OPTHA LE5 Flashcards
Retinal vascular changes most commonly seen in acute severe hypertensive patients:
A. Flame-shaped hemorrhages
B. Cotton-wool patches
C. Lipid exudates
D. A & B
E. A & C
D. A & B (Flame-shaped hemorrhages and Cotton-wool patches)
Rationale: Acute severe hypertension often leads to retinal vascular damage, presenting as flame-shaped hemorrhages and cotton-wool patches. These changes result from capillary damage and ischemia affecting the superficial layers of the retina.
Retinal vascular changes seen in patients with chronic hypertension:
A. Copper or silver wiring of the arterioles
B. Lipid exudates
C. Flame-shaped hemorrhages
D. Cotton-wool patches
E. All of the above
E. All of the above
Rationale: Chronic hypertension induces a spectrum of retinal changes. These include copper or silver wiring of arterioles due to sclerosis, lipid exudates from increased vascular permeability, and flame-shaped hemorrhages and cotton-wool patches due to ischemic damage.
Hallmark of malignant hypertension:
A. Flame-shaped hemorrhages
B. Cotton-wool patches
C. Optic disc swelling
D. Lipid exudates
E. All of the above
C. Optic disc swelling
Rationale: Malignant hypertension is characterized by severe, uncontrolled blood pressure leading to optic disc swelling (papilledema). This is a key feature, indicating increased intracranial pressure and significant damage to the optic nerve.
A transient ischemic attack involving the ocular circulation may manifest with the following ocular manifestation(s):
A. Monocular dimming of vision
B. Sudden transient, painless visual loss
C. Sudden transient, painful visual loss
D. A & B
E. A & C
D. A & B (Monocular dimming of vision and Sudden transient, painless visual loss)
Rationale: A transient ischemic attack (TIA) of the ocular circulation, known as amaurosis fugax, typically presents as sudden, transient, painless visual loss or monocular dimming of vision. This occurs due to temporary arterial occlusion, often associated with emboli.
Most common source of emboli in the elderly:
A. Emboli of cardiac origin
B. Fibrin and cholesterol from carotid artery plaques
C. Talc
D. Fat
E. None of the above
B. Fibrin and cholesterol from carotid artery plaques
Rationale: In elderly patients, emboli commonly originate from ulcerated plaques in the carotid arteries, composed of fibrin and cholesterol. These emboli can travel to the ocular arteries, causing vision disturbances such as amaurosis fugax.
Central retinal vein occlusion:
A. Sudden persistent, painless loss of vision
B. Retinal hemorrhages and cotton-wool patches
C. Narrowed retinal arterioles and a pale retina
D. A & C
E. A & B
E. A & B (Sudden persistent, painless loss of vision and Retinal hemorrhages and cotton-wool patches)
Rationale: Central retinal vein occlusion (CRVO) typically presents as a sudden, painless loss of vision and is associated with retinal hemorrhages and cotton-wool patches. It occurs due to the obstruction of the central retinal vein, leading to increased retinal venous pressure.
The most common type of intraocular malignancy in adults:
A. Primary ocular melanoma
B. Large cell lymphoma
C. Metastatic carcinoma
D. A & B
E. None of the above
C. Metastatic carcinoma
Rationale: Metastatic carcinoma is the most common type of intraocular malignancy in adults, often originating from primary tumors in the breast or lung. These metastases commonly affect the choroid due to its rich vascular supply.
The most common site for ocular metastasis:
A. Cornea
B. Lens
C. Vitreous
D. Choroid
E. Iris
D. Choroid
Rationale: The choroid is the most common site for ocular metastasis because of its high blood flow, which makes it a frequent target for metastatic tumor cells from systemic malignancies.
The most common ocular manifestation of patients with connective tissue disorders:
A. Episcleritis
B. Scleritis
C. Iritis
D. Keratoconjunctivitis sicca
E. Peripheral corneal ulceration
D. Keratoconjunctivitis sicca
Rationale: Keratoconjunctivitis sicca, or dry eye syndrome, is the most common ocular manifestation of connective tissue disorders like rheumatoid arthritis. It results from reduced tear production due to inflammation of the lacrimal glands.
