Pediatric Ocular Trauma — MCQs
Which of the following is not a differential diagnosis of non-accidental injury?
A boy presents with diplopia and restriction of eye movements following blunt trauma to his eye. X-ray reveals blow out fracture of orbit. Which part of orbit is most likely damaged?
Which drug is generally contraindicated in the management of traumatic hyphema in a patient with sickle cell disease?
A baby was vigorously shaken by parents. What do you expect in the baby?
In which of the following conditions does Berlin's edema occur?
In a radiograph of suspected non-accidental injury, which of the following fractures is LEAST specific for child abuse?
True about acid injury to eye are all except?
Cover test and prism testing are used to diagnose which ocular condition?
In blowout fractures, which of the following is seen?
Blowout fracture of the orbit is characterized by all, except
Pediatric Ocular Trauma Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not a differential diagnosis of non-accidental injury?
- A. Osteogenesis imperfecta
- B. Scurvy
- C. Caffey's disease
- D. Osteopetrosis (Correct Answer)
Explanation: ***Correct: Osteopetrosis*** - Osteopetrosis is a rare genetic disorder characterized by **increased bone density** due to defective osteoclast function - While it causes bones to be brittle and prone to fracture, it has **distinctive radiological features** including diffuse sclerosis and "bone-within-bone" appearance - The **increased bone density on X-ray** is pathognomonic and readily distinguishes it from NAI, making it **less likely to be confused** with non-accidental injury in clinical practice - Fractures occur but the radiological pattern is diagnostic of the underlying metabolic bone disease *Incorrect: Osteogenesis imperfecta* - This is a **classic differential** for NAI causing **multiple brittle bone fractures** that can be mistaken for abuse - Features include **blue sclera**, **dentinogenesis imperfecta**, **wormian bones**, and **family history** - Often presents with multiple fractures at different stages of healing, mimicking the pattern seen in NAI *Incorrect: Scurvy* - Caused by **vitamin C deficiency**, leads to defective collagen synthesis - Results in **subperiosteal hemorrhages**, **metaphyseal fractures**, and **periosteal elevation** that closely mimic NAI - Additional features include **gingival bleeding**, **petechiae**, **follicular hyperkeratosis**, and **poor wound healing** *Incorrect: Caffey's disease* - Also known as **infantile cortical hyperostosis**, presents in infants under 6 months - Causes **periosteal reactions**, **bone thickening**, and **soft tissue swelling** in long bones, ribs, and mandible - The periosteal new bone formation can be mistaken for healing fractures from NAI, making it an important differential
Question 2: A boy presents with diplopia and restriction of eye movements following blunt trauma to his eye. X-ray reveals blow out fracture of orbit. Which part of orbit is most likely damaged?
- A. Inferior wall (Correct Answer)
- B. Medial wall
- C. Lateral wall
- D. Superior wall
Explanation: ***Inferior wall*** - The **inferior wall** (orbital floor) is the most common site for **blowout fractures** because it is the weakest and thinnest part of the orbital bone. - A fracture here often causes **entrapment** of the inferior rectus muscle and/or periorbital tissues, leading to **diplopia** and **restricted eye movements**, especially on upward gaze. *Medial wall* - While relatively thin, the medial wall is less commonly fractured in isolation than the inferior wall in typical blowout injuries. - Fractures here might involve the **ethmoid sinuses** and can lead to **subcutaneous emphysema** or **epistaxis**, which are not reported as primary symptoms in this case. *Lateral wall* - The lateral wall is the **thickest and strongest** part of the orbit, making fractures of this wall less common in isolated blowout injuries. - Fractures here typically require significant force and are often associated with other facial bone trauma. *Superior wall* - The superior wall (orbital roof) is made of the **frontal bone** and is relatively thick, making fractures here uncommon. - Fractures of the superior wall carry a risk of **intracranial injury** due to proximity to the brain, which is not suggested by the patient's presentation.
