Vitreoretinal Surgeries — MCQs
What is the most common cause of vitreous hemorrhage in diabetic retinopathy?
Which of the following treatments is not suitable for advanced proliferative diabetic retinopathy with extensive vitreoretinal fibrosis and tractional retinal detachment?
Pneumoretinopexy is an outpatient procedure in which retinal detachment is sealed with air insufflation. Which of the following gases is used in pneumoretinopexy?
On measuring 3.5 to 4 mm posterior to the limbus in a phakic eye and plunging a 30 gauge needle perpendicular to sclera, you pass through
A 44-year-old woman presents with sudden painless loss of vision with a history of previous similar episodes. Fundoscopy shows no glow. What could be the possible diagnosis?
Which of the following accurately describes management of Grade 3 pelvic organ prolapse in an elderly woman who is a poor surgical candidate?
How many incisions are used in the divided system approach of pars plana vitrectomy?
What is the immediate management approach for severe vitreous hemorrhage in the eye?
A 56-year-old patient presents after 3 days of cataract surgery with a history of increasing pain and diminished vision after an initial improvement. The most likely cause would be –
Identify the surgical step shown in the image given below
Vitreoretinal Surgeries Indian Medical PG Practice Questions and MCQs
Question 1: What is the most common cause of vitreous hemorrhage in diabetic retinopathy?
- A. Non-proliferative diabetic retinopathy
- B. Proliferative diabetic retinopathy (Correct Answer)
- C. Severe non-proliferative diabetic retinopathy
- D. Diabetic macular edema
Explanation: ***Proliferative diabetic retinopathy*** - **Neovascularization** is the hallmark of proliferative diabetic retinopathy (PDR), where new, fragile blood vessels grow on the surface of the retina and optic disc. - These delicate vessels can easily rupture and bleed into the vitreous humor, leading to a **vitreous hemorrhage**. *Non-proliferative diabetic retinopathy* - This stage is characterized by **microaneurysms**, hemorrhages, and cotton wool spots, but typically lacks significant neovascularization. - While it involves retinal vascular damage, the absence of **newly formed, fragile vessels** makes vitreous hemorrhage less common. *Severe non-proliferative diabetic retinopathy* - This stage shows extensive microvascular abnormalities, including numerous hemorrhages and venular beading, but generally **still no new vessel formation**. - Without the presence of **fragile neovascular membranes**, the risk of significant vitreous hemorrhage is lower compared to PDR. *Diabetic macular edema* - This condition involves **fluid leakage** from damaged retinal vessels into the macula, causing vision loss. - While it's a common complication of diabetes, it primarily causes **macular swelling** and does not directly lead to vitreous hemorrhage.
Question 2: Which of the following treatments is not suitable for advanced proliferative diabetic retinopathy with extensive vitreoretinal fibrosis and tractional retinal detachment?
- A. Removal of epiretinal membrane
- B. Photocoagulation (Correct Answer)
- C. Vitrectomy
- D. Reattachment of detached or torn retina
Explanation: ***Photocoagulation*** - The question asks for a treatment **not suitable** for **advanced proliferative diabetic retinopathy** with **extensive vitreoretinal fibrosis** and **tractional retinal detachment (TRD)**. - **Panretinal photocoagulation (PRP)** is a laser treatment used to ablate ischemic peripheral retina and prevent neovascularization in proliferative diabetic retinopathy. However, it is a **preventive measure** used in **earlier stages of PDR** before the development of extensive fibrosis and tractional detachment. - Once **tractional retinal detachment** has developed with **extensive vitreoretinal fibrosis**, photocoagulation alone **cannot relieve the mechanical traction** on the retina or **reattach the detached retina**. At this advanced stage, **surgical intervention is required**. - While endolaser photocoagulation can be performed **during vitrectomy** as an adjunctive measure, standalone photocoagulation is not suitable as a primary treatment for established TRD with extensive fibrosis. *Vitrectomy* - **Pars plana vitrectomy** is the **definitive surgical treatment** for advanced PDR with tractional retinal detachment and extensive vitreoretinal fibrosis. - The procedure involves removal of the vitreous gel, fibrovascular membranes, and blood, which relieves traction on the retina and allows for retinal reattachment. - This is the **gold standard treatment** for this condition. *Removal of epiretinal membrane* - **Membrane peeling** (removal of epiretinal and fibrovascular membranes) is an **essential component** of vitrectomy for tractional retinal detachment. - Removing these membranes relieves the mechanical traction causing the retinal detachment, making this a **suitable and necessary** treatment step. - This is performed as part of the comprehensive vitrectomy procedure. *Reattachment of detached or torn retina* - **Retinal reattachment** is the primary **therapeutic goal** for tractional retinal detachment in advanced PDR. - This is achieved through vitrectomy with membrane peeling, often combined with endolaser, fluid-gas exchange, or silicone oil tamponade. - This is clearly a **suitable treatment objective** for this condition.
