Académique Documents
Professionnel Documents
Culture Documents
7. In patients with shock, what is the most frequent single cause of death?
a. hemorrhage
b. myocardial infarction
c. ventilatory failure
d. sepsis
13. Which of the following classes of oral hypoglycemic agents has been
associated with worsening macular edema?
a. sulfonylureas
b. a-glucosidase inhibitors
c. biguanides
d. thiazolidinediones
14. Patients with multiple endocrine neoplasia syndrome type 2B (MEN 2B)
are likely to have which of the following ophthalmic findings?
a. prominent corneal nerves
b. bitemporal hemianopsia
c. exophthalmos
d. hypertensive retinopathy
17. Which of the following types of dementia is more likely to present with
formed visual hallucinations
a. Alzheimer's disease
b. Lewy body dementia
c. vascular dementia
d. dementia associated with Parkinson's disease
18. Which of the following is the leading cause of mortality among women in
the United States?
a. atherosclerotic heart disease
b. breast cancer
c. ovarian cancer
d. stroke
20. When LDL goals are not achieved by lifestyle changes alone in a patient
with hypercholesterolemia, what is the next step?
a. begin nicotinic acid
b. begin bile acid sequestrants
c. begin statin medications
d. change the LDL goal
21. Adverse ocular reactions seen with use of digoxin include which of the
following?
a. glare phenomenon and xanthopsia
b. corneal microdeposits
c. keratoconjunctivitis sicca
d. bull's-eye maculopathy
25. You suspect that an older patient who presents with a hyphema has been
abused. What is your first step?
a. Call the patient's primary care physician about the suspected abuse.
b. Treat the suspected eye injury and address the nature of the injury on a follow-up
examination, after obtaining further information from the family.
c. Advise the caregiver to watch the patient for unstable balance and possible falls.
d. Complete a written report promptly, document any suspicious injuries, and
report your suspicions to the appropriate authorities.
32. The single most effective measure that can be instituted to reduce the risk
of chronic obstructive pulmonary disease is
a. weight loss
b. exercise
c. reduction of respiratory infections by hand washing
d. smoking cessation
33. Which of the following is the best test to monitor heparin therapy?
a. prothrombin time
b. partial thromboplastin time
c. bleeding time
d. platelet count
34. If the risk of endophthalmitis is 1% per year in one hospital and 0.01% in
another over a 1-year period, the risk difference is
a. 0.01% over 1 year
b. 100%
c. 100% over 1 year
d. 0.99% over 1 year
35. In a screening test applied to 250 patients, the sensitivity was estimated to
be 80%. If 100 patients have the disease, then how many patients were false-
negatives?
a. 75
b. 180
c. 20
d. 170
Answers
4. d. The most effective screening technique remains the Papanicolaou test ("Pap
smear").Fourier transform infrared (FTIR) spectroscopy is a new tool for screening
cervical cancer and has a sensitivity of85% and a specificity of91 %. PCR DNA
techniques can be used to help detect concomitant HPV infection.
5. b. The minimum age for administration of DTaP is 6 weeks. The first hepatitis B
immunization should be given at birth, before discharge from the hospital. If the
mother is HBs Ag positive, the infant should receive hepatitis B immunoglobulin
as well. The first dose of MMR (measles, mumps, rubella) vaccine is given
between 12 and 15 months of age. Pregnancy is a contraindication for the varicella
vaccine.
7. c. Ventilatory failure is the most significant factor in the morbidity and mortality
of shock, with subsequent hypoxemia and metabolic acidosis leading to many
complications.
11. a. Retinal and choroidal microvascular lesions are one of the more common
manifestations of ocular involvement with systemic lupus erythematosus (SLE).
Discoid lesions of the skin of the eyelids and keratitis sicca from secondary Sjogren
syndrome are also common when the eye is involved.
Recurrent unilateral anterior uveitis would be unusual with SLE; it is much more
common with HLA-B27-associated diseases such as ankylosing spondylitis. A
heliotrope rash of the eyelids, although rare, is almost pathognomonic for
dermatomyositis. Autoimmune conjunctivitis can be a feature of reactive arthritis.
12. b. Fasting plasma glucose (FPG) is the preferred test. The oral glucose
tolerance test may be more sensitive than the FPG, but it is not routinely used
because it is costlier, inconvenient, and difficult to reproduce. The hemoglobin A1c
measurement is not currently recommended for diagnosing diabetes, although this
may change when the test becomes more standardized.
Although measuring urine glucose is much easier than measuring blood glucose, it
is not sensitive, because blood glucose levels need to be quite elevated before
glucose appears in urine. Measurement of urinary ketones is useful during periods
of illness or stress, because any positive value suggests the presence of ketonemia;
however, measurement of urinary ketones is not used for the diagnosis of diabetes.
14. a. Prominent corneal nerves are reported to occur in 100% of affected patients.
This finding is significant because almost all affected patients will develop
medullary thyroid cancer; however, because this may not appear until the patient's
second or third decade, the ophthalmic manifestations may be the initial indication
that the syndrome is present. Bitemporal hemianopsia can occur with pituitary
tumors, which are part of multiple endocrine neoplasia syndrome type 1 (MEN 1).
Exophthalmos can occur in Gravess disease but is not part of the spectrum of the
MEN syndromes. Hypertensive retinopathy can occur in patients with
pheochromocytoma, which can be part of MEN 2A and 2B.
15. c. The main treatment is levodopa (L-dopa), which is generally initiated when
symptoms become significant. Usually patients are given levodopa combined with
carbidopa (Lodosyn), often as a combined pill (Sinemet).
Dopamine itself cannot be given because it does not cross the blood-brain barrier.
Pramipexole (Mirapex) stimulates dopamine receptors in the brain and can be
given alone or in combination with levodopa, but it is less effective than levodopa.
Benztropine (Cogentin), an anticholinergic drug, was a common treatment for
Parkinson disease before the introduction of levodopa.
Anti cholinergics may help control tremor and rigidity, although their benefit is
limited and their effect is usually short-lived.
16. c. It is unusual for patients experiencing a genuine seizure to shut their eyes
during the episode, whereas patients who are feigning a seizure often keep their
eyes closed. Patients who are having seizures may commonly have either
horizontal or vertical gaze deviations.
The gaze tends to be directed away from the site of the cortical lesion during a
seizure and then toward the site of the lesion after the seizure. Monocular
nystagmus can occur during the clonic stage of a seizure. Diminished saccadic
movement is a side effect of the anti seizure medication carbamazepine (Tegretol).
17. b. Lewy body dementia is the second most common form of neurodegenerative
dementia after Alzheimer's disease, and patients with this syndrome often present
with complex, formed visual hallucinations. Although there may be considerable
clinical and neuropathologic overlap among the various types of dementia, visual
hallucinations are not routinely a symptom of vascular dementia, Alzheimer's
disease, or dementia associated with Parkinson disease.
18. a. Atherosclerotic coronary artery disease is by far the number one killer of
women and men, not only in the United States but also in the world. It is estimated
that every minute 1 person in the United States dies of coronary artery disease. The
number of women who die from cardiovascular disease is 10 times that from breast
cancer.
19. d. Dietary therapy should be the first line of treatment in reducing serum
cholesterol. Regular aerobic exercise and limited alcohol intake have a beneficial
effect on serum cholesterol by increasing HDL cholesterol. Medications are used
after other modalities such as diet and exercise have not lowered cholesterol
adequately. Weight loss can be associated with a lowering of cholesterol; however,
in and of itself, it is not the first line of treatment for reducing serum cholesterol.
20. c. Statins are the first choice for medical therapy in virtually all patients whose
LDL goals cannot be achieved by therapeutic lifestyle changes alone.
21. a. The glare phenomenon and disturbances of color vision are the most striking
and the most common adverse ocular reactions seen with the use of digoxin.
Corneal microdeposits occur with use of chloroquine and amiodarone.
Keratoconjunctivitis sicca is not a specific side effect of digoxin but may be
observed in patients using ~-blockers. Bull's-eye maculopathy may be a side effect
of chloroquine.
22. b. If a patient is not expected to survive at least 1 year with good functional
status, an implantable cardioverter-defibrillator (ICD) is not recommended under
current ACC/ AHA guidelines. Survival and functional status are improved with an
ICD in the setting of a previous cardiac arrest, hemodynamically unstable
ventricular tachycardia episode, or inducible ventricular arrhythmias on
electrophysiologic testing. ICDs are not indicated for chronic atrial fibrillation.
23. a. Statins are the first choice for medical therapy in patients who have not
achieved LDL goals through therapeutic lifestyle changes (TLC) alone.
The role of statins in relation to the risk of age-related macular degeneration
(AMD) is unclear, but multiple studies suggest a decreased risk, particularly in late
stages of AMD. The JUPITER study suggests that patients with an elevated C-
reactive protein and no hyperlipidemia have a reduced risk of stroke and coronary
artery disease when statins are used.
24. d. Patients with the metabolic syndrome have 3 or more of the following: a
decreased HDL, increased abdominal obesity, elevated triglycerides, hypertension,
and an elevated fasting glucose. Elevated HDL is generally a protective factor,
reducing the risk of cardiovascular events.
25. d. In many states, reporting suspected elder abuse is mandatory. You should be
aware of your state's rules and regulations. Trauma to the eyes can be seen in elder
abuse. If you suspect elder abuse, you need to report this immediately and not wait
until a follow-up appointment. Sometimes the caregiver may be the abuser, and
examining and interviewing the patient alone may alert you to the abuse situation.