Question 3: Which drug is generally contraindicated in the management of traumatic hyphema in a patient with sickle cell disease?
- A. Timolol
- B. Steroids
- C. Acetazolamide (Correct Answer)
- D. Atropine
Explanation: ***Acetazolamide*** - **Acetazolamide** is a **carbonic anhydrase inhibitor** that is **generally contraindicated** in patients with **sickle cell disease or trait**. - It causes **systemic acidosis** by increasing renal bicarbonate excretion, which lowers blood pH. - **Acidosis promotes sickling** of red blood cells, which can lead to **vaso-occlusion**, increased blood viscosity, and potential complications including **anterior chamber obstruction** and **secondary glaucoma**. - Despite its usefulness in lowering intraocular pressure in other settings, this risk makes it contraindicated in sickle cell patients with hyphema. *Timolol* - **Timolol** is a **beta-blocker** that reduces aqueous humor production and is generally **safe and effective** for reducing **intraocular pressure** in traumatic hyphema. - It does not cause systemic acidosis or affect red blood cell sickling. - Commonly used in hyphema management regardless of sickle cell status. *Steroids* - **Topical or systemic steroids** are often used to reduce **inflammation** and anterior chamber reaction in traumatic hyphema. - They help prevent **secondary hemorrhage** and reduce complications. - They do not contribute to red blood cell sickling or systemic acidosis and are safe in sickle cell disease. *Atropine* - **Atropine** is a **cycloplegic agent** used to paralyze the ciliary body and dilate the pupil, which helps **relieve pain** and prevent **posterior synechiae** in hyphema. - It has no adverse effects related to **sickle cell disease** or red blood cell sickling. - Routinely used in hyphema management.
Question 4: A baby was vigorously shaken by parents. What do you expect in the baby?
- A. Ruptured spleen
- B. Rib fractures
- C. Sub-dural hematoma (Correct Answer)
- D. Pelvic fracture
Explanation: ***Sub-dural hematoma*** - **Shaken baby syndrome** results from violent shaking, leading to rapid acceleration and deceleration that causes tearing of the **bridging veins** in the brain. - This tearing results in a **subdural hematoma**, which is a collection of blood between the dura mater and arachnoid mater. *Ruptured spleen* - While possible in severe trauma, a ruptured spleen is less common with shaking alone and more often associated with **direct abdominal impact**. - The mechanisms of injury for splenic rupture typically involve significant blunt force to the abdomen, which is not the primary injury in shaken baby syndrome. *Rib fractures* - Rib fractures are indicators of significant chest compression or **direct impact**, which can occur in child abuse but are not the primary, immediate effect of shaking a baby. - While rib fractures can be a component of child abuse, they typically result from a different type of forceful interaction than shaking. *Pelvic fracture* - Pelvic fractures in infants typically require **high-energy trauma**, such as a fall from a significant height or a motor vehicle accident. - They are highly unlikely to result from shaking alone, as the pelvis is not directly impacted during a typical shaking event.
Question 5: In which of the following conditions does Berlin's edema occur?
- A. Open angle glaucoma
- B. After cataract surgery
- C. After concussional trauma (Correct Answer)
- D. Diabetic retinopathy
Explanation: ***After concussional trauma*** - **Berlin's edema**, also known as **commotio retinae**, is a form of **retinal edema** that occurs following **blunt trauma** to the eye. - It results from the disruption of the **photoreceptor outer segments** and retinal pigment epithelium, leading to a **dull, gray-white appearance** of the retina. *Open angle glaucoma* - Characterized by **progressive optic nerve damage** and visual field loss, typically due to elevated intraocular pressure, without retinal edema. - The primary pathology involves the **trabecular meshwork**, not direct retinal swelling. *After cataract surgery* - A common complication is **cystoid macular edema** (Irvine-Gass syndrome), which affects the macula and can cause blurred vision. - This is distinct from Berlin's edema, as it is a **post-surgical inflammatory response**, not a direct traumatic injury. *Diabetic retinopathy* - Involves various retinal changes due to diabetes, such as **microaneurysms**, hemorrhages, and **macular edema** from leaky vessels. - It is a **metabolic and vascular disease**, not a direct consequence of acute ocular trauma.