The most common severe ocular manifestation of systemic lupus erythematosus:
A. Keratoconjunctivitis sicca
B. Scleritis
C. Peripheral corneal ulcers
D. Retinopathy and optic neuropathy
E. None of the above
D. Retinopathy and optic neuropathy
Rationale: Systemic lupus erythematosus (SLE) can cause severe ocular manifestations such as retinopathy and optic neuropathy, which are associated with vasculitis and ischemic damage to retinal and optic nerve tissues.
This condition is a widespread inflammatory disease affecting small and medium-sized blood vessels, most commonly in middle-aged men:
A. Periarteritis Nodosa
B. Giant cell arteritis
C. Ankylosing spondylitis
D. Systematic Lupus Erythematosus
E. Rheumatoid Arthritis
A. Periarteritis Nodosa
Rationale: Periarteritis nodosa (also known as polyarteritis nodosa) is a systemic vasculitis that affects small and medium-sized arteries, leading to inflammation and damage. It commonly presents in middle-aged men with symptoms that can affect multiple organs, including the eyes.
Ocular complications may occasionally be the presenting feature of this disease and do not correlate with the severity or course of the systemic signs:
A. Rheumatoid Arthritis
B. Juvenile Rheumatoid Arthritis
C. Hypertension
D. Diabetes Mellitus
E. None of the above
B. Juvenile Rheumatoid Arthritis
Rationale: In juvenile rheumatoid arthritis (JRA), ocular complications such as iritis or uveitis may be present even in mild cases of the disease and do not necessarily correlate with the severity of joint involvement. Regular ophthalmic screening is recommended for early detection and management.
Ocular manifestations of this disease are most often seen in patients with more active and severe forms of the disease and in those with extraarticular complications:
A. Ankylosing spondylitis
B. Periarteritis nodosa
C. Juvenile rheumatoid arthritis
D. Rheumatoid arthritis
E. Osteoarthritis
D. Rheumatoid arthritis
Rationale: In rheumatoid arthritis, ocular manifestations such as scleritis, episcleritis, and peripheral corneal ulcers are more common in patients with severe disease and extraarticular complications, indicating a higher level of systemic inflammation.
Which condition is characterized by inflammation of the superficial tissue overlying the sclera, typically presenting with mild to moderate pain, tenderness, and localized or diffuse redness of the eye?
A. Scleritis
B. Uveitis
C. Episcleritis
D. Blepharitis
E. A & B
C. Episcleritis
Rationale: Episcleritis is a benign inflammatory condition affecting the episclera, the tissue between the conjunctiva and sclera. It presents with mild to moderate pain and localized redness and often resolves without specific treatment.
Most common presentation of giant cell arteritis:
A. Non-embolic central retinal artery occlusion
B. Ischemic optic neuropathy
C. Cranial motor nerve paralysis
D. Keratoconjunctivitis sicca
E. Uveitis
B. Ischemic optic neuropathy
Rationale: Giant cell arteritis most commonly presents with ischemic optic neuropathy, leading to sudden, severe vision loss. It is an inflammatory condition affecting large and medium-sized arteries, including those supplying the optic nerve.
Management of the congestive phase of thyroid ophthalmopathy:
A. Tear substitutes
B. Corticosteroids
C. Orbital irradiation
D. Surgical decompression
E. All of the above
E. All of the above
Rationale: Management of thyroid ophthalmopathy in the congestive phase includes tear substitutes for dryness, corticosteroids to reduce inflammation, and, in severe cases, orbital irradiation or surgical decompression to alleviate pressure on the optic nerve and prevent vision loss.
An autoimmune disease affecting the acetylcholine receptors, causing a conduction defect at the neuromuscular junction:
A. Multiple Sclerosis
B. Thyroid disorders
C. Myasthenia gravis
D. Ankylosing Spondylitis
E. Systemic Lupus Erythematosus
C. Myasthenia gravis
Rationale: Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction by targeting acetylcholine receptors, leading to muscle weakness. Ocular symptoms often include ptosis and diplopia.