26. a. Depression is a very frequent problem in the older population, and loss of
vision often leads to depression. The role of ophthalmologists is to understand the
effects that loss of vision and blindness will have on patients. Be aware of
community resources, such as a vision rehabilitation center, to which the patient
can be referred. Having a staff member in the office who can help the patient
contact such resources can be an invaluable first step.
27. b. Traumatic brain injury in older adults is commonly caused by falls. Fall-
related direct expenses for those over age 65 totaled over $19 billion in 2000 in the
United States. Vision disorders are responsible for 4% of falls. After a fall in an
older adult, he or she may experience depression and loss of mobility, self-
confidence, and independence.
28. c. Ideal diseases to screen for are the ones that are reliably detectable, treatable,
or preventable, progressive (especially if untreated), and generally asymptomatic.
A high, rather than low, prevalence argues in favor of screening. For a rare disease,
screening may not prove cost -effective.
29. a. Evidence suggests that hypertension in the young is more common than
previously recognized and has substantial long-term health consequences. It is
recommended that children older than 3 years who are seen in a medical setting
have their blood pressure measured.
30. c. Carotid end arterectomy is beneficial for symptomatic patients with recent
non disabling carotid artery ischemic events and ipsilateral 70%-99% carotid artery
stenosis. It is not beneficial for symptomatic patients with 0%-29% or 100%
stenosis, and its potential benefit for symptomatic patients with 30%-69% stenosis
is uncertain.
31. b. All suspected cases of stroke and threatened stroke should prompt computed
tomography (CT) of the brain. Computed tomography is very sensitive to the
presence of intracranial hemorrhage.
Magnetic resonance imaging (MRI), however, is often more sensitive than CT in
detecting an evolving stroke within hours of its onset and an early cerebral
infarction; CT results may be negative for up to several days after an acute cerebral
infarct.
32. d. Smoking cessation is the single most effective intervention to reduce the risk
of chronic obstructive pulmonary disease or slow its progression. Ophthalmologists
should not underestimate the impact of discussing the harmful effects of smoking
with their patients.
34. d. Risk difference is the difference between 2 risk measures and has
dimensions, so the correct answer is option d because 1% per year minus 0.01% per
year is 0.99% per year.
35. c. Sensitivity refers to the proportion of those who have the disease who screen
positive.
If 80% of the 100 who have the disease screened positive, then 20% of those who
have the disease, or 20 out of 100, screened negative.
02 - Fundamentals and Principles of Ophthalmology
1. If all the nerves passing through the annulus of Zinn were transected,
what nerve would continue to function?
a. superior division of cranial nerve III
b. cranial nerve IV
c. nasociliary branch of cranial nerve V (V1)
d. optic nerve
3. What is the ratio of optic nerve axons that cross at the optic chiasm to
those that do not cross at the optic chiasm?
a. 67:33
b. 50:50
c. 30:70
d. 53:47
14. What pair accurately matches a cell-type origin with the correct tear-
layer product?
a. goblet cells- lipid layer
b. meibomian glands-mucin layer
c. glands of Krause-aqueous layer
d. glands of Wolfring-mucin layer
15. What option most accurately describes the immunoglobulin(s) that can
be found in the tear film?
a. IgA only
b. IgA and IgG only
c. IgG and IgM only
d. IgA, IgG, IgM, and IgD
18. What mechanism holds the flap created during laser in situ
keratomileusis (LASIK) in place after surgery?
a. endothelial- Descemet membrane interaction
b. endothelial pump
c. Bowman layer- stromal adhesions
d. Stromal collagen adhesions
20. What pigment within the retinal pigment epithelium is responsible for
the signal generated in fundus auto fluorescence imaging?
a. melanin
b. lipofuscin
c. rhodopsin
d. lutein
21. The retinal pigment epithelium is the first site of melanogenesis in the
body. Ocular melanin has been shown to participate in what process?
a. pathogenesis of retinitis pigmentosa
b. vitamin A metabolism
c. retinal adhesion
d. retinal development and neuronal migration
22. Age-related loss of type IX collagen has been implicated in what process
related to the vitreous?
a. vitreous hemorrhage
b. angiogenesis
c. increased diffusion of oxygen from the anterior segment into the posterior
segment
d. vitreous liquefaction
23. What vitamin is most critical for the photoreceptor response to light?
a. A
b. B
c. C
d. E
26. Atropine, 1%, has how many milligrams of drug per drop, assuming 20
drops per milliliter?
a. 1 mg
b. 0.5 mg
c. 0.1 mg
d. 0.05 mg
31. What systemic side effect may result from treatment with oral carbonic
anhydrase inhibitors?
a. insomnia
b. weight gain
c. hyperkalemia
d. aplastic anemia
1. b. Cranial nerve IV passes through the superior orbital fissure but not through
the annulus Of Zinn.
2. c. The lateral rectus muscle originates from the annulus of Zinn. The superior,
inferior, medial, and lateral rectus muscles all arise from the annulus of Zinn.
3. d. Anatomical studies demonstrate that more axonal fibers cross at the optic
chiasm than do not cross, in a 53:47 ratio.
4. b. The cavernous sinus is where the trigeminal nerve (ophthalmic branch) and
the nerves controlling eye movement are in proximity to one another.
5. a. The ganglion cells are the first cells to differentiate in the embryonic eye.
7. c. The retinoblastoma gene is located on the long arm of chromosome 13. The
aniridia gene, PAX6, and the Wilms tumor gene are adjacent on chromosome 11;
their proximity is important to recognize, as children with aniridia need to be
screened for Wilms tumor.
Retinoblastoma occurs at a rate of approximately 1 per 15,000-20,000 li\e births.
Most cases of retinoblastoma are unilateral and not inherited. Of people who
inherit the gene mutation, 90% will develop retinoblastoma (90% penetrance).
8. c. More than 100 different mutations in the rhodopsin gene are known to cause
retinitis pigmentosa. Juvenile glaucoma is associated with myocilin mutations,
Leber hereditary optic neuropathy is associated with mitochondrial DNA
mutations, and Stargardt disease is associated with ABCA4 gene mutations.
12. d. Many common eye diseases are complex genetic diseases involving the
effects of multiple genes. Examples include glaucoma, age-related macular
degeneration, and myopia.
The combined effects of many genes, along with health habits and environmental
factors, result in the disease.
13. c. The optic nerve, cornea, and retinal pigment epithelium are not part of the
uvea. The uveal tract is the main vascular compartment of the eye and consists of
the iris, ciliary body, and choroid.
14. c. Goblet cells produce the mucin layer, and meibomian glands form the lipid
layer. Glands of Krause and Wolfring produce the aqueous layer.
15. d. Proteins in the tear film include immunoglobulin A (IgA) and secretory
IgA (sigA). IgA is formed by plasma cells in interstitial tissues of the main and
accessory lacrimal glands and by the substantia propria of the conjunctiva. The
secretory component is produced within lacrimal gland acini, and sigA is
secreted into the lumen of the main and accessory lacrimal glands. IgA plays a
role in local host -defense mechanisms of the external eye, as shown by
increased levels of IgA and IgG in human tears associated with ocular
Inflammation. Other immunoglobulins in tears are IgM, IgD, and IgE. Vernal
conjunctivitis causes elevated tear and serum levels of IgE, increased IgE-
producing plasma cells in the giant papillae of the superior tarsal conjunctiva,
and elevated histamine levels.
20. b. Lipofuscin molecules are the fine yellow-brown pigment granules of the
retina. They are thought to be "wear-and-tear" deposits resulting from
phagosomal activity. Histologically, lipofuscin stains with Sudan stain and
exhibits auto fluorescence.
22. d. Vitreous liquefaction, also known as syneresis, begins with the breakdown
of collagen fibrils into smaller fragments. This liquefaction is thought to occur
because of a loss of "shielding" of type II collagen by type IX collagen. This
process has no direct effect on the development of vitreous hemorrhage unless it
leads to the development of posterior vitreous detachment (PVD).
A PVD can protect against retinal neovascularization by eliminating the scaffold
for fibrovascular proliferation. Oxygen tension increases in the posterior
chamber in post vitrectomized eyes.
24. b. Compared with younger patients, older patients have less lean body mass
because of decreased muscle bulk, less body water, decreased albumin, and
increased relative adipose tissue. These physiologic differences alter tissue
binding and drug distribution.
Human renal function decreases with age. Hepatic perfusion and enzymatic
activity decrease with age.
25. d. Increased viscosity of the vehicle generally increases drug retention in the
inferior culde-sac, aiding drug penetration.
26. b. A 1% solution has 1 g/ 100 mL, or 1000 mg/ 100 mL, of active ingredient.
Assuming there are 20 drops/mL, 1 drop contains 0.05 mL of drug. Multiplying
1000 mg/100 mL x 0.05 mL yields 0.5 mg per drop of atropine available for
systemic absorption.
28. b. Miotic agents constrict the pupillary sphincter and the ciliary muscle.
Ciliary muscle contraction results in increased myopia and a decreased central
anterior chamber. Pupillary constriction causes decreased night vision but
increases the range of accommodation (pinhole effect).
Questions 1-6 refer to the figure above. An object is 1. 0 m to the left of a -1.00
D thin lens.
