Esotropia — MCQs
A child presents with unilateral white reflex (leukocoria) and raised intraocular pressure, raising suspicion of retinoblastoma. Which of the following investigations is the most appropriate to perform?
The most common type of strabismus seen in myopes is?
Child with mild squint. Intrauterine, birth history, developmental history till date all normal. Corneal light reflex normal. All other eye parameters normal except exaggerated epicanthal fold. Diagnosis ?
PDA true is all except -
Shortening of 2 mm of axial length of the eyeball causes?
A 26-year-old female presents with an insidious onset of diplopia on alternate cover test, exhibiting a right hypertropia that worsens on right head tilt and left gaze. Which muscle is paralyzed?
Esotropia is commonly seen in which type of refractive error?
Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen
A 10-year-old child presents with inward turning of the right eye, and examination shows limited abduction of the affected eye. What is the most likely diagnosis?
The following spectacle is used in? (AIIMS Nov 2018)
Esotropia Indian Medical PG Practice Questions and MCQs
Question 1: A child presents with unilateral white reflex (leukocoria) and raised intraocular pressure, raising suspicion of retinoblastoma. Which of the following investigations is the most appropriate to perform?
- A. Ultrasound imaging of the eye
- B. Measurement of intraocular pressure
- C. Detailed examination under anesthesia (Correct Answer)
- D. CT imaging of the orbit and head
Explanation: ***Detailed examination under anesthesia*** - A **detailed examination under anesthesia (EUA)** is crucial for accurately assessing the extent of intraocular lesions in children, particularly those with suspected retinoblastoma. It allows for a thorough and precise evaluation of tumor size, location, and multifocality that is otherwise difficult to achieve in an awake child. - EUA often includes fundus photography, ultrasonography, and sometimes anterior segment examination, all performed systematically without the child moving. It is the gold standard for **diagnosing and staging retinoblastoma**. *Ultrasound imaging of the eye* - **Ocular ultrasound** is a key component of the investigation and can help identify the intraocular mass and detect calcifications, which are characteristic of retinoblastoma. - However, ultrasound alone is often insufficient to fully characterize the tumor's extent or for precise staging, and it doesn't replace the need for direct visualization and comprehensive examination. *Measurement of intraocular pressure* - **Raised intraocular pressure** is a symptom that can be present in retinoblastoma but is not a diagnostic tool for the condition itself; it indicates secondary glaucoma due to the tumor. - While important for clinical management, measuring IOP does not directly visualize or characterize the tumor to confirm the diagnosis of retinoblastoma. *CT imaging of the orbit and head* - While **CT imaging** can detect orbital and intracranial extension of retinoblastoma, it involves **ionizing radiation**, which is a significant concern in children, especially those with an increased genetic risk for secondary cancers. - **MRI** is generally preferred over CT for assessing extraocular extension and possible central nervous system involvement due to its superior soft tissue contrast and lack of radiation exposure.
Question 2: The most common type of strabismus seen in myopes is?
- A. Intermittent Exotropia (Correct Answer)
- B. Intermittent Esotropia
- C. Esotropia Hypotropia complex
- D. Exotropia Hypotropia complex
Explanation: ***Intermittent Exotropia*** - Myopes often employ less **accommodative effort** for near tasks, leading to reduced **accommodative convergence** and an increased tendency for the eyes to drift outwards. - This outward deviation, or **exotropia**, is frequently intermittent, especially during fatigue or inattention. *Intermittent Esotropia* - **Esotropia** is an inward turn of the eye and is typically associated with **hyperopia** due to excessive accommodative effort leading to increased accommodative convergence. - While it can be intermittent, it is not the most common form of strabismus in myopic individuals. *Esotropia hypotropia complex* - This complex involves both an inward deviation (**esotropia**) and a downward deviation (**hypotropia**). - It is not typically seen in healthy myopes and would suggest other underlying **neurological** or **structural abnormalities**. *Exotropia Hypotropia complex* - While **exotropia** can be common in myopes, the additional presence of **hypotropia** (downward deviation) suggests a more complex strabismic picture. - This combination is not the most frequent strabismus seen in uncomplicated myopia and may indicate **cranial nerve palsies** or **orbital anomalies**.