Question 3: Pneumoretinopexy is an outpatient procedure in which retinal detachment is sealed with air insufflation. Which of the following gases is used in pneumoretinopexy?
- A. Nitrous oxide
- B. Oxygen
- C. Sulfur hexafluoride (Correct Answer)
- D. Carbon dioxide
Explanation: ***Sulfur hexafluoride*** - **Sulfur hexafluoride (SF6)** is a commonly used gas in **pneumatic retinopexy** due to its expansive properties and inertness within the eye. - It provides a **temporary tamponade effect** against the retinal tear, allowing the retina to reattach. - SF6 expands to approximately **twice its injected volume** and provides tamponade for **1-2 weeks**. - **Perfluoropropane (C3F8)** is another gas commonly used in pneumatic retinopexy, which lasts longer (6-8 weeks) but expands more (up to 4 times). *Nitrous oxide* - **Nitrous oxide** is primarily used as an **anesthetic gas** and for pain relief in medical procedures. - It is not suitable for intraocular tamponade due to its rapid absorption and potential to expand existing intraocular gas bubbles dangerously. *Oxygen* - **Oxygen** is essential for cellular respiration and is a fundamental component of the air we breathe. - It is **highly soluble** in intraocular fluids and would be quickly absorbed, making it ineffective for sustained retinal tamponade. *Carbon dioxide* - **Carbon dioxide** is a natural byproduct of metabolism and is used in some surgical contexts (e.g., laparoscopy) to create a working space. - Like oxygen, it is **highly soluble** and would dissipate too quickly to provide the necessary long-term tamponade for retinal reattachment.
Question 4: On measuring 3.5 to 4 mm posterior to the limbus in a phakic eye and plunging a 30 gauge needle perpendicular to sclera, you pass through
- A. Tenon's capsule
- B. Ora serrata
- C. Zonules
- D. Pars plana (Correct Answer)
Explanation: ***Pars plana*** - A 3.5 to 4 mm distance posterior to the limbus in a phakic eye precisely targets the **pars plana**, the safest region for intraocular injections and surgeries to avoid lens damage. - Plunging a needle perpendicular to the sclera at this specific distance allows direct access to the vitreous cavity through the **pars plana**, bypassing critical structures. *Tenon's capsule* - **Tenon's capsule** is a fibrous sheath that envelops the eyeball, and it would be the first layer pierced, but not the final structure accessed for an intraocular procedure at this depth. - While the needle would pass through Tenon's capsule, it is an **extraocular structure** and not the target for safe intraocular access when aiming 3.5-4 mm posterior to the limbus. *Ora serrata* - The **ora serrata** is the jagged anterior termination of the retina and is located approximately 6-8 mm posterior to the limbus in the superior aspect and 5-6 mm inferiorly. - A needle plunged 3.5-4 mm from the limbus would **not reach** the ora serrata and would be positioned anterior to it. *Zonules* - The **zonules of Zinn** are suspensory ligaments that hold the lens in place, originating from the ciliary body and attaching to the lens capsule. - These structures are located more anteriorly within the anterior chamber and behind the iris, and plunging a needle 3.5-4 mm posterior to the limbus would **bypass the zonules entirely**.
Question 5: A 44-year-old woman presents with sudden painless loss of vision with a history of previous similar episodes. Fundoscopy shows no glow. What could be the possible diagnosis?