The -1.00 D lens is, in turn, 1.5 m to the left of a +1.50 D thin lens.
2. What are the characteristics (e.g., real or virtual, upright or inverted, and
transverse magnification) of the intermediate image?
a. upright, real, enlarged
b. inverted, real, reduced
c. upright, virtual, enlarged
d. upright, virtual, reduced
3. What is the size of the intermediate image compared with the object?
a. one-fourth the size
b. one-half the size
c. same size
d. twice the size
4. What is the location of the final image?
a. 1.0 m to the left of the second lens
b. 1.0 m to the right of the second lens
c. 4.0 m to the right of the second lens
d. at optical infinity
6. What is the size of the final image compared with the original object?
a. one-fourth the size
b. one-half the size
c. same size
d. twice the size
12. Why is there no anterior chamber depth term in the SRK equation?
a. The formula was specifically designed to eliminate the need for this
measurement.
b. Regression analysis did not show increased accuracy when anterior chamber
depth was included in the IOL formula.
c. Modern IOLs are all designed to have about the same anterior chamber depth.
d. The postoperative anterior chamber depth is not necessarily the same as the
measured preoperative anterior chamber depth.
13. The ability of a light wave from a laser to form stable interference
fringes with another wave from the same beam, separated in time, is an
illustration of what property?
a. temporal coherence
b. spatial coherence
c. dispersion
d. intensity
16. The anterior and posterior focal points of a thin lens are located at
different distances from the lens. Additionally, the nodal points of the lens
do not correspond with the principal points. Which of the following
statements is true?
a. This situation is not possible as described.
b. The optical characteristics described are found only in thick-lens or multi-
element systems.
c. Media of different refractive indices bound the lens.
d. Two separated principal planes must be used to define the lens
mathematically.
20. A Snellen visual acuity of20/20 is equivalent to which of the following log
MAR values?
a. 1.00
b. 0.00
c. 10.00
d. 0.10
25. Which of the following statements about the prescription of visual aids is
true?
a. The Kestenbaum rule provides an endpoint to determine the addition required
to read 1M type.
b. Base-in prisms increase effective magnification for binocular patients using
reading spectacles.
c. Illuminated stand magnifiers help overcome stability and lighting problems
associated with higher-power magnification.
d. Optical magnification is sufficient for patients with severely reduced contrast
sensitivity.
26. Which of the following conditions best characterizes a person with low
vision?
a. a bitemporal hemianopia
b. best -corrected visual acuity of 20/70 or worse
c. myopia greater than -20 D
d. a disability related to visual dysfunction
31. Which of the following statements correctly describes the far point of the
non accommodated -4.00 D myopic eye?
a. The far point and the fovea are conjugate points.
b. The far point is 25 cm posterior to the eye.
c. The far point is 20 cm in front of the eye.
d. The far point is nearer to the eye than is the point of focus of the fully
accommodated eye.
32. Which of the following statements describes the near point of a fully
accommodated young hyperopic eye in which the amplitude of
accommodation is greater than the amount of hyperopia?
a. The near point is beyond plus infinity.
b. The near point is between plus infinity and the cornea.
c. The near point is behind the eye.
d. The near point is beyond minus infinity, optically speaking.
35. Which of the following factors increases the risk of infection in a patient
using extended wear contact lenses?
a. switching to daily-wear lenses
b. exposure to smoke
c. normal eyelid function
d. intact corneal epithelium
37. Which of the following conditions typically affects central vision more
than the peripheral visual field?
a. retinitis pigmentosa
b. age-related macular degeneration
c. retinal detachment
d. panretinal photocoagulation
38. Which of the following statements about the entrance pupil of the eye is
true?
a. It is the pupil we see when we look at a patient's eye.
b. It is the image formed by the lens of the anatomic pupil.
c. It is located 0.5 mm posterior to the anatomic pupil.
d. It is 10%-15% smaller than the anatomic pupil.
39. What is the Brewster angle when light travels from air to glass (n =
1.500)?
a. 65.7
b. 47.6
c. 56.3
d. 41.8
40. What is the critical angle for light traveling from glass (n = 1.500) to air?
a. 65.7
b. 47.6
c. 56.7
d. 41.8
Answers
1. c. Vergence is the ratio of refractive index, n, divided by the distance from the
object or to the image. Vergence (in diopters) = n/distance (in meters). Vergence
is negative for divergent light and positive for convergent light. In this case, the
lenses are in air, for which the refractive index, n, is 1.000. Light diverges from
the object so the vergence is negative.
The object is 1.0 m from the lens and therefore has a vergence of -1.00 D = -
1.000/ 1.0 m = -1.00 D. The first lens adds an additional -1.00 D of vergence.
Light leaving the lens, therefore, has a vergence of -2.00 D. Light rays with a
vergence of -2.00 D appear to be coming from a point 0.5 m to the left of the
lens.
2. d. The terms anterior focal point and posterior focal point can be confusing
because, for minus lenses, the anterior focal point is actually behind the posterior
focal point. The anterior focal point, F., is always in object space, and the
posterior focal point, FP, is always in image space. By convention, primed letters
indicate image space and unprimed letters, object space. Often, the anterior focal
point is designated F and the posterior focal point, F'. For a -1.00 D thin lens in
air, F is 1.0 m behind the lens, and F' is 1.0 min front of the lens. For all thin
lenses, the principal planes coincide. Likewise, the nodal points coincide.
The image features can be determined graphically, as shown in the figure below.
A ray from the tip of the object directed to F exits the lens parallel to the optical
axis. A ray from the tip of the object parallel to the axis exits the lens divergent,
as if it had come from F'.
A ray from the tip of the object directed to the nodal points exits undeviated and,
in this case, undisplaced, as shown in black below. The image characteristics-
upright, virtual, and reduced-are apparent from this graphical approach
3. b. Using only the ray traversing the nodal points and similar triangles, the
height of the intermediate image is found to be one-half the height of the object
(see figure on the next page). The transverse magnification is +0.5x
4. b. To answer questions 4-6, we treat the intermediate image as the object for
the second lens. From this point on, the first lens can be ignored.
The intermediate image is 2.0 m to the left of the second lens. The vergence of
light entering the second lens is, therefore, -0.50 D. The lens adds+ 1.50 D of
vergence. Therefore, the light exiting the lens has avergence of+ 1.00 D. Light
rays with a vergence of+ 1.00 D come to a focus 1.0 m to the right of the second
lens.
5. d. For the second lens F' is 2/3 m (0.66 m) to the right of the lens, and F is
0.66 m to the left of the lens. Rays can be traced as before. A ray passing from
the object tip parallel to the axis emerges as a ray going through F'. A ray
through F emerges parallel to the axis. A ray through the coincident nodal points
is undeviated and undisplaced.
The image is inverted compared with both the intermediate object and the
original object, is real, and is half the size of the intermediate image and
therefore is also smaller than the original object.
6. a. By similar triangles, the image is half the size of the intermediate image.
The intermediate image is half the size of the object. Consequently, the final
image is (1/2)(1/2) = 1/4 the size of the original object.
7. a. The power of a mirror is 2/r, or in this case, + 1.00 D. The object vergence
is -2.00 D, so the image vergence is -1.00 D. Therefore, the image is virtual and
1.0 m behind the mirror. The image is upright, and the transverse magnification
is + 2x, as shown in the figure
8. c. The intraocular lens (IOL) must, of course, have an index of refraction
different from that of the aqueous and vitreous for it to have any significant
refractive effect. The refractive contribution of the cornea must not be neglected;
in fact, it must be specifically considered. The IOL must provide only the
vergence that is still required at the IOL plane, which is the total vergence
required minus that already provided (at the IOL plane) by the cornea. Although
the anterior chamber depth appears to have little importance in regression-
derived formulas, it is essential in formulas based on geometric optics. The
formula for the change in vergence with change in location is the familiar P/(1-
Pd), where a vergence of power P is moved a distance d. If the refractive index,
n, of the material is not 1, a "reduced distance" of din must be substituted.
11. b. The power of any rotationally symmetric refracting surface is given by the
equation
For the posterior corneal surface, n2 is 1.336 (aqueous humor) and n1 is 1.376
(cornea).
It is apparent from this calculation that the cornea has a slight diverging
(negative) refracting power under water. In this environment, the crystalline lens
has more converging power than the cornea in the average eye. This explains
why things appear blurry when you open your eyes under water if you are not
wearing goggles.
12. b. No optical principles were used to derive the SRK formula. Rather, it was
derived using only statistical methods, specifically by using linear regression
based on a large number of cases with anterior chamber IOL implants. During
development, the formula included terms for (preoperative) axial length, average
K readings, and anterior chamber depth (ACD). The statistical correlation
between preoperative ACD and IOL power was very weak, so the ACD term did
not significantly enhance accuracy, and it was dropped from the final formula.
The SRK formula was not intended to eliminate the need for an ACD
measurement; the measurement was simply found to be unnecessary. With the
introduction of posterior chamber IOLs, it was found that the SRK formula still
worked well provided that the A constant was modified for different implant
designs. Although adjusting the A constant is perhaps not the best way to adjust
for variations in ACD, it is sufficiently accurate for clinical purposes. Option c is
incorrect because, clearly, all IOLs are not intended to have the same ACD.