Question 6: In a radiograph of suspected non-accidental injury, which of the following fractures is LEAST specific for child abuse?
- A. Metaphysis corner fracture
- B. Costochondral & rib junction fracture
- C. Parietal bone fracture (Correct Answer)
- D. Sternal fracture
Explanation: ***Parietal bone fracture*** - While **parietal bone fractures** are commonly seen in both accidental and non-accidental pediatric head trauma, they are **less specific for child abuse** compared to the classic skeletal injuries listed below. - Isolated skull fractures, particularly **simple linear parietal fractures**, can result from accidental falls and require additional clinical context (age, mechanism, associated injuries) to determine if abuse is suspected. - Complex, multiple, or depressed skull fractures are more concerning, but a simple parietal fracture alone is less diagnostic than the pathognomonic fractures of NAI. *Metaphyseal corner fracture* - Also known as **"bucket handle"** or **"corner" fractures**, these are **highly specific and virtually pathognomonic** for **non-accidental injury** in infants and young children. - They result from violent **shaking, twisting, or pulling forces** applied to the extremities, causing avulsion at the metaphyseal-epiphyseal junction. - These fractures are rarely seen in accidental trauma. *Costochondral & rib junction fracture* - **Posterior rib fractures** and **costochondral junction fractures** are **highly specific for NAI** in infants. - They result from **anteroposterior chest compression** during forceful squeezing or gripping of the thorax. - Accidental rib fractures in children are rare due to chest wall elasticity, making these fractures particularly suspicious. *Sternal fracture* - **Sternal fractures** are extremely rare in children due to the **flexibility of the pediatric sternum** and chest wall. - Their presence, especially without a history of **severe high-impact trauma** (e.g., motor vehicle collision), is **highly suspicious for non-accidental injury**. - Often result from direct forceful blows or severe compression injuries.
Question 7: True about acid injury to eye are all except?
- A. more destructive than alkali injuries (Correct Answer)
- B. steroids are used to control inflammation
- C. makes a barrier and prevent deeper penetration
- D. glaucoma is most preventable complication following acid injury
Explanation: ***more destructive than alkali injuries*** - This statement is **false**. **Alkali burns** are generally more severe than acid burns because alkalis have **liquefactive necrosis**, which allows them to penetrate deeper into ocular tissues. - Acids cause **coagulative necrosis**, which forms a protective barrier that limits further penetration, making them typically less destructive than alkali injuries. *steroids are used to control inflammation* - **Topical corticosteroids** are commonly used in the management of ocular chemical burns, including acid injuries, to help **control inflammation** and reduce the risk of secondary complications. - However, their use must be carefully monitored due to potential side effects like increased intraocular pressure and delayed corneal healing. *makes a barrier and prevent deeper penetration* - **Acidic substances** cause **coagulative necrosis** of the superficial tissues, which creates a protective barrier of denatured proteins. - This barrier helps to prevent the acid from penetrating deeper into the ocular structures, thus often limiting the extent of damage compared to alkali burns. *glaucoma is most preventable complication following acid injury* - **Glaucoma** is indeed a significant complication of ocular acid injuries and can be prevented through **immediate copious irrigation**, control of inflammation, and monitoring of intraocular pressure. - While various complications can occur (corneal opacification, symblepharon, limbal stem cell deficiency), glaucoma prevention through early intervention and appropriate medical management is a key focus in acute management, making this statement acceptable as true.
Question 8: Cover test and prism testing are used to diagnose which ocular condition?