- A. Vitreous Hemorrhage (Correct Answer)
- B. Rhegmatogenous Retinal Detachment
- C. Acute Angle-Closure Glaucoma
- D. Fungal Keratitis
Explanation: ***Vitreous Hemorrhage*** - **Painless vision loss** is a hallmark symptom, and **previous similar episodes** suggest a recurrent condition, characteristic of vitreous hemorrhage from fragile vessels. - The **"no glow"** on fundoscopy indicates that light from the ophthalmoscope is unable to reflect off the retina due to something obstructing the clear media, such as blood in the vitreous cavity. *Rhegmatogenous Retinal Detachment* - While it causes **painless vision loss**, patients often report **floaters** or **flashes of light** preceding the detachment, which are not mentioned here. - Fundoscopy in rhegmatogenous retinal detachment would typically show a **grayish, elevated retina**, often with folds, not a complete loss of red reflex or ''no glow.'' *Acute Angle-Closure Glaucoma* - Characterized by **sudden, severe eye pain**, blurred vision, and often a **red eye** with a fixed, mid-dilated pupil. - Fundoscopy would typically reveal a **cupped optic disc** in advanced stages, but the primary finding is elevated intraocular pressure, with a clear vitreous, thus allowing an initial glow. *Fungal Keratitis* - This is an **infection of the cornea** that typically presents with pain, redness, photophobia, and a visible corneal ulcer or infiltrate. - Vision loss is gradual, and fundoscopy would still show a **normal red reflex** unless the corneal opacity is extremely dense, which is not implied by "no glow."
Question 6: Which of the following accurately describes management of Grade 3 pelvic organ prolapse in an elderly woman who is a poor surgical candidate?
- A. Bladder sling
- B. Vaginal hysterectomy
- C. Pessary placement (Correct Answer)
- D. Kegel exercises
Explanation: ***Pessary placement*** - **Pessaries** are a less invasive, effective option for **pelvic organ prolapse** management in patients who are **poor surgical candidates**, helping to support prolapsed organs. - They also serve as a good temporary option to improve symptoms before surgical intervention. *Bladder sling* - A **bladder sling** is a surgical procedure used primarily to treat **stress urinary incontinence**, not pelvic organ prolapse. - This option is unsuitable for a patient who is a **poor surgical candidate**. *Vaginal hysterectomy* - A **vaginal hysterectomy** involves surgical removal of the uterus through the vagina, which is a definitive treatment for **uterine prolapse**. - However, surgical interventions are contraindicated for an **elderly woman** who is a **poor surgical candidate** due to potential risks. *Kegel exercises* - **Kegel exercises** are beneficial for strengthening the **pelvic floor muscles** and preventing the progression of early-stage prolapse or improving mild symptoms. - However, they are generally **insufficient** for managing **Grade 3 pelvic organ prolapse**, which requires more robust support.
Question 7: How many incisions are used in the divided system approach of pars plana vitrectomy?
- A. 1
- B. 3 (Correct Answer)
- C. 2
- D. 4
Explanation: ***3*** - The **divided system approach** of pars plana vitrectomy utilizes **three incisions**: one for the **infusion cannula**, one for the **vitrector**, and one for the **light pipe**. - These three ports provide stable access for instrumentation and fluid infusion during the vitrectomy procedure. *1* - A single incision would be insufficient for a pars plana vitrectomy, as it requires simultaneous delivery of infusion fluid, vitrectomy, and illumination. - This approach is not feasible for the complex maneuvers required in vitrectomy. *2* - Two incisions would typically accommodate the vitrector and light source, but would lack the crucial **infusion cannula** to maintain intraocular pressure and refill the eye as vitreous is removed. - While some specialized single-port techniques exist for very limited procedures, standard pars plana vitrectomy requires three ports for optimal safety and efficacy. *4* - While additional incisions can be made for specific instruments (e.g., foreign body removal, bimanual surgery), the **divided system approach** for standard pars plana vitrectomy fundamentally uses three primary incisions. - More than three incisions are not part of the standard divided system approach but rather auxiliary port placements for advanced or complex cases.