Option d is not the best choice for subtle reasons. The preoperative ACD
certainly differs from the postoperative ACD, but the question is not
whether the measurements differ, but rather whether the preoperative ACD
statistically correlates with IOL power. The preoperative and postoperative
ACDs can differ and yet the preoperative ACD may still correlate statistically
with IOL power. The reason the SRK formula contains no ACD term is not
because the preoperative and postoperative ACDs differ but because preoperative
ACD does not correlate with IOL power.
14. d. In the United States and Canada, legal blindness is defined as visual acuity
in the better eye of 20/200 or worse. This level corresponds to severe low vision,
in which the patient's reading speed is slowed despite use of monocular reading
aids (not binocular prismatic glasses). Using the Kestenbaum rule, the dioptric
power of the add is the reciprocal of the visual acuity fraction. Thus, a 10.00 D
lens, not a l0x magnifier (a 40.00 D lens), would be the most appropriate aid.
Referral to an orientation and mobility specialist is usually not needed until the
profound low vision range (20/500-20/100) is reached.
15. b. A useful rule of thumb is that for small angles, a prism diopter produces a
little more than half a degree of deviation. Thus, a 15~ prism produces slightly
more than 7.5 of deviation, so the only reasonable choice is option b.
alternatively, the exact value can be calculated. A 15~ prism deflects light 15 cm
at a distance of 100 cm. The tangent of the angle of the deflection is 15/100; the
angle, therefore, is arctan (0.15) = 8.53.
16. c. Although a thick-lens or multi-element lens system could have the features
described, the lens in the question is thin. By definition, the principal planes and
nodal points coincide when media with different refractive indices surround a
lens; however, the anterior and posterior focal lengths are different. The nodal
points shift in the direction of the medium with the higher refractive index.
17. c. Laser light is created when atoms of an active medium are exposed to a
source of energy (the pumping source). This introduction of energy causes most
of the active medium's electrons to rise to a higher energy state, a condition
called population inversion. Some of these high-energy electrons undergo
spontaneous emission, generating photons. If these photons first encounter low-
energy electrons, they are merely absorbed. However, if they encounter other
high -energy electrons, stimulated emission occurs. In order to maintain
the chain reaction of stimulated emissions, mirrors are placed at each end of the
cavity, an optical feedback arrangement. One mirror reflects totally and the other
partially. Most of the coherent light generated is reflected back into the ca ity to
produce more stimulated emissions. The relatively small amount of light that is
allowed to pass through the partially reflecting mirror produces the actual laser
beam.
18. d. The nerve fiber layer is birefringent, meaning it polarizes light or changes
the polarization of incident light that passes through it. The scanning laser
polarimeter uses this property to measure nerve fiber layer thickness. The cornea
also polarizes light, so a corneal compensator is necessary to eliminate the
cornea's polarization effects.
19. b. Because red rays focus behind blue rays, the eye must make an
accommodative effort to focus on red print after looking at blue print. It must
relax accommodation to focus on blue print after looking at red print. The brain
therefore perceives that the red print is in front of the blue print when both are
displayed against the same background. Achromatopsia or any other color defect
affects the way the retinal image is converted into nerve impulses but has no
effect on the quality of the retinal image, which is determined solely by the
ocular media.
20. b. Log MAR is calculated by taking the logarithm of the reciprocal of the
Snellen fraction. For instance, if the Snellen visual acuity is 20/200, then the
reciprocal is 200/20, or 10, and the logarithm of 10 is 1. Likewise, for a 20/20
eye, the reciprocal of the Snellen visual acuity is also 20/20, or 1, and the
logarithm of 1 is 0.
21. a. If the retinoscopy streak is horizontal, the axis of the cylindrical lens is
also horizontal (180). Thus, the sphero cylindrical lens combination for this
patient (before subtracting the working distance adjustment) is + 3.00 + 1.00 x
90. The working distance (67 cm, or 0.67 m) must be subtracted from the final
refraction. Thus, subtracting 1/0.67 m, or 1.50 D, yields the correct answer: +
1.50 + 1.00 x 90. Note that the cylindrical power acts 90 from the axis. If the
retinoscopy streak is horizontal, the axis of the cylindrical lens is 180, but the
actual power is at 90. Accordingly, the powers (after subtracting the working
distance) are +1.50 D at 90 and +2.50 D at 180.
28. b. When looking through a small pupil, the observer can improve
visualization by narrowing his or her effective inter pupillary distance. This can
be accomplished by several means. Moving the ophthalmoscope's mirror closer
to the observer (the "small-pupil feature" available on some ophthalmoscopes)
decreases the distance between the light paths to the observer's left and right
eyes, effectively narrowing the observer's inter pupillary distance.
If the examiner can slightly converge, it will narrow the observer's effective inter
pupillary distance. Increasing the distance between the observer and the patient
decreases the angle formed by the observer's 2 eyes and the patient's eye, thereby
allowing the light paths from the observer's eyes to "squeeze through" a smaller
pupil.
29. b. Changes of 0.25 D and 0.50 Din sphere and cylinder are likely to be
below the "just noticeable" threshold for a patient with 20/100 visual acuity.
Because the first issue to rule out when vision changes is a change in refraction,
an additional attempt should be made to refine the refraction using larger-step
changes in sphere and cylinder. The darkroom pinhole test is a test of potential
vision. It should be performed after the refraction has been optimized.
30. a. An optical system's nodal points are the points through which light rays
entering or leaving the system are undeviated (but not necessarily undisplaced).
In the reduced schematic eye, the nodal points coincide and are located 5.6 mm
posterior to the corneal surface. Because all light rays passing through this point
are undeviated, a light ray that leaves the tip of an object will pass through the
nodal point and strike the retina undeviated. Retinal image size can be calculated
by similar triangles if both the image height and distance are known.
31. a. The far point of the eye and the fovea are always corresponding points
when accommodation is relaxed. All the other statements are false. The far point
is 25 cm in front of the eye and is farther away from the near point of the fully
accommodated eye.
32. b. The non accommodated hyperopic eye has a far point behind the eye. A
virtual image of the retina forms at this location. As the eye begins to
accommodate, the point of focus recedes to minus infinity. Minus infinity and
plus infinity are essentially the same optically. As the eye continues to
accommodate through optical infinity, the point of focus moves in front of the
eye to a point between plus infinity and the cornea. The near point of the eye, in
diopters, is equal to the far point location, in diopters, plus the amplitude of
accommodation. Because we are told that the amount of hyperopia is less than
the amplitude of accommodation, we conclude that the near point is in front of
the eye (between infinity and the cornea).
35. b. There are many risk factors associated with even the most current
extended-wear contact lenses, including swimming with the lenses, previous
history of eye infection, any exposure to smoke, abnormal eyelid function,
severe dry eye, and corneal neovascularization.
36. b. Patients with central scotomata can still read by using eccentric fixation,
along with appropriate magnification and enhanced contrast, if necessary.
Reading speed is usually decreased, but reading ability can often be improved
with training and practice
38. a. The entrance pupil of the eye is the pupil we see when we look at a
patient's eye. For a refractive index of n = 4/3 and a cornea with a power of +43
.00 D, the entrance pupil is the image of the anatomical pupil formed by the
cornea. The crystalline lens does not contributeto the formation of the entrance
pupil. The entrance pupil is located about 0.5 mm in front of the anatomical
pupil and is about 13%- 15% larger.
39. c. The formula is
14. What disease may be diagnosed by finding Heinz bodies on red blood
cell membranes in an anterior chamber aspirate?
a. lymphoma
b. siderosis
c. pseudoexfoliation
d. ghost cell glaucoma
15. A 35-year-old woman, recently diagnosed with rheumatoid arthritis,
presents with a violaceous scleral nodule. The biopsy will most likely reveal
which of the following?
a. palisading arrangement of histiocytes/giant cells around necrotic/necrobiotic
collagen fibers
b. sparse inflammatory infiltrate composed of lymphocytes and plasma cells
c. colonies of gram-negative bacteria associated with acute necrotizing
inflammation
d. circumscribed proliferation of spindle cells in chronically inflamed, richly
vascular, and myxoid stroma
32. Which of the following is not a clinical risk factor for metastatic disease
in patients with uveal melanoma?
a. large tumor size
b. ciliary body involvement
c. young age
d. extraocular extension
33. Which of the following is the most important risk factor for the
development of uveal melanoma?
a. dysplastic nevus syndrome
b. light-colored complexion
c. ocular melanocytosis
d. ultraviolet light exposure
35. With which of the following organs must the ophthalmologist be most
concerned about in a patient with retinal capillary hemangioblastoma?
a. brain and kidney
b. liver and lung
c. bowel and skin
d. organs of the immune system and central nervous system
36. What association distinguishes von Hippel-Lindau syndrome from von
Hippel disease?
a. intracranial calcifications, ash-leaf spots, retinal astrocytomas
b. cafe-au-lait spots, Lisch nodules, optic pathway gliomas
c. pheochromocytomas, cerebellar hemangioblastomas, renal cell carcinomas
d. limbal dermoids, upper eyelid colobomas, preauricular tags
37. Which of the following is the most important histopathologic risk factor
for mortality in the enucleated globe from a patient with retinoblastoma?
a. the presence of anterior segment involvement
b. the extent of retinal detachment
c. the extent of optic nerve and choroidal invasion
d. the size of the tumor
41. When a parent has bilateral retinoblastoma, which risk factors apply to
the affected parent's children?
a. 85% risk of developing retinoblastoma
b. risk of bilateral disease in all affected children
c. risk of developing retinoblastoma in males only
d. 45% risk of developing retinoblastoma
42. What is the primary treatment for a 2-year-old child with unilateral
retinoblastoma classified as International Classification Group E?
a. systemic chemotherapy alone
b. intra-arterial chemotherapy
c. enucleation
d. radiation alone
43. What is the treatment of choice for metastatic carcinoma to the eye?
a. chemotherapy
b. external-beam radiation
c. brachytherapy
d. individually tailored in each case
7. a. A frozen section is indicated when the results of the study will affect
management of the patient in the operating room. Two common indications for
frozen section are to determine whether resection margins are free of tumor and
to determine whether the surgeon has obtained a representative biopsy specimen
in the case of metastases. Interpretation or diagnosis of a lesion requires
permanent sections. Permanent sections are always preferred
and are the standard for formal diagnosis based on pathologic findings.