Optic neuritis:
A. Acute painful vision loss in one or both eyes
B. Treat initial episode with intravenous methylprednisolone
C. Acute painless vision loss in one or both eyes
D. A & B
E. B & C
D. A & B (Acute painful vision loss in one or both eyes and Treat initial episode with intravenous methylprednisolone)
Rationale: Optic neuritis typically presents with acute, painful vision loss in one or both eyes. Treatment with intravenous methylprednisolone can accelerate visual recovery and reduce the risk of developing multiple sclerosis.
A 75-year-old female presents with ptosis and diplopia noted a few days prior. Associated symptoms are headache and scalp tenderness. Ocular examination reveals an outward deviation of the eye on the involved side, with sparing of the pupil. Fundoscopy shows arteriosclerotic arterioles and occasionally lipid exudates. What is your tentative diagnosis?
A. Thyroid ophthalmopathy
B. Giant cell arteritis
C. Myasthenia gravis
D. Diabetic Neuropathy
E. None of the above
B. Giant cell arteritis
Rationale: The presentation of ptosis, diplopia, headache, and scalp tenderness, along with ocular findings, suggests giant cell arteritis. This condition can lead to cranial nerve palsies due to ischemia, and timely diagnosis is crucial to prevent bilateral vision loss.
Giant cell arteritis
What additional examination(s) would you have done to confirm the diagnosis?
A. Fasting blood sugar
B. Thyroid function test
C. Erythrocyte Sedimentation Rate
D. Tensilon testing
E. All of the above
C. Erythrocyte Sedimentation Rate
Rationale: An elevated erythrocyte sedimentation rate (ESR) is a key diagnostic marker for giant cell arteritis. It helps confirm the diagnosis, and prompt treatment with corticosteroids can prevent complications such as vision loss.
What is the pathophysiology of the cranial motor nerve paralysis?
A. Conduction defect at the neuromuscular junction due to involvement of the acetylcholine receptors
B. Nerve ischemia resulting from occlusion of the vascular supply to the nerve
C. Enlargement of the extraocular muscles secondary to lymphocytic infiltration
D. Intracranial tumor
E. None of the above
B. Nerve ischemia resulting from occlusion of the vascular supply to the nerve
Rationale: Cranial motor nerve paralysis can result from ischemia due to compromised blood supply. This is commonly seen in conditions such as diabetes and giant cell arteritis, where vascular insufficiency affects the cranial nerves.
What cranial nerve is involved?
A. Cranial nerve VI
B. Cranial nerve V
C. Cranial nerve III
D. Cranial nerve IV
E. Cranial nerve VII
C. Cranial nerve III
Rationale: Cranial nerve III (oculomotor nerve) is commonly affected in ischemic conditions, leading to symptoms such as ptosis and outward deviation of the eye, often with sparing of the pupil.
Cranial motor nerve paralysis
How would you manage the patient?
A. Tear substitute
B. Muscle/Lid surgery
C. Corticosteroids
D. Insulin
E. Tensilon
C. Corticosteroids
Rationale: Management of cranial motor nerve paralysis, particularly when associated with giant cell arteritis, includes corticosteroids to reduce inflammation and prevent further vascular damage.
A young woman presents with visual loss. Ophthalmoscopic evaluation reveals a pale swollen disc. What is your tentative diagnosis?
A. Systemic lupus Erythematosus
B. Rheumatoid arthritis
C. Ankylosing spondylitis
D. Central Retinal Artery Occlusion
E. Giant cell arteritis
A. Systemic lupus erythematosus (SLE)
Rationale: SLE can cause optic neuropathy and retinal vasculitis, which can present with a pale, swollen optic disc. The presence of visual loss and optic disc changes can be consistent with lupus involvement of the optic nerve, particularly in young women.
