

A. Senile ectropion
B. Senile entropion (Correct Answer)
C. Cicatricial entropion
D. Paralytic entropion

Explanation: **Explanation:** **Senile (Involutional) entropion** is primarily caused by age-related changes in the lower eyelid. The pathophysiology involves four key factors: 1. **Horizontal lid laxity** (stretching of canthal tendons). 2. **Vertical instability** due to **attenuation or dehiscence of the lower lid retractors** (capsulopalpebral fascia). 3. **Overriding of the preseptal orbicularis oculi** over the pretarsal orbicularis. 4. Enophthalmos (atrophy of orbital fat). **Plication (shortening/tucking) of the inferior lid retractors** (e.g., Jones procedure) directly addresses the vertical instability by re-establishing the downward pull on the tarsal plate, preventing it from rotating inward. **Analysis of Incorrect Options:** * **Senile ectropion:** This involves an outward turning of the lid. While horizontal laxity is present, the surgical focus is on horizontal shortening (e.g., Lateral Tarsal Strip) rather than retractor plication. * **Cicatricial entropion:** Caused by conjunctival scarring (e.g., Trachoma, Stevens-Johnson Syndrome). The treatment requires addressing the scarred tissue, often via a mucous membrane graft or tarsal rotation (Wies procedure), not retractor repair. * **Paralytic entropion:** This is a distractor; facial nerve palsy typically causes **paralytic ectropion** due to loss of orbicularis oculi tone. Entropion is not a standard feature of paralysis. **High-Yield Clinical Pearls for NEET-PG:** * **Jones Procedure:** Specifically refers to the plication of lower lid retractors for involutional entropion. * **Quickert’s Sutures:** Temporary everting sutures used for bedside management of entropion. * **Wies Procedure:** A full-thickness eyelid transverse incision with everting sutures, used for both involutional and mild cicatricial entropion. * **Key distinction:** If the question mentions "overriding of orbicularis," think **Entropion**; if it mentions "punctal eversion," think **Ectropion**.

Question 83: A patient with fixed dilated pupil, iris atrophy, and secondary glaucoma after penetrating keratoplasty is suggestive of which syndrome?

A. Benedict's syndrome
B. Posner-Schlossman syndrome
C. Kaufmann's syndrome
D. Uretes Zavalia syndrome (Correct Answer)

Explanation: **Explanation:** **Urrets-Zavalia Syndrome (UZS)** is the correct diagnosis. It is a rare but classic complication characterized by a **permanent fixed dilated pupil**, iris atrophy, and secondary glaucoma following ophthalmic procedures, most classically **Penetrating Keratoplasty (PKP)** for keratoconus. * **Pathophysiology:** The exact mechanism is debated but is primarily attributed to **iris ischemia**. This occurs due to a sudden rise in intraocular pressure (IOP) post-operatively (often from viscoelastic retention or surgical trauma) which compresses the iris root and its vasculature against the peripheral cornea, leading to sphincter paralysis and atrophy. * **Clinical Features:** Fixed mydriasis (non-reactive to light or pilocarpine), iris thinning/atrophy, and posterior synechiae. **Analysis of Incorrect Options:** * **Benedict’s Syndrome:** A brainstem stroke syndrome (Midbrain) involving the 3rd nerve fascicle and red nucleus, presenting with ipsilateral CN III palsy and contralateral tremors/ataxia. * **Posner-Schlossman Syndrome (Glaucomatocyclitic Crisis):** Characterized by recurrent episodes of very high IOP associated with mild anterior uveitis and fine keratic precipitates. The pupil is typically normal or slightly dilated during an attack, but it does not cause permanent iris atrophy or follow PKP. * **Kaufmann’s Syndrome:** This is not a standard ophthalmic eponym related to this presentation; Herbert Kaufman is a famous corneal surgeon, but no such syndrome exists with these features. **High-Yield Pearls for NEET-PG:** * **Classic Association:** Keratoconus patients undergoing PKP are at the highest risk. * **Trigger:** Use of strong mydriatics (like Atropine) post-operatively was historically linked to this, though IOP spikes are the primary driver. * **Management:** Prevention is key by controlling post-op IOP. Once established, the pupil changes are usually irreversible.