Question 3: Child with mild squint. Intrauterine, birth history, developmental history till date all normal. Corneal light reflex normal. All other eye parameters normal except exaggerated epicanthal fold. Diagnosis ?
- A. Pseudostrabismus (Correct Answer)
- B. Exophoria (outward drift)
- C. Esophoria (inward drift)
- D. Accommodative esotropia
Explanation: ***Pseudostrabismus*** * The presence of **exaggerated epicanthal folds** can create the optical illusion of a child having misaligned eyes, even when the eyes are perfectly straight. * The normal **corneal light reflex** (Hirschberg test) confirms that the eyes are properly aligned, and the perceived "squint" is not a true strabismus. *Exophoria (outward drift)* * This condition involves a **tendency for the eyes to drift outwards**, which would be detected by specific cover/uncover tests. * An outward drift would usually result in an abnormal corneal light reflex, and the exaggerated epicanthal folds would not explain this type of misalignment. *Esophoria (inward drift)* * This is a **tendency for the eyes to drift inwards**, which would also be revealed by tests for phorias and often by an abnormal corneal reflex. * The clinical presentation points away from a true inward deviation, as the corneal reflex is normal. *Accommodative esotropia* * This is a **true inward turning of the eye** (strabismus) that is often linked to uncorrected farsightedness (hyperopia). * It would present with an **abnormal corneal light reflex** and would not be explained solely by epicanthal folds, as it involves actual ocular deviation.
Question 4: PDA true is all except -
- A. More common in preterm baby
- B. Left to right shunt
- C. More common in term baby (Correct Answer)
- D. Acyanotic congenital heart disease
Explanation: ***More common in term baby*** ✗ (EXCEPTION - This is FALSE) - This statement is **INCORRECT** and is the exception among the options. - PDA is actually significantly **more prevalent in premature infants**, not term babies, due to the immaturity of the ductus arteriosus and its closure mechanisms. - The persistence of the ductus arteriosus is a major complication of **prematurity**, with incidence inversely proportional to gestational age. *More common in preterm baby* ✓ - **TRUE statement**: Patency of ductus arteriosus (PDA) is indeed much more common in preterm babies, especially those with very low birth weight. - The physiological closure mechanisms, including increased oxygen tension and decreased prostaglandin E2 levels, are less effective in **premature infants**. - Incidence can be as high as **60-70% in infants <28 weeks gestation**. *Left to right shunt* ✓ - **TRUE statement**: In most cases, the pressure in the aorta is higher than in the pulmonary artery, leading to a **left-to-right shunt** of blood through the PDA. - This shunting causes increased pulmonary blood flow, which can lead to **pulmonary congestion** and heart failure if significant. - Creates the characteristic **continuous "machinery" murmur**. *Acyanotic congenital heart disease* ✓ - **TRUE statement**: PDA is classified as an **acyanotic congenital heart disease** because the shunt is typically left-to-right, meaning oxygenated blood recirculates to the lungs. - Cyanosis (bluish discoloration of the skin) only occurs in rare instances of **Eisenmenger syndrome**, where severe pulmonary hypertension reverses the shunt to right-to-left.
Question 5: Shortening of 2 mm of axial length of the eyeball causes?
- A. 3D myopia
- B. 2D myopia
- C. 6D hypermetropia (Correct Answer)
- D. 1D hypermetropia
Explanation: ***6D hypermetropia*** - A 1 mm shortening of the **axial length** of the eyeball typically results in approximately **3 diopters** of hypermetropia. - Therefore, a 2 mm shortening would cause **6 diopters** (2 mm x 3 D/mm) of hypermetropia. *3D myopia* - Myopia (nearsightedness) is caused by an **eyeball that is too long** or a cornea that is too steeply curved, not by a shortened axial length. - A 2 mm shortening would cause **hypermetropia** (farsightedness), not myopia. *2D myopia* - This option incorrectly identifies both the **type of refractive error** (myopia instead of hypermetropia) and the magnitude of the change. - Shortening of the axial length makes the eye effectively **farsighted**, not nearsighted. *1D hypermetropia* - While reflecting the correct type of refractive error (hypermetropia), the **magnitude is incorrect**. - A 1 mm change in axial length results in about 3 diopters, so 2 mm would be **6 diopters**, not 1 diopter.