- A. Strabismus
- B. Both A & B (Correct Answer)
- C. Heterophoria
- D. None of the options
Explanation: ***Both A & B*** - The **cover test** and **prism testing** are fundamental diagnostic tools used to detect and quantify **both manifest and latent ocular deviations**. - **Cover-uncover test** detects **strabismus (heterotropia)** - a manifest deviation present even with both eyes open. - **Alternate cover test** reveals the **total deviation**, including both manifest strabismus and latent heterophoria. - **Prism testing** is used to **quantify both conditions** - measuring the angle of deviation in both tropias and phorias. - These tests work together to diagnose the full spectrum of ocular misalignment disorders. *Strabismus (alone)* - While partially correct, this option is incomplete. - Cover test and prism testing are indeed used for strabismus, but they also diagnose heterophoria. - Selecting only strabismus ignores the heterophoria component. *Heterophoria (alone)* - While partially correct, this option is incomplete. - Cover test (especially alternate cover test) and prism testing do diagnose heterophoria, but they equally diagnose manifest strabismus. - The cover-uncover test is the **primary clinical test for detecting manifest strabismus**. - Selecting only heterophoria ignores the strabismus component. *None of the options* - Incorrect, as both strabismus and heterophoria are correctly diagnosed using these tests.
Question 9: In blowout fractures, which of the following is seen?
- A. Bulbar hemorrhage
- B. None of the options
- C. Enophthalmos (Correct Answer)
- D. Exophthalmos
Explanation: ***Enophthalmos*** - A **blowout fracture** of the orbit typically involves the orbital floor or medial wall from direct trauma to the eye or periorbital region. - The fracture allows orbital contents (fat and muscle) to herniate into the maxillary sinus or ethmoid sinuses, **increasing orbital volume**. - This increased volume causes the eye to recede backward into the orbit, resulting in **enophthalmos** (sunken eye appearance). - **Key clinical features**: enophthalmos, diplopia (due to inferior rectus/medial rectus entrapment), restricted eye movements, infraorbital nerve hypoesthesia. *Exophthalmos* - **Exophthalmos** (proptosis) is forward protrusion of the eye, occurring when orbital volume is **decreased** or orbital contents are **increased** (e.g., thyroid eye disease, orbital tumors, orbital hemorrhage). - This is the **opposite** of enophthalmos and would not occur in a blowout fracture where orbital volume increases. *Bulbar hemorrhage* - **Subconjunctival hemorrhage** may occur as an associated finding from ocular trauma but is not a characteristic or defining feature of blowout fractures. - Many types of blunt ocular trauma can cause conjunctival hemorrhage without orbital fracture. *None of the options* - Incorrect because **enophthalmos** is the classic and characteristic finding of orbital blowout fractures.
Question 10: Blowout fracture of the orbit is characterized by all, except
- A. Exophthalmos (Correct Answer)
- B. Tear drop sign
- C. Diplopia
- D. Forced duction test
Explanation: ***Exophthalmos*** - **Exophthalmos** (protrusion of the eyeball) occurs when there is an increase in orbital contents, such as from a tumor or edema behind the globe. - In a **blowout fracture**, the orbital contents herniate into the adjacent sinus, leading to an increase in orbital volume, which typically causes **enophthalmos** (recession of the eyeball), not exophthalmos, as the globe sinks into the enlarged bony cavity. *Tear drop sign* - The **tear drop sign** is a classic radiological finding on sinus X-rays or CT scans in blowout fractures. - It represents the **herniated orbital tissue** (fat and/or muscle) projecting into the maxillary sinus, resembling a teardrop. *Diplopia* - **Diplopia** (double vision) is a common symptom of blowout fractures, especially on upward or downward gaze. - It results from the **entrapment** of an extraocular muscle (most commonly the inferior rectus) in the fractured bone, limiting its movement. *Forced duction test* - The **forced duction test** is a clinical maneuver used to assess the presence of mechanical restriction of eye movement. - A positive forced duction test, indicating mechanical restriction due to muscle entrapment, is a characteristic finding in blowout fractures and helps differentiate it from nerve palsies.
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