14. d. Ghost cells are hemolyzed erythrocytes that have lost most of their
intracellular hemoglobin. Heinz bodies are the remaining denatured, precipitated
hemoglobin particles within the ghost cells.
16. a. Under normal conditions, the lens epithelial cells terminate at the lens
equator. When the equatorial lens epithelial cells migrate onto the posterior lens
capsule, they swell (referred to as bladder cells of Wedl), resulting in posterior
subcapsular cataract formation.
18. b. The internal limiting membrane is the innermost layer of the neurosensory
retina and, though attached to the vitreous, is not considered a component of the
vitreous. The hyaloid face is the outer surface of the vitreous cortex. The
hyaloideocapsular ligament forms the anterior border of the vitreous, which is
attached to the lens capsule. The vitreous base is a firm circumferential
attachment of the vitreous straddling the ora serrata.
20. a. Nerve fiber layers in the outer plexiform layer (nerve fiber layer of Henle)
run obliquely, allowing for the accumulation of fluid in the macula, which
appears as cysts when there is abnormal permeability of the blood-retina barrier.
24. a. The correct answer is the presence of hair follicles. An epidermoid cyst is
lined with keratinized stratified squamous epithelium similar to epidermis but
does not have skin adnexal structures such as hair follicles or glands. A dermoid
cyst is lined with epidermal epithelium and has adnexal structures. Both types of
cysts will generate a mixed inflammatory response if they rupture.
27. d. The correct answer is viral. A papilloma, typical of infection of the skin
with human papillomavirus, is defined as acanthotic epithelium with a
fibrovascular core. Bacterial infections typically cause an abscess or cellulitis.
Inflammatory lesions are typically erythematous. Sun exposure may cause
hyperpigmentation, wrinkling, or actinic keratosis (i.e., a flat, red, scaly lesion).
28. d. Squamous cell carcinoma in situ implies that the neoplasm is confined to
the epithelium and does not break through the basement membrane and extend
into the underlying stroma.
30. b. In acquired optic atrophy, there is loss of axonal fibers, which results in a
decrease in the optic nerve diameter with corresponding widening of the
intermeningeal (subarachnoid) space. Additional changes include gliosis and
thickening of the fibrovascular pial septa.
32. c. Old age was found to be a risk factor for metastatic uveal melanoma. The
other choices are also well-established risk factors.
34. d. The liver is by far the most frequent site of metastasis from uveal
melanoma, and metastasis to other organs, such as the lungs, skin, and bones, is
rarely found without liver involvement.
35. a. The presence of a retinal capillary hemangioblastoma (previously known
as retinal capillary hemangioma) suggests the possibility of von Hippel- Lindau
(VHL) syndrome resulting from a mutation of the VHL gene on chromosome 3.
Patients with VHL syndrome are at risk for cerebellar hemangioblastomas,
pheochromocytomas, and renal cell carcinomas. Genetic screening of such
patients should be considered.
37. c. Invasion of the optic nerve increases the risk of central nervous system
metastasis either by direct access in or along the nerve or by seeding of the
subarachnoid space. Massive, deep invasion of the choroid increases the risk of
hematogenous spread (metastases).
1. Which of the following structures is the neural integrator for vertical and
torsional gaze?
a. nucleus prepositus hypoglossi
b. interstitial nucleus of Cajal
c. nucleus raphe interpositus
d. rostral interstitial nucleus of the medial longitudinal fasciculus
3. The maxillary division of the trigeminal nerve (V2) enters the skull base
through which foramen?
a. foramen ovale
b. foramen lacerum
c. foramen spinosum
d. foramen rotundum
5. A 29-year-old obese woman notes new headaches for the past year. Which
of the following features would be most consistent with pseudopapilledema?
a. blurring of the disc margins
b. cup- disc ratio of 0.3
c. obscuration of the retinal vessels
d. hyperemia of the disc surface
6. Which of the following signs is more consistent with a retinopathy than an
optic neuropathy?
a. visual acuity of 20/80 in both eyes
b. central scotoma revealed on perimetry
c. Amsler grid testing with missing lines
d. photostress test recovery time of 90 seconds
12. Following a stroke, a patient can see moving objects in his blind
hemifield; however, static objects are invisible to him. What is the name for
this disorder?
a. Anton syndrome
b. palinopsia
c. Riddoch phenomenon
d. visual anesthesia
16. A 27-year-old man with monthly migraine headache has a dilated left
pupil and blurred vision. He denies diplopia. His last headache was 2 weeks
ago and resolved after 1 day. Visual acuity is 20/20 OU, ocular motility is
normal, and there is no ptosis. The pupils measure 5 mm OD, 6.5 mm OS,
and they constrict to 3 mm OD, 5.5 mm OS with light stimulus. Direct and
consensual reactions are the same in each eye. What is the next step in
managing this patient?
a. urgent noninvasive angiography (magnetic resonance angiography or computed
tomography angiography)
b. hospital admission to a neuro-intensive care unit
c. reassurance and outpatient observation
d. laboratory screening for organophosphate poisoning
19. A 59-year-old woman reports inability to see road signs when driving and
has had 3 minor collisions in the past 6 months. Spontaneous, rapid onjugate
eye movements occur in short bursts both vertically and horizontally. Her
systemic diseases (hypertension, hyperlipidemia) are under good control,
although she has been unable to stop smoking cigarettes. Where would a
mass lesion be most likely present?
a. frontal lobe of brain
b. lower pole of right kidney
c. iliac crest bone marrow
d. middle lobe of lung
20. A 24-year-old woman has had intermittent blurred vision for the past 3
months. Visual acuity is 20/30 in each eye with full fields and normal fundus
appearance. You observe a low-amplitude, moderate-frequency, right-eating
horizontal jerk nystagmus. After documenting your findings, you now
observe a left-beating jerk nystagmus. What findings would you expect on
magnetic resonance imaging of the brain?
a. periventricular white matter lesions on FLAIR sequences
b. empty sella and chiasmal Displacement on sagittal Tl sequences
c. pineal gland enlargement with coronal T1 contrast enhancement
d. clival tumor with midbrain compression on axial Tl contrast-enhanced images
21. Where is the central lesion located that can cause bilateral light- near
dissociation of the pupils?
a. dorsal midbrain
b. nucleus of Budge-Waller in the upper spinal cord
c. hypothalamus
d. occipital lobe
23. A patient presents with facial weakness, diplopia, ataxia, and areflexia.
Which of the following is the most likely cause?
a. Miller Fisher syndrome
b. Ramsay Hunt syndrome
c. Melkersson-Rosenthal syndrome
d. a cerebellopontine angle tumor
25. A 45-year-old man presents with several episodes per day of severe left-
sided orbital and temporal pain lasting 5-10 minutes and occasionally
associated with left ptosis and miosis.
Which of the following is the most likely diagnosis?
a. cluster headache
b. paroxysmal hemicrania
c. hemicrania continua
d. idiopathic stabbing headache
26. A patient receiving prophylactic migraine treatment experiences blurred
vision associated with pain. Which of the following is the most likely migraine
drug used by the patient?
a. gabapentin
b. naproxen
c. topiramate
d. verapamil
27. Which of the following clinical findings is most likely to suggest the need
for additional diagnostic testing in a patient with migraine headache?
a. absence of family history
b. presence of a visual aura with hemianopic distribution
c. presence of a visual field defect
d. pulsating character of headache
28. When the clinician suspects a nonorganic loss of vision in a patient who
claims to see nothing, which of the following test results may be helpful in
establishing the presence of some vision?
a. The eyes do not move during a mirror test.
b. Proprioceptive testing results are normal.
c. The eyes move with rotation of an optokinetic nystagmus drum.
d. There is a normal pupillary reaction to bright light.
29. In a patient with a fixed, dilated pupil, which test result best helps
identify a pharmacologic blockade as opposed to a third nerve palsy or Adie
tonic pupil?
a. normal pupillary light response in the fellow eye
b. minimal pupillary constriction after 0.125% pilocarpine
c. rapid pupillary constriction after 10% phenylephrine
d. absent pupillary constriction after 1% pilocarpine
30. A 68-year-old patient presents with transient visual loss and double
vision. The patient works in telemarketing and has noted recent tongue
discomfort after 1 hour on the job.