Question 84: What is the percentage of endothelial cell loss during Descemet's stripping automated endothelial keratoplasty?

A. 0 – 5%
B. 10 – 20%
C. 30 – 40% (Correct Answer)
D. 50 – 60%

Explanation: **Explanation:** The correct answer is **30 – 40%**. **1. Understanding the Concept:** Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) involves replacing the patient’s diseased endothelium and Descemet’s membrane with a donor disc consisting of posterior stroma, Descemet’s membrane, and endothelium. Despite being a "micro-incision" procedure, significant endothelial cell loss (ECL) occurs due to the mechanical trauma of folding the graft, inserting it through a small incision, and the use of air/gas bubbles to tamponade the graft against the host stroma. Large-scale clinical trials (such as the Cornea Preservation Time Study) and meta-analyses consistently report an average ECL of **30% to 40%** within the first 6 to 12 months post-operatively. **2. Analysis of Incorrect Options:** * **A (0 – 5%) & B (10 – 20%):** These values are too low. While modern techniques (like using inserters) aim to reduce trauma, the physiological stress of surgery and the "remodeling" phase of the graft always result in a loss higher than 20%. * **D (50 – 60%):** This represents excessive loss, usually seen only in complicated cases, primary graft failure, or severe surgical trauma. If ECL exceeds 50% early on, the graft is at high risk of decompensation. **3. High-Yield Clinical Pearls for NEET-PG:** * **DMEK vs. DSAEK:** Descemet’s Membrane Endothelial Keratoplasty (DMEK) generally has a **lower** long-term cell loss and better visual outcomes compared to DSAEK, as the graft is thinner and more physiological. * **Primary Indication:** The most common indication for DSAEK/DMEK is **Fuchs’ Endothelial Dystrophy** and **Pseudophakic Bullous Keratopathy (PBK)**. * **Incision Size:** DSAEK typically requires a 3.0 to 5.0 mm incision, whereas DMEK can be performed through a smaller 2.8 mm incision. * **The "Interface":** Unlike Penetrating Keratoplasty (PKP), DSAEK leaves a stromal-to-stromal interface, which can occasionally limit final visual acuity due to interface haze.

Question 85: Which of the following is NOT true regarding suprachoroidal hemorrhage?

A. Shallowing of anterior chamber
B. Expulsion of intraocular contents
C. Bleeding from short posterior ciliary artery into suprachoroidal space
D. Self-resolving (Correct Answer)

Explanation: **Suprachoroidal Hemorrhage (SCH)** is one of the most dreaded complications of intraocular surgery (like cataract or glaucoma surgery). It occurs due to the rupture of the **long or short posterior ciliary arteries**, leading to the accumulation of blood in the potential space between the choroid and the sclera. ### Why "Self-resolving" is NOT true: Suprachoroidal hemorrhage is a **surgical emergency**, not a self-limiting condition. If it occurs intraoperatively (Expulsive Hemorrhage), it requires immediate closure of the wound to prevent permanent vision loss. Post-operatively, it often requires surgical intervention (sclerotomy) to drain the blood and manage secondary complications like intractable glaucoma or retinal detachment. ### Explanation of Incorrect Options: * **Shallowing of anterior chamber:** As blood accumulates in the suprachoroidal space, it pushes the ciliary body and iris diaphragm forward, leading to a sudden shallowing of the AC. * **Expulsion of intraocular contents:** In "Expulsive Hemorrhage," the rapid increase in intraocular pressure can force the vitreous, lens, or even the retina out through the surgical incision. * **Bleeding from short posterior ciliary artery:** This is the classic pathophysiological mechanism. Sudden hypotony (low pressure) during surgery causes these vessels to rupture into the suprachoroidal space. ### High-Yield Clinical Pearls for NEET-PG: * **Risk Factors:** Systemic hypertension (most common), advanced age, glaucoma, high myopia, and aphakia. * **Intraoperative Signs:** Sudden loss of red reflex, hardening of the globe (rock hard eye), and gaping of the wound. * **Management:** Immediate suturing of the wound is the first step. Definitive drainage of the hemorrhage is typically delayed for **7–14 days** to allow for clot liquefaction. * **Prophylaxis:** Preoperative control of BP and intraocular pressure (IOP) is crucial.