Question 6: A 26-year-old female presents with an insidious onset of diplopia on alternate cover test, exhibiting a right hypertropia that worsens on right head tilt and left gaze. Which muscle is paralyzed?
- A. Left superior rectus
- B. Right superior oblique (Correct Answer)
- C. Right inferior rectus
- D. Left inferior oblique
Explanation: ***Right superior oblique*** - A paralyzed **right superior oblique** muscle causes a **right hypertropia** that worsens on **right head tilt** (positive Bielschowsky's head tilt test) and **left gaze**, which are classic signs of a **fourth nerve palsy**. - The superior oblique muscle is responsible for **intorsion**, **depression**, and **abduction** of the eye, and its weakness leads to characteristic vertical and torsional diplopia. - This presentation follows the **Parks-Bielschowsky three-step test**: hypertropia increases on contralateral gaze and ipsilateral head tilt. *Left superior rectus* - Paralysis of the **left superior rectus** would cause a **left hypotropia** (left eye lower than right), not a right hypertropia that worsens on right head tilt. - It would worsen on **left head tilt** and **left gaze** (ipsilateral to the affected muscle). - Its primary action is **elevation**, with secondary actions of **adduction** and **intorsion**. *Right inferior rectus* - Paralysis of the **right inferior rectus** would cause a **right hypertropia** that worsens on **right gaze** and **right head tilt**. - However, it would worsen on **downgaze** (not left gaze), which is a key differentiating feature from superior oblique palsy. - Its primary action is **depression**, with secondary actions of **adduction** and **extorsion**. *Left inferior oblique* - Paralysis of the **left inferior oblique** would cause a **left hypotropia** that worsens on **right gaze** and **right head tilt**. - This does not match the clinical presentation of right hypertropia worsening on left gaze and right head tilt. - Its primary action is **elevation**, with secondary actions of **abduction** and **extorsion**.
Question 7: Esotropia is commonly seen in which type of refractive error?
- A. Myopia
- B. Hypermetropia (Correct Answer)
- C. Astigmatism
- D. Presbyopia
Explanation: ***Hypermetropia*** - **Esotropia**, or convergent strabismus, is commonly associated with **uncorrected hypermetropia**, especially in children. - The constant effort to **accommodate** to see clearly for hypermetropic individuals can lead to excessive convergence, causing the eye to turn inward. *Myopia* - Myopia, or **nearsightedness**, rarely causes esotropia. - In some cases, high myopia can be associated with **exotropia** (divergent strabismus) due to reduced accommodative effort. *Astigmatism* - **Astigmatism** causes blurry vision at all distances due to an irregularly shaped cornea or lens, but it is not directly linked to specific forms of strabismus like esotropia or exotropia. - While it can contribute to **amblyopia** if severe and uncorrected, it does not typically cause the eyes to turn inward. *Presbyopia* - **Presbyopia** is an age-related loss of the eye's ability to focus on nearby objects due to stiffening of the lens. - It affects accommodation but does not cause strabismus such as esotropia; it typically begins around age 40.