Which of the following results supports your suspected diagnosis?
a. erythrocyte sedimentation rate= 10 mm/hr; C-reactive protein= 10 (normal,< 1)
b. negative result on temporal artery biopsy
c. normal platelet count
d. family history of autoimmune disease
31. A 25-year-old woman has a negative past medical history and a 2-week
history of pain on eye movement, a relative afferent pupillary defect, and
decreased color perception.
Which diagnostic study would be most appropriate?
a. fluorescein angiography with attention to the macula
b. screening blood work for human leucocyte antigen A-29 and B-5
c. magnetic resonance imaging of the brain with and without contrast
d. skin biopsy with microscopic dermal evaluation
32. A patient presents acutely with headache, mild ipsilateral ptosis, and
amaurosis fugax. She reports a history of trauma several weeks prior to
presentation.
Which study would you order first?
a. computed tomography scan of the brain and orbits
b. bilateral carotid Doppler studies
c. magnetic resonance imaging (MRI) of the brain with and without contrast
d. MRI and magnetic resonance angiography of the neck
Answers
1. b. The interstitial nucleus of Cajal is the neural integrator for vertical and
torsional gaze. The nucleus prepositus hypoglossi is the neural integrator for
horizontal gaze. The nucleus raphe interpositus contains omnipause cells. The
rostral interstitial nucleus of the medial longitudinal fasciculus contains the
excitatory burst neurons for vertical and torsional gaze.
2. a. The posterior inferior cerebellar artery supplies the lateral medulla, where
sympathetic fibers continue from the hypothalamus.
3. d. V2 enters the foramen rotundum, V3 enters the foramen ovale, the middle
meningeal artery enters the foramen spinosum, and the internal carotid artery
passes through the foramen lacerum.
6. d. The visual acuity can be reduced to any level in 1 or both eyes with either
entity. Central scotomata occur with both maculopathies and optic neuropathies.
Amsler grid testing with missing lines can occur with both entities, whereas
Amsler grid testing with distorted lines is highly suggestive of retinopathy.
Normal eyes recover from a photostress test within 30 seconds.
9. a. Transient visual loss from an embolus typically lasts 10- 15 minutes and is
unilateral.
Migraine typically develops and resolves over a longer time period, 20-30
minutes. Also, migraine and seizure cause bilateral, not monocular, visual
disturbance. Drusen can cause monocular visual loss but the duration is typically
seconds.
10. b. A rise in body temperature does not affect retinal function, cardiac rhythm,
or intraocular pressure. Slowing of neural signals related to a rise in body
temperature occurs when the myelin sheath that contains the synaptic nodes is
damaged, as in optic neuritis.
11. b. Optic ataxia is a disconnection between visual input and the motor system.
Ocular motor apraxia is the loss of voluntary movement of the eyes while fixating
on a target.
Prosopagnosia is the inability to recognize familiar faces. Simultanagnosia is a
failure to integrate multiple elements of a scene.
16. c. This patient has a benign episodic pupillary mydriasis and no ocular
motility deficit or ptosis. In such a situation, third nerve palsy is not a
consideration. Many patients with migraine experience intermittent pupillary
mydriasis that does not correspond temporally to the headache itself.
17. a. The patient is likely to have ischemic sixth nerve palsy. Although
neuroimaging may be indicated, her age and medical history require that
unrecognized diabetes mellitus or giant cell arteritis be excluded as potential
causes before obtaining imaging.
18. b. The examination findings are concerning for a partial left third nerve palsy
with pupil involvement. A difference in reactivity, and not marked anisocoria,
may be the only sign.
In a patient of this age, aneurysm at the junction of the posterior communicating
artery and internal carotid artery is the most likely cause, and a major risk factor
for aneurysm formation is cigarette smoking.
19. d. The patient has opsoclonus, and the most likely cause in an adult is
paraneoplastic syndrome from a small cell carcinoma of the lung.
20. a. You are observing periodic alternating nystagmus (PAN). Because the
patient is symptomatic, it is probably acquired rather than congenital. In young
women, the most likely cause of PAN is demyelinating disease such as multiple
sclerosis. Brain magnetic resonance imaging with sagittal FLAIR sequences is
particularly sensitive for locating the typical white matter lesions of this disease.
21. a. Dorsal midbrain damage can result in midsize pupils with poor light
response and preserved near response. A lesion of the nucleus of Budge-Waller
causes Horner syndrome, as does a hypothalamic one. A lesion of the occipital
lobe does not affect the pupils.
22. b. Sectoral palsy of the iris sphincter is one characteristic of Adie tonic pupil.
Isolated unilateral mydriasis from a tonic pupil occurs from injury to the
postganglionic parasympathetic fibers, so there is no alteration of eyelid function.
Iris heterochromia and supersensitivity to apraclonidine are signs associated with
an oculosympathetic deficit.
26. c. Topiramate may result in acute bilateral angle-closure glaucoma and acute
myopic shift, which are usually reversible upon cessation of the drug. The other
agents do not commonly cause visual side effects.
27. c. The presence of a visual field defect requires further evaluation. A patient
with migraine headache and bilateral homonymous visual field deficit needs
neuroimaging study to exclude a structural brain disorder (e.g., mass, vascular
malformation). Pulsating headache is very common in patients with migraine.
Typical visual auras have a hemianopic distribution.
A family history of migraine is often but not always elicited in patients with
migraine headache.
28. c. In complete blindness, the eyes should not move with rotation of the
optokinetic nystagmus (OKN) drum. The OKN system uses smooth pursuit
followed by a saccade when the maximum amplitude of pursuit is exceeded,
eliciting movement. Patients with nonorganic loss of vision may be able to avoid
looking at the OKN by looking away during testing or focusing past the drum and
should be observed carefully during testing. Mirror testing is also very helpful in
establishing nonorganic total visual loss, and the eyes will mo e to follow the
mirror. Proprioceptive testing does not require vision, and pupils will react in the
presence of cortical blindness.
32. d. MRI is the best diagnostic test in patients suspected of having carotid artery
dissection, which will not be definitively identified by carotid Doppler studies.
MRI or magnetic resonance angiography has better resolution for soft tissue than
does computed tomography.
Carotid ultrasound is not adequate for detecting arterial dissection.
06 - Pediatric Ophthalmology and Strabismus
1. A pediatrician performs the red reflex examination (Bruckner test) on a
3-month-old infant. What does this test assess?
a. accommodation
b. visual acuity
c. optic nerve function
d. ocular alignment
4. What anatomical feature of the inferior oblique muscle differs from that of
the other extraocular muscles?
a. Its origin is on the medial side on the orbit.
b. It is innervated by the inferior division of cranial nerve III.
c. It passes through the trochlea before inserting on the globe.
d. Its primary action is elevation.
8. What are the primary synergistic (yoke) muscles that are used for gazing
up and to the right?
a. left inferior oblique and right superior oblique
b. left superior rectus and right inferior oblique
c. left inferior oblique and right superior rectus
d. left superior oblique and right superior rectus
9. What is the term for the positions of gaze in which a single extraocular
muscle is the prime mover of each eye?
a. secondary positions
b. midline positions
c. diagnostic positions
d. cardinal positions
15. For which type of exodeviation are orthoptic exercises the most
appropriate initial therapy?
a. Duane retraction syndrome
b. convergence insufficiency
c. dissociated horizontal deviation
d. positive angle kappa
16. A patient is found to have A-pattern exotropia with a compensatory head
posture. What head posture is the clinician most likely to observe?
a. chin up
b. chin down
c. right head tilt
d. right head turn
17. What clinical finding accompanies the upward movement of the eye in
DVD?
a. extorsion of the globe
b. downward movement of the fellow eye on cover testing
c. upbeat nystagmus
d. Esotropia
22. What beneficial effect on the visual field can occur as a result of
strabismus surgery?
a. expansion of the binocular visual field following surgery for exotropia
b. constriction of an overly wide peripheral field following surgery for exotropia
c. expansion of the binocular visual field following surgery for esotropia
d. elimination of monofixation syndrome due to overlapping fields following
surgery for infantile Esotropia
23. What refractive condition is true for most infants during the first year of
life?
a. relatively flat cornea that steepens over time
b. hyperopic refractive error that decreases over time
c. intraocular lens power that increases over time
d. visual acuity of 20/30, measured by preferential looking (PL), that decreases
over time
24. What eye movement abnormality can occur in healthy infants in the first
months of life?
a. intermittent esotropia
b. constant exotropia
c. vertical nystagmus
d. ocular flutter
28. Which of the following conditions of the affected eye may be associated
with pseudoptosis?
a. hypotropia
b. DVD
c. Duane retraction syndrome
d. infantile esotropia
29. What congenital eyelid malformation would most likely require early
repair?
a. dystopia canthorum
b. eyelid coloboma
c. euryblepharon
d. telecanthus
33. Curvilinear tears in Descemet membrane are most often seen in what
ocular condition?
a. congenital hereditary endothelial dystrophy (CHED)
b. Peters anomaly
c. primary congenital glaucoma
d. amniocentesis injury
39. What is the pattern of genetic inheritance in the majority of patients with
primary congenital glaucoma?
a. autosomal dominant
b. sporadic
c. X-linked recessive
d. autosomal recessive
42. That is the most significant risk factor for developing retinopathy of
prematurity (ROP)?
a. male sex
b. gestational age
c. white race
d. lung disease
43. Why are magnetic resonance imagings (MRI) and ultrasonography the
preferred imaging modalities instead of a computed tomography (CT) scan in
a pediatric patient with presumed retinoblastoma?
a. .tvlRI and ultrasonography are better at detecting calcium in the tumor.
b. CT scan subjects the child to radiation.
c. MRI and ultrasonography are better at showing bony abnormalities in the orbit.
d. MRI and ultrasonography are easier to obtain in a child.