Question 86: Following cataract surgery, a patient comes with complaints of decreased visual acuity. On examination, posterior capsular opacification is seen. What type of laser can be used to treat this condition?

A. Argon
B. Argon fluoride
C. Femto laser
D. Nd YAG laser (Correct Answer)

Explanation: ***Nd YAG laser*** - The **Nd YAG laser** (Neodymium-doped Yttrium Aluminum Garnet) is the gold standard for treating **Posterior Capsular Opacification (PCO)**, which causes secondary visual decline after cataract extraction. - It employs **photodisruption** (a non-thermal process creating plasma) to precisely cut an opening in the opacified posterior capsule, restoring the visual axis (YAG capsulotomy). *Femto laser* - The **Femtosecond laser** is commonly used for creating the corneal flap in **LASIK** or performing certain steps (**capsulotomy**, lens fragmentation) during primary cataract surgery. - It is not typically used for the treatment of *established* PCO as the **Nd YAG** laser procedure is faster, more efficient, and specifically designed for posterior capsule cutting. *Argon fluoride* - **Argon fluoride** is the emission medium for the **Excimer laser**, which operates in the ultraviolet spectrum. - The primary application of the Excimer laser in ophthalmology is **photoablation** of corneal tissue for refractive surgery (e.g., **PRK** and **LASIK**). *Argon* - The **Argon laser** is a thermal laser used primarily for **photocoagulation** in retinal conditions, such as treating **diabetic retinopathy** or performing peripheral iridotomy. - It is unsuitable for PCO treatment because its thermal mechanism would cause unnecessary heat damage to surrounding structures, unlike the non-thermal **photodisruption** of the Nd YAG laser.

Question 87: Following a fungal corneal ulcer, a farmer underwent corneal transplant surgery. What is the preservative used for storing the donor corneal graft and the suture material used in the procedure?

A. Polyethylene glycol, Nylon
B. Moist chamber, Vicryl
C. Ethanol, Silk
D. McCarey-Kaufman, Nylon (Correct Answer)

Explanation: ***McCarey-Kaufman, Nylon*** - **McCarey-Kaufman (MK) medium** is the classic short-term preservation medium (effective for up to 4 days) traditionally used for storing donor corneal grafts, ensuring the vitality of the essential **endothelial cells**. *Note: Modern practice now primarily uses Optisol-GS, Cornisol, or Eusol-C for longer storage (14+ days), but MK medium remains the standard textbook answer.* - The procedure employs fine, non-absorbable **10-0 Nylon** monofilament sutures, which is the standard material for penetrating keratoplasty and maintains long-term structural integrity and precise corneal curvature. *Incorrect: Polyethylene glycol, Nylon* - **Polyethylene glycol (PEG)** is an osmotic agent and lubricant but is not utilized as the primary, formulated storage medium for whole donor corneal grafts required for transplantation. - While **Nylon** is the correct suture material, the incorrect association with PEG as the storage medium makes this option unsuitable. *Incorrect: Ethanol, Silk* - **Ethanol** is highly damaging and denaturing to living tissues, particularly the delicate **corneal endothelium**, rendering the graft non-viable upon exposure. - **Silk** sutures are generally avoided in penetrating keratoplasty because they are braided, have high tissue reactivity, and carry a risk of introducing infection or generating excessive inflammation. *Incorrect: Moist chamber, Vicryl* - Storage in a **moist chamber** offers minimal nutritional support and is only suitable for very short-term storage (<24 hours), often resulting in significant **endothelial cell loss** for longer storage periods. - **Vicryl** (Polyglactin 910) is an **absorbable suture** that breaks down rapidly, making it inappropriate for penetrating keratoplasty where non-absorbable material is needed to maintain tectonic support and corneal shape for extended periods.