Question 8: Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen
- A. A-3, B-4, C-2, D-1
- B. A-1, B-4, C-3, D-2 (Correct Answer)
- C. A-4, B-2, C-3, D-1
- D. A-2, B-4, C-3, D-1
Explanation: **A-1, B-4, C-3, D-2** - **Caplan syndrome** was first described in **coal workers** with **rheumatoid arthritis** and progressive massive fibrosis. - **Asbestosis** is often associated with **pleural effusion**, which can be benign or malignant. - **Mesothelioma** typically involves the **lower lobes** of the lungs, specifically the pleura, and is strongly linked to asbestos exposure. - **Sarcoidosis** is characterized by **non-caseating granulomas**, which have a predilection for the **upper lobes** of the lungs. *A-3, B-4, C-2, D-1* - This option incorrectly states that Caplan syndrome involves the lower lobe; **Caplan syndrome** is defined by the presence of large nodules in the lungs of coal workers with rheumatoid arthritis, and their specific lobar distribution is not a defining characteristic. - This option incorrectly states that Mesothelioma has an upper lobe predominance; **Mesothelioma** is a pleural malignancy and typically involves the **lower lobes**, extending along the pleura. *A-4, B-2, C-3, D-1* - This option incorrectly associates Caplan syndrome with pleural effusion; **Caplan syndrome** manifests as rheumatoid nodules in the lungs, not primarily pleural effusion. - This option incorrectly states that Asbestosis has an upper lobe predominance; **Asbestosis** predominantly affects the **lower lobes** of the lungs, causing interstitial fibrosis. *A-2, B-4, C-3, D-1* - This option incorrectly states that Caplan syndrome has an upper lobe predominance; the defining feature of **Caplan syndrome** is the combination of rheumatoid arthritis and pneumoconiosis, not specific lobar involvement. - This option correctly identifies pleural effusion with asbestosis and lower lobe involvement with mesothelioma, but **Caplan syndrome** is not characterized by upper lobe predominance.
Question 9: A 10-year-old child presents with inward turning of the right eye, and examination shows limited abduction of the affected eye. What is the most likely diagnosis?
- A. Concomitant strabismus
- B. Paralytic squint (Correct Answer)
- C. Exotropia
- D. Hypertropia
Explanation: ***Paralytic squint*** - The key finding is an **inward turning of the right eye** (**esotropia**) combined with **limited abduction** of that eye, strongly suggesting paralysis or weakness of the **lateral rectus muscle**. - A paralytic squint is characterized by an **underacting extraocular muscle**, leading to a deviation that varies with the direction of gaze and often results in **diplopia** (double vision) and a compensatory head turn. *Concomitant strabismus* - In concomitant strabismus, the **degree of ocular deviation is constant** in all directions of gaze, and there is no limitation of eye movement. - It typically results from an **imbalance in the binocular visual system** rather than a muscle paralysis. *Exotropia* - **Exotropia** refers to an **outward turning of the eye**, which is the opposite of the inward turning (**esotropia**) described in the clinical presentation. - While it is a type of strabismus, its direction of deviation does not match the patient's symptoms. *Hypertropia* - **Hypertropia** is an **upward deviation of one eye**, meaning the affected eye is higher than the other. - This condition is also not consistent with the reported inward turning of the eye.
Question 10: The following spectacle is used in? (AIIMS Nov 2018)
- A. Progressive glasses for presbyopia
- B. Bifocal glasses for presbyopia (Correct Answer)
- C. Bifocals for paediatric pseudo-phakia
- D. Bifocals for adult aphakia
Explanation: ***Bifocal glasses for presbyopia*** - The image clearly shows spectacle lenses with a visible **horizontal line separating two distinct optical powers**, which is characteristic of **bifocal lenses**. - **Presbyopia** is the condition where the eye's lens loses its ability to focus on near objects, requiring a different optical correction for near vision separate from distance vision, precisely what bifocals provide. *Progressive glasses for presbyopia* - **Progressive lenses** offer a gradual change in optical power from distance to near vision without a visible dividing line, unlike the spectacles shown. - They provide a continuous range of focus, but the absence of a visible segment in progressive lenses differentiates them from bifocals. *Bifocals for paediatric pseudo-phakia* - While pediatric pseudophakia (presence of an intraocular lens in a child) might require bifocals, the question asks for the primary use of the *pictured* bifocals, which commonly address **age-related presbyopia**. - Additionally, pseudophakia itself doesn't inherently imply a need for bifocals unless there's an accommodative issue, which is more typically associated with adult presbyopia. *Bifocals for adult aphakia* - **Aphakia** is the absence of the natural lens in the eye, which requires strong corrective lenses. While bifocals can be used in aphakia to provide both distance and near correction, the pictured bifocals are a standard design most commonly associated with correcting **presbyopia** in the general population. - Aphakic corrections generally involve much higher power lenses, which might appear thicker or have different characteristics than the standard bifocal shown.
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