48. What is the most common cause of visual impairment in children with
abusive head trauma?
a. cortical or cerebral visual impairment
b. optic atrophy
c. retinal detachment
d. vitreous hemorrhage
1. d. The red reflex examination (Bruckner test) evaluates the clarity and
symmetry of the red reflex, identifies significant or asymmetric refractive errors,
and determines the position of the corneal light reflex, which provides an estimate
of ocular misalignment.
4. a. The inferior oblique muscle is the only extraocular muscle whose origin is on
the medial orbital wall. The inferior division of the third cranial nerve innervates
the medial rectus, inferior rectus, and inferior oblique muscles. The superior
oblique muscle is the only extraocular muscle that passes through the trochlea.
The primary action of the inferior oblique muscle is extorsion. The primary action
of the superior rectus muscle is elevation.
5. a. Elastin is one component of the pulley; the others are smooth muscle and
collagen. Striated muscle, hyaluronic acid, and chondroitin sulfate are not known
constituents of the pulleys.
9. d. By having the patient move the eyes to the 6 cardinal positions, the clinician
can isolate and evaluate the ability of each of the 6 extraocular muscles to move
each eye.
11. c. The Krimsky test does not rely on a sensory or motor response from the
patient. Motor test results will not be accurate if there is eccentric fixation. The
Lancaster test depends on the patient's subjective localization of the targets, which
may not be accurate in the presence of poor vision or anomalous retinal
correspondence.
12. c. Bifocals reduce the need for accommodation at near and thus allow the
potential development of fusion and stereopsis. Overminused glasses increase
accommodation. Alternate occlusion theoretically reduces suppression but has no
role in the treatment of high AC/ A esotropia. Base-in prism would increase the
deviation in a patient with high AC/ A esotropia.
17. a. Patients with dissociated strabismus may have accompanying extorsion and
exodeviation (not esodeviation) of the elevating eye. Typically, there is no
hypodeviation of the fellow eye on cover testing, due to an apparent violation of
Hering's law of motor correspondence.
DVD is usually seen in infantile strabismus. In this form of strabismus, any
associated nystagmus is of the latent variety, which has a horizontal vector.
22. c. Correction of esotropia can expand the binocular visual field. Surgery for
exotropia constricts the binocular visual field. Monofixation is not eliminated in
patients with infantile strabismus even if the eyes are aligned well.
23. b. In general, eyes are hyperopic at birth, becoming more so until age 7 years,
when they experience a myopic shift toward plano. The newborn has a steeper
cornea and a higher intraocular lens power, both of which decrease over time.
Visual acuity of infants aged 3 months is in the 20/120 range when measured by
preferential looking (PL). Visually evoked potential (VEP) testing estimates
acuity to be 20/20 at 6 months of age.
24. a. In the first few months of life, episodes of intermittent strabismus are
common. Constant strabismus is not normal, even at this early age. Vertical
nystagmus and ocular flutter are also not normal.
25. c. Inherited retinal dystrophies are the most common cause of paradoxical
pupils. Patients with aniridia and anterior segment dysgenesis have abnormal
irises but not paradoxical pupils. Pupillary reactions are normal in cerebral visual
impairment.
26. c. Although there is some variability, the nervous system is typically mature
enough at age 6- 8 weeks for an infant to maintain visual fixation and react with
facial expressions.
29. b. Eyelid coloboma (eyelid cleft, eyelid notch) carries a risk of exposure
keratopathy, and early closure of the eyelid defect is often required.
30. d. Although all the listed treatments may be effective for some hemangiomas,
oral propranolol is now preferred for the treatment of vision-threatening
periocular hemangiomas. Topical timolol may be an effective treatment for
superficial hemangiomas but not for orbital lesions.
32. b. Nasolacrimal duct obstruction typically occurs at the most distal portion of
the lacrimal duct, because of incomplete canalization at or around full-term
gestation (40 weeks) of what was a solid structure in the fetus. This blockage
occurs at the valve of Hasner. The canaliculi and puncta and the valve of
Rosenmiiller, which is in the region of the junction of the canaliculi, are more
likely to have canalized normally.
33. c. Tears in Descemet membrane (Haab striae) are seen because of a rapid
stretching of the cornea in primary congenital glaucoma. They are not seen in
congenital hereditary endothelial dystrophy (CHED) or Peters anomaly. Trauma
from amniocentesis may result in a penetrating injury of the cornea. Tears in
Descemet membrane may also be seen in a forceps injury sustained during
delivery, but these are usually linear, not curvilinear.
35. d. In patients with sporadic aniridia, the presence of Wilms tumor must be
excluded with a renal ultrasound scan, which must be repeated until molecular
genetic analysis rules out an llpl3 deletion and confirms an intragenic PAX6
mutation. Iris abnormalities that are associated with systemic abnormalities
include neuroblastoma in patients with Horner syndrome, Lisch nodules in
patients with neurofibromatosis, and heterochromia in patients with Waardenburg
syndrome.
36. a. Infants with Chlamydia trachomatis infection acquired at birth may present
with papillary conjunctivitis during the first week of life. Although the eye disease
is usually selflimited, C trachomatis infection may cause pneumonia and otitis
media in neonates.
Therefore, systemic treatment with oral erythromycin is indicated.
41. d. Anterior uveitis is the most common uveitis seen in children. It is most
often idiopathic, related to trauma, or associated with juvenile idiopathic arthritis.
42. b. The 2 strongest risk factors for retinopathy of prematurity (ROP) are
gestational age and birth weight. Although race and lung disease are also risk
factors, they are not as significant as gestational age and birth weight. There is no
difference in the risk of ROP between the sexes.
43. b. Unlike magnetic resonance imaging (MRI) and ultrasonography, a
computed tomography (CT) scan subjects patients to radiation. Children with
heritable retinoblastoma are at high risk for secondary radiation-induced tumors,
so any additional radiation should be avoided, if possible.
44. b. Morning glory disc anomaly has been associated with basal encephalocele
in patients with midfacial anomalies, PHACE syndrome (posterior fossa
malformations, hemangiomas, arterial lesions, cardiac and eye anomalies), and
abnormalities of the carotid circulation, including moyamoya disease.
45. a. Optic discs with small cup- disc ratios that may resemble papilledema are
commonly seen in hyperopic eyes. Optic discs in myopic eyes do not have this
appearance. Strabismus is not associated with pseudopapilledema.
46. c. Sickle cell testing must be performed in all African American patients with
hyphema. Because of sickling of the red blood cells in the anterior chamber,
sickle cell trait or disease may result in elevated intraocular pressure, even in the
presence of a small hyphema.
48. a. The most common cause of visual impairment in children with abusive
head trauma is from cortical or cerebral visual impairment due to neurologic
damage. Optic atrophy and retinal injury may also cause decreased vision, but
they are less common causes.
1. When removing bone from the medial wall of the orbit in an orbital
decompression, the surgeon can locate the ethmoidal arteries along the
a. spheno ethmoidal recess
b. superior orbital fissure
c. fronto ethmoidal suture
d. infra orbital canal
11. All of the following orbital diseases may improve with corticosteroids
except
a. thyroid eye disease
b. orbital mucocele
c. nonspecific orbital inflammation
d. orbital lymphoma
13. A patient with declining visual acuity has an optic nerve sheath
meningioma that does not extend outside the orbit. Which of the following is
the best treatment?
a. systemic corticosteroid therapy
b. fractionated stereotactic radiation therapy
c. proton beam radiation
d. exenteration
16. A 30-year-old man is evaluated in the emergency room for trauma to the
right orbit. The patient has marked proptosis and an intraocular pressure of
40 mm Hg on the affected side. A CT scan shows intraorbital hemorrhage.
Which of the following actions would be the least effective in acutely reducing
intraocular pressure?
a. lateral canthotomy and cantholysis
b. administration of topical aqueous suppressants
c. administration of intravenous mannitol
d. administration of high-dose oral corticosteroids
18. The best approach to an intraconal orbital tumor located between the
optic nerve and the lateral rectus is
a. transcaruncular orbitotomy
b. vertical eyelid-splitting orbitotomy
c. medial orbitotomy
d. lateral orbitotomy
19. Dermoid and epidermoid cysts of the orbit are typically located
a. deep in the orbit when seen in young children
b. within the lacrimal gland
c. along the inferior orbital rim
d. in the superior temporal or superior nasal orbital quadrant
20. A biopsy is obtained for a presumed lympho proliferative disorder. The
appropriate way to submit the tissue is
a. alcohol-fixed
b. fresh
c. formalin-fixed
d. frozen
21. During decompression of the orbital floor, diplopia and dystopia can be
minimized by preserving
a. the palatine bone
b. the orbital strut between the medial wall and floor
c. the zygomatic bone
d. the ethmoid bone
2. c. The superior ophthalmic vein drains into the cavernous sinus and is typically
seen on neuroimaging studies coursing across the superior orbit. This vein
enlarges in conditions such as dural cavernous sinus fistula that increase venous
pressure within the cavernous sinus, with the superior ophthalmic vein
transmitting this pressure into the orbit.