A 35-year-old female presents with lid retraction and proptosis of the right eye accompanied by tearing, photophobia, redness, and foreign-body sensation. What is your tentative diagnosis?
A. Thyroid Ophthalmopathy
B. Myasthenia Gravis
C. Giant cell arteritis
D. Sjögren’s syndrome
E. All of the above
A. Thyroid Ophthalmopathy
Rationale: The presence of lid retraction and proptosis along with symptoms like tearing, photophobia, redness, and a foreign-body sensation are characteristic features of thyroid ophthalmopathy. This condition, also known as Graves’ orbitopathy, is often associated with hyperthyroidism and involves inflammation and swelling of the extraocular muscles, leading to proptosis and other ocular symptoms.
A 45-year-old non-insulin-dependent male patient of 10-year duration presents with ophthalmoscopic findings of microaneurysms, flame-shaped hemorrhages, and occasional lipid exudates. Visual acuity is 20/20 Jaeger 1 with prescription glasses. What is your diagnosis?
A. Early non-proliferative diabetic retinopathy
B. Advanced non-proliferative diabetic retinopathy
C. Proliferative diabetic retinopathy
D. Vitreous hemorrhages
E. Macular edema
A. Early non-proliferative diabetic retinopathy
Rationale: The presence of microaneurysms, flame-shaped hemorrhages, and lipid exudates in a diabetic patient with preserved visual acuity is consistent with early non-proliferative diabetic retinopathy. This stage involves mild retinal changes without significant vision loss, and early detection is key for monitoring and preventing progression.
Early NPDR
How would you manage this patient?
A. Strict blood sugar control
B. Annual ophthalmological examinations
C. Ophthalmoscopy by primary-care physician for signs at other intervals
D. Laser panretinal photocoagulation
E. A, B & C
E. A, B & C
Rationale: Management of early non-proliferative diabetic retinopathy includes strict blood sugar control (to prevent progression), annual ophthalmological examinations for monitoring, and ophthalmoscopy by a primary-care physician at other intervals to detect any changes. Laser panretinal photocoagulation is not indicated at this early stage.
Any patient with ptosis and diplopia of unclear etiology, especially if variable and worsening with fatigue, should be presumed to have:
A. Giant cell arteritis
B. Periarteritis
C. Myasthenia Gravis
D. Thyroid Ophthalmopathy
E. Diabetes Mellitus
C. Myasthenia Gravis
Rationale: Myasthenia gravis presents with fluctuating muscle weakness that worsens with fatigue. Ocular symptoms often include ptosis and diplopia, which are key features for suspecting this autoimmune disorder affecting neuromuscular transmission.
Within 5 years of an episode of optic neuritis, more than 40% of women aged 20 to 40 will manifest signs and symptoms of:
A. Systemic Lupus Erythematosus
B. Multiple Sclerosis
C. Giant cell Arteritis
D. Ethambutol toxicity
E. Ankylosing Spondylitis
B. Multiple Sclerosis
Rationale: Optic neuritis is often an early manifestation of multiple sclerosis (MS), particularly in women aged 20 to 40. MS is a demyelinating disease of the central nervous system, and optic neuritis can be a precursor to more generalized neurological symptoms.
Diplopia in thyroid ophthalmopathy is due to:
A. Extraocular muscle involvement secondary to lymphocytic infiltration
B. Optic nerve compression
C. Lid retraction
D. Proptosis
A. Extraocular muscle involvement secondary to lymphocytic infiltration
Rationale: Thyroid ophthalmopathy causes inflammation and lymphocytic infiltration of the extraocular muscles, leading to their enlargement. This results in restricted eye movement and subsequent diplopia (double vision).
Diplopia in thyroid ophthalmopathy is due to:
A. Extraocular muscle involvement secondary to lymphocytic infiltration
B. Optic nerve compression
C. Lid retraction
D. Proptosis
A. Extraocular muscle involvement secondary to lymphocytic infiltration
Rationale: In thyroid ophthalmopathy, inflammation and lymphocytic infiltration lead to hypertrophy of the extraocular muscles. This results in restricted eye movement, which causes diplopia (double vision).