Question 8: What is the immediate management approach for severe vitreous hemorrhage in the eye?
- A. Steroids
- B. Antibiotics
- C. Conservative management (observation) (Correct Answer)
- D. Vitrectomy
Explanation: ***Correct: Conservative management (observation)*** - **Conservative management with observation** is the immediate approach for severe vitreous hemorrhage, as most cases resolve spontaneously over 2-3 months - Initial management includes **bed rest with head elevation** to allow blood to settle inferiorly and **bilateral eye patching** to reduce eye movement - This approach allows time for **spontaneous resorption** of blood while monitoring for complications like retinal detachment - **Vitrectomy is reserved for later** if there's no improvement after 2-3 months, or if there are urgent indications like retinal detachment *Incorrect: Vitrectomy* - While vitrectomy is definitive treatment, it is **not immediate management** for uncomplicated vitreous hemorrhage - **Indications for vitrectomy** include: failure to clear after 2-3 months of observation, bilateral hemorrhage in diabetics, suspected retinal detachment, or ghost cell glaucoma - Immediate vitrectomy would expose patients to **unnecessary surgical risks** when most cases resolve spontaneously *Incorrect: Steroids* - **Steroids** reduce inflammation but do not address the blood in the vitreous cavity - They have **no role** in managing vitreous hemorrhage itself, though they may be used for associated inflammatory conditions *Incorrect: Antibiotics* - **Antibiotics** treat bacterial infections and have **no role** in vitreous hemorrhage management, which is a bleeding issue, not an infection - Inappropriate antibiotic use contributes to resistance without providing benefit for this condition
Question 9: A 56-year-old patient presents after 3 days of cataract surgery with a history of increasing pain and diminished vision after an initial improvement. The most likely cause would be –
- A. Posterior capsular opacification
- B. Endophthalmitis (Correct Answer)
- C. Central retinal vein occlusion
- D. Retinal detachment
Explanation: ***Endophthalmitis*** - The presentation of **increasing pain** and **diminished vision** within days of cataract surgery, following an initial improvement, is highly suggestive of acute **postoperative endophthalmitis**. - This severe **intraocular inflammation** is often caused by bacterial infection introduced during surgery, leading to rapid vision loss if not treated promptly. *Posterior capsular opacification* - This condition typically presents weeks to months or even years after cataract surgery, not within 3 days. - It usually causes **gradual blurring of vision** without pain, unlike the acute symptoms described. *Central retinal vein occlusion* - This condition presents with **sudden, painless vision loss** and a characteristic appearance on fundoscopy (e.g., "blood and thunder" retina). - It is not directly related to cataract surgery and would not typically cause increasing pain. *Retinal detachment* - Symptoms usually include **new floaters**, **flashes of light**, and a **"curtain" or "shadow"** over the field of vision, often developing suddenly and progressing. - While it causes vision loss, it is typically painless and not a direct complication presenting with pain within 3 days post-surgery, especially after initial improvement.
Question 10: Identify the surgical step shown in the image given below
- A. Capsulorrhexis
- B. Hydrodissection
- C. Intraocular lens implantation
- D. Lens aspiration (Correct Answer)
Explanation: ***Lens aspiration*** - The image shows a **phacoemulsification handpiece** (the instrument with the shining tip and central bore tube) actively fragmenting and aspirating the lens material, indicated by the cloudy material being removed. - This step is part of cataract surgery where the cataractous lens material is removed from the eye. *Capsulorrhexis* - This involves creating a **continuous curvilinear tear** in the anterior lens capsule, typically done at the beginning of cataract surgery. - The image does not show a tearing or incising action on the capsule; instead, it depicts material removal. *Hydrodissection* - This step involves injecting a **fluid wave** between the lens capsule and the lens cortex to separate them, facilitating nuclear rotation and removal. - The image depicts the removal of lens material, not the injection of fluid to separate layers. *Intraocular lens implantation* - This step involves inserting the **artificial lens** into the capsular bag after the cataractous lens has been removed. - The visual cues in the image indicate material removal and emulsification, not the insertion of a new lens.
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