Question 88: The type of iridectomy shown in the image is:

A. Peripheral basal iridectomy (Correct Answer)
B. Sector iridectomy
C. Button-hole iridectomy
D. Complete iridectomy

Explanation: ***Peripheral basal iridectomy*** - The image clearly depicts an iris with a small, circular opening located at its **periphery**, specifically at the base near the ciliary body. - This type of opening is characteristic of a **peripheral basal iridectomy**, which creates an alternative pathway for aqueous humor flow to relieve pupillary block, often associated with angle-closure glaucoma. *Sector iridectomy* - A **sector iridectomy** involves removing a full-thickness, wedge-shaped section of the iris that extends from the pupillary margin to the iris root, creating a keyhole-shaped pupil. - The image does not show a wedge-shaped defect extending to the pupil. *Button-hole iridectomy* - A **button-hole iridectomy** is typically a small, central opening in the iris that is completely surrounded by iris tissue, often performed for optical purposes. - The image shows a peripheral opening, not a central one. *Complete iridectomy* - A **complete iridectomy** implies the removal of the entire iris, or at least a very large portion, which would result in a highly enlarged and distorted pupil. - The image shows a small, localized opening, not extensive iris removal.

Question 89: A patient on day 2 after cataract surgery has developed the following findings which are diagnostic of:

A. Acute postoperative glaucoma
B. Acute postoperative endophthalmitis (Correct Answer)
C. Acute bullous keratopathy
D. Acute anterior uveitis

Explanation: **Acute postoperative endophthalmitis (Correct)** - The image shows severe **corneal edema and clouding**, **fibrin exudates** in the anterior chamber forming a notable **hypopyon**, and inflamed conjunctiva with extensive **redness**. These are classic signs of acute endophthalmitis occurring shortly after cataract surgery. - Endophthalmitis is a severe intraocular inflammation usually caused by **bacterial infection** post-surgery, leading to rapid vision loss if not treated urgently. - Day 2 post-operative timing is characteristic of acute bacterial endophthalmitis, which requires immediate intravitreal antibiotics and vitreous tap/biopsy. *Acute postoperative glaucoma (Incorrect)* - This condition is characterized by **elevated intraocular pressure** which can cause corneal edema, but the profound inflammatory signs like hypopyon and extensive fibrin are not typical primary features of glaucoma. - While glaucoma can cause diffuse corneal edema and pain, the prominent **pus collection (hypopyon)** and severe fibrin exudate seen here point more strongly to infection. *Acute bullous keratopathy (Incorrect)* - Bullous keratopathy primarily involves **corneal swelling and epithelial bullae formation** due to endothelial dysfunction, often chronic. - Although corneal edema is present, the extensive **intraocular inflammation**, specifically the hypopyon and dense fibrin, is not a hallmark of bullous keratopathy itself, but rather a sign of severe infection or inflammation. *Acute anterior uveitis (Incorrect)* - Anterior uveitis involves inflammation of the iris and ciliary body, leading to symptoms like **photophobia**, pain, and **cells and flare** in the anterior chamber and sometimes **hypopyon**. - While hypopyon can occur in severe uveitis, the image displays a more severe and diffuse inflammatory process with significant corneal involvement and opacification that is characteristic of an intraocular infection rather than sterile uveitis.

Question 90: The patient underwent complete iridectomy in aphakia. Comment on the diagnosis:

A. Festooned pupil
B. Hammock pupil
C. Key hole pupil (Correct Answer)
D. D-Shaped

Explanation: ***Keyhole pupil*** - The image shows a pupil with a superior **keyhole shape** (like an inverted keyhole), which is characteristic after a **surgical iridectomy** due to **cataract surgery**. - This shape results from the removal of a portion of the iris, typically for **visual axis clearance** or **glaucoma management**. *Festooned pupil* - A festooned pupil is typically seen in cases of **posterior synechiae**, where the iris adheres to the lens capsule, leading to an **irregular, scalloped pupil margin** even when dilated. - The image does not show multiple irregular adhesions, but rather a surgical alteration of the iris. *Hammock pupil* - The term "hammock pupil" is not a standard ophthalmological descriptor for a specific pupil deformity. - It does not accurately describe the appearance of the pupil in the provided image. *D-Shaped* - A D-shaped pupil is often associated with conditions like **iridodialysis** (detachment of the iris root), where a segment of the iris pulls away from its insertion, or after some types of **iris reconstruction**. - While the pupil is irregular, it specifically presents with a superior excision, not a broad D-shape.

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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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