An adult patient with a 15-year history of non-insulin-dependent diabetes comes to your office for the first time. She tells you that she has never seen an ophthalmologist nor has had a dilated ophthalmoscopic examination. Her visual acuity is normal, but on dilated fundus examination, you find neovascularization of the optic disc. What is your diagnosis?
A. Central retinal vein occlusion
B. Macular edema
C. Early non-proliferative diabetic retinopathy
D. Advanced non-proliferative diabetic retinopathy
E. Proliferative diabetic retinopathy
E. Proliferative diabetic retinopathy
Rationale: The presence of neovascularization of the optic disc indicates proliferative diabetic retinopathy, an advanced stage of diabetic retinopathy characterized by the growth of new, fragile blood vessels on the retina in response to ischemia.
Proliferative diabetic retinopathy
What would be the best management for this patient?
A. Strict blood sugar control
B. Fluorescein angiography
C. Pan retinal laser photocoagulation
D. Vitrectomy
E. A, B & C
E. A, B & C
Rationale: Management of proliferative diabetic retinopathy includes strict blood sugar control, fluorescein angiography to evaluate the extent of neovascularization, and panretinal laser photocoagulation to reduce the risk of vision loss by preventing further neovascular growth.
A 45-year-old man comes to your office complaining of headaches and nosebleeds. His blood pressure is 180/120 mm Hg. On dilated fundus examination, you find numerous exudates, flame-shaped hemorrhages, cotton-wool spots, and severe attenuation of the arterioles. You do not find AV crossing changes, and the arteriolar light reflex is normal. What is your diagnosis?
A. Chronic hypertension
B. Acute, severe hypertension
C. Papilledema
D. Hyperviscosity syndromes
E. Central retinal artery occlusion
B. Acute, severe hypertension
Rationale: The findings of numerous exudates, flame-shaped hemorrhages, cotton-wool spots, and severe attenuation of the arterioles are consistent with acute, severe hypertension, which causes retinal damage due to the rapid rise in blood pressure. Immediate blood pressure control is critical to prevent further complications.
Acute vs Chronic Hypertension:
Acute Hypertension: Often presents with retinal findings such as flame-shaped hemorrhages, cotton-wool spots, and severe attenuation of arterioles. These changes result from a rapid rise in blood pressure causing damage to the retinal microvasculature.
Chronic Hypertension: Usually presents with more permanent retinal changes, including arteriolar narrowing, arterio-venous crossing changes (AV nicking), and a copper or silver wiring appearance of the arterioles due to thickening of vessel walls. Chronic damage results from prolonged exposure to elevated blood pressure.
A 67-year-old man experienced sudden loss of vision in the left eye 3 hours ago. You record VA as OD 20/20 and OS no light perception. The right pupil responds to light directly but not consensually. The left eye responds to light consensually but not directly. Dilated fundus examination of the right eye is normal. The left eye shows a white opacified retina, a cherry-red spot in the macula, and a sluggish retinal circulation. What is your diagnosis?
A. Central retinal artery occlusion OS
B. Central retinal vein occlusion OS
C. Optic atrophy OS
D. Optic neuritis OS
A. Central retinal artery occlusion OS
Rationale: The presence of a cherry-red spot at the macula, a white opacified retina, and sudden profound visual loss are characteristic features of central retinal artery occlusion. It results from an embolic event leading to ischemia of the retina. Immediate intervention is crucial to attempt to restore circulation, although prognosis for visual recovery is generally poor.
Central retinal artery occlusion OS
What is the proper management for the patient?
A. Pan retinal laser photocoagulation
B. Intermittent pressure on the affected eye in the hope that the induced alterations of intraocular pressure may dislodge an embolus
C. Detection of underlying disease (such as giant-cell arteritis) or a site of embolus formation (such as carotid atheroma) that may lead to future vascular occlusions
D. A, B, & C
E. B & C
E. B & C
Rationale: Management of central retinal artery occlusion includes applying intermittent pressure to the affected eye to potentially dislodge the embolus, as well as detecting underlying conditions (such as giant-cell arteritis or carotid atheroma) to prevent future vascular occlusions.
A man who has recently moved to the area is referred to you by a friend. He reports feeling tired lately, becoming fatigued after only moderate activity. He is also concerned about his vision; everything seems “dingy” or “yellow” to him. He’s not sure when the visual symptom started. The patient has a history of heart disease, for which he takes cardiac medications. Examination reveals no health problems, other than his heart disease, which appears stable. What is the ophthalmological diagnosis?
A. Digitalis Toxicity
B. Amiodarone Toxicity
C. Ethambutol Toxicity
D. Chloroquine Toxicity
E. Thioridazine Toxicity
A. Digitalis Toxicity
Rationale: The visual symptoms of “yellow” vision, known as xanthopsia, are a classic sign of digitalis toxicity. Digitalis is a cardiac medication that can cause visual disturbances, particularly in patients on long-term therapy.
Toxicity Keypoints:
Digitalis Toxicity: Causes visual disturbances such as yellow vision (xanthopsia), blurred vision, and occasionally central scotomas. It is associated with dosage levels and long-term use.
Amiodarone Toxicity: Can lead to corneal deposits (seen as whorl keratopathy), which are usually asymptomatic but may cause halos or visual disturbances. Long-term use can also lead to optic neuropathy.
Ethambutol Toxicity: Associated with dose-related optic neuropathy, which can present as decreased visual acuity and color vision defects. It is often reversible if detected early.
Chloroquine Toxicity: Causes bull’s eye maculopathy, which is characterized by concentric rings of pigment changes in the retina, potentially leading to irreversible vision loss if not monitored.
Thioridazine Toxicity: Can cause pigmentary retinopathy, especially with long-term use, leading to symptoms such as reduced night vision and peripheral vision loss.
A busy student comes to you during exam week because she is experiencing severe headaches. As part of a complete physical, you perform a basic eye examination. During ophthalmoscopy, you cannot fully see the optic disc because the patient’s pupil is very small. You find no contraindications to dilate the pupil, so you decide to do so to facilitate ophthalmoscopy. Your patient is brown-eyed, 20 years old, and has no other health complaints. Which of the following drugs would you select to dilate the pupils?
A. Phenylephrine hydrochloride 0.12%
B. Phenylephrine hydrochloride 2.5%
C. Phenylephrine hydrochloride 10%
D. Atropine sulfate 1%
E. Tropicamide plus phenylephrine hydrochloride 2.5%
E. Tropicamide plus phenylephrine hydrochloride 2.5%
Rationale: When maximum mydriasis is required, particularly to examine the far periphery of the retina, phenylephrine in combination with tropicamide is ideal due to their additive effects. This combination is also effective for dilating the pupil of a brown iris, which tends to be less responsive to mydriatics than a blue iris. The 2.5% solution of phenylephrine is preferred over the 10% solution to minimize the risk of acute hypertension or myocardial infarction.
Topical ocular diagnostic drug extremely helpful in detecting abrasions of the corneal surface:
A. Tropicamide
B. Sodium fluorescein
C. Proparacaine hydrochloride 0.5%
D. Timolol
E. Pilocarpine
B. Sodium fluorescein
Rationale: Sodium fluorescein is a topical dye used in ophthalmology to detect corneal abrasions or epithelial defects. It highlights areas of damage by staining them, making them easily visible under blue light.
Originally used to treat malaria and now used to treat rheumatoid arthritis, lupus erythematosus, and other autoimmune disorders:
A. Digitalis
B. Amiodarone
C. Ethambutol
D. Chloroquine
E. Thioridazine
D. Chloroquine
Rationale: Chloroquine was initially used to treat malaria but is also effective in treating autoimmune disorders like rheumatoid arthritis and lupus erythematosus due to its immunomodulatory properties.