3. a. Orbital lymphoma primarily affects the anterior orbit and may be seen
protruding beneath the conjunctiva in the cul-de-sac. Systemic lupus
erythematosus may cause telangiectasia and edema of the eyelids. Lymphangioma
has a vascular appearance and may affect the conjunctiva. Necrobiotic
xanthogranuloma is associated with skin lesions with a propensity to ulcerate and
fibrose.
14. c. Thyroid eye disease is the most common cause of both unilateral and
bilateral proptosis in adults. Proptosis is seen in up to 60% of patients with thyroid
eye disease.
15. b. Excellent bony detail with simultaneous resolution of soft tissues makes CT
scanning the study of choice in the evaluation for fractures with acute orbital
trauma. MRI and orbital ultrasound studies may provide better detail of certain
soft tissues and have greater utility in the evaluation of certain foreign bodies, but
do not provide the bony detail seen in CT.
16. d. The trauma with proptosis suggests extrinsic compression of the globe,
which raises intraocular pressure. A lateral canthotomy and cantholysis will
typically lower intraocular pressure in this situation. Mannitol and topical aqueous
suppressants will lower intraocular pressure arising from intrinsic or extrinsic
factors. High-dose corticosteroids are postulated to have neuroprotective effects,
but also carry numerous risks. They have no direct immediate effect on
intraocular pressure.
18. d. Lateral orbitotomy provides the most direct route to this lesion located
between the nerve and the lateral rectus muscle. Medial incisions such as the
transcaruncular and medial orbitotomy would lead to the medial orbital space on
the opposite side of orbit compared to the lesion. The eyelid-splitting incision
would also take the surgeon through a less-direct route to the lateral wall.
19. d. These lesions are thought to occur at lines of fetal suture closure. They are
commonly (70%) located around the fronto-zygomatic suture line. They also
occur at other fetal tissue suture lines, especially in the head and neck.
21. b. Complete removal of the orbital floor with release of the periosteum may
result in downward displacement of the globe following orbital decompression.
Risks for this are diminished if the anterior portion of the medial orbital strut is
left intact.
22. d. The surgical goal is to remove the entire lesion with the cyst wall intact.
Leaving behind any of the wall of a dermoid cyst will result in recurrence of the
lesion. Leaving any keratin contents behind will result in an acute inflammatory
reaction. Dermoid cysts are often removed when they become clinically apparent
to prevent rupture and an inflammatory reaction. Bone remodeling rarely requires
intervention, and malignant transformation is rare.
23. b. Nonporous implants are an excellent, cost-effective choice for patients not
requiring implant integration and have a lower rate of extrusion when compared to
porous implants.
They transfer motility to the ocular prosthesis only though passive movement.
24. b. Although dermis-fat grafts tend to grow with surrounding orbit in children,
in adults resorption is unpredictable. They are valuable when there is limited
conjunctiva in the socket and can be used as patch grafts in cases of implant
exposure.
25. c. Although gradual involution over months has been observed with
keratoacanthoma, this is regarded as a low-grade squamous cell carcinoma. Thus
complete surgical excision is recommended.
26. c. Vertical tension on the eyelids can cause eyelid retraction or ectropion.
When planning reconstruction of an eyelid defect, the tension of closure should be
directed horizontally.
27. d. Recurrent chalazion may represent an underlying malignancy. Sebaceous
adenocarcinoma may originate in the tarsal plate or the lash margin. A superficial
shave biopsy may reveal chronic inflammation, but miss an underlying tumor.
Thus a full-thickness diagnostic biopsy of the eyelid is recommended.
28. a. Frontalis suspension is correct, because this is a severe, bilateral ptosis with
poor levator function. Mullerectomy and the Fasanella-Servat procedure generally
work better in patients with mild cases of ptosis with better levator function.
Large levator resections can work with in patients with poor levator function but
in a unilateral, not bilateral, case.
29. c. The lateral tarsal strip needs to be attached to the periosteum inside the
orbital rim so that the eyelid will be well-apposed to the globe. Suturing the strip
to the external periosteum would leave the eyelid too distracted from the globe.
Attachment to the opposite eyelid margin and canthal limb would not provide
adequate support or place the eyelid in the proper position with respect to the
globe.
30. a. The lacrimal sac is located in the anterior medial orbit within a bony fossa
that is bordered by the anterior and posterior lacrimal crests, to which the anterior
and posterior crura of the medial canthal tendon attach.
31. a. The initial treatment of canaliculitis is curettage, which may require snip
incision of the puncta to allow access. Some surgeons advocate initial
conservative treatment with warm soaks, digital massage, and topical antibiotic
therapy.
3. Which of the following laboratory test results would be consistent with dry
eye?
a. tear hyperosmolarity
b. decreased level of matrix metalloproteinase-9
c. increased level of tear lactoferrin
d. increased level of tear lysozyme
18. Which of the following neoplastic lesions of the conjunctiva is most likely
to be associated with a systemic neoplastic disease?
a. ocular surface squamous neoplasia
b. conjunctival papilloma
c. conjunctival lymphoma
d. conjunctival myxoma
19. Which of the following is a risk factor for tumor recurrence after the
successful treatment of ocular surface squamous neoplasia?
a. presence of leukoplakia
b. coexistence of ocular surface squamous neoplasia and pterygium
c. tarsal involvement
d. male sex
21. Which statement best characterizes the corneal injury caused by birth
trauma?
a. a corneal abrasion that heals, leaving no permanent injury
b. a stretching of the corneal stroma leading to a keratoconus-like protrusion
c. a stretching of Descemet membrane that leads to endothelial dysfunction and
corneal edema
d. a vertical break in the corneal endothelium, leaving vertical ruptures in Descemet
membrane that lead to corneal edema; the edema often clears and may produce
high astigmatism
22. Which of the following corneal dystrophies is autosomal recessive?
a. macular dystrophy
b. lattice dystrophy type 1
c. granular dystrophy
d. Fuchs endothelial corneal dystrophy
24. Which of the following metabolic disorders that affect the cornea is X-
linked recessive?
a. Hunter syndrome
b. Hurler syndrome
c. Maroteaux-Lamy syndrome
d. Scheie syndrome
27. Which of the following is the most significant risk factor for pterygium
development?
a. peripheral ulcerative keratitis
b. connective tissue disease
c. UV light exposure
d. dry eye
28. Terrien marginal degeneration is characterized by which of the following?
a. a primarily inflammatory condition
b. corneal thinning that usually begins superiorly
c. male predilection
d. spontaneous corneal perforation
32. Which clinical finding best supports a diagnosis oflimbal stem cell failure?
a. corneal thinning and melting
b. corneal edema
c. absence of limbal palisades of Vogt with superficial corneal neovascularization
d. corneal opacities with deep corneal neovascularization
33. Which of the following statements is best in relation to corneal surface
healing?
a. Central corneal epithelium is maintained by continued centripetal movement of
central corneal epithelium toward the periphery.
b. The corneal epithelium is entirely regenerated about every 21 days, with the
stem cells serving as the source of this renewal.
c. When there is concurrent damage to the limbal stem cells, the conjunctival cells
do not become involved in repopulating the corneal surface.
d. The limbal basal layer contains the stem cells of the corneal epithelium that
normally repopulate the corneal surface.
2. d. Dry eye is associated with decreases in the Schirmer I test result, tear
meniscus height, and tear breakup time. The symptom of foreign-body sensation
should have improved after artificial tear supplementation or use of topical
cyclosporine. However, redundancy of the inferior bulbar conjunctiva that
overhangs the lower eyelid margin is a clinical sign of conjunctivochalasis, which
typically does not improve with artificial tear supplementation or use of topical
cyclosporine. Patients with this condition may require resection or cautery to
eliminate the redundant conjunctiva.
4. d. Although a Gundersen flap procedure and tarsorrhaphy are viable options for
the treatment of neurotrophic corneal ulcers, they should be reserved for patients in
whom other interventions have failed. In many cases, patching, increased
lubrication, or placement of bandage contact lenses combined with careful
monitoring will lead to resolution of the ulcer without more invasive therapy. A
Boston keratoprosthesis is indicated for end-stage corneal disease with significant
corneal scarring.
5. c. Unilateral stem cell deficiency secondary to contact lens wear is usually mild
and responds well to discontinuation of contact lens use along with a short course
of topical corticosteroids. If these measures are not effective, then localized corneal
debridement of the superior portion of the irregular epithelium will allow the
healthy inferior corneal epithelium to replace the abnormal epithelium produced by
the stem cell dysfunction.
Limbal stem cell allograft transplantation is reserved for more severe cases of stem
cell dysfunction such as that typically associated with Stevens-Johnson syndrome
or bilateral chemical injuries.
6. b. Human immunodeficiency viruses cannot survive outside the host because
their lipid bilayer envelopes-which are integral to their pathogenicity degrade with
exposure to the environment. Adenoviridae are double-stranded DNA viruses, but
this makeup has no effect on their survival. Numerous individual Adenoviridae
serotypes do exist, but this fact also has no bearing on their ability to survive for
relatively long periods on inanimate surfaces. Non enveloped viruses such as the
Adenoviridae survive and remain infective because their surface structure does not
include degradable lipids.
9. c. The most common fungal corneal pathogens are Candida species, and the
smear result is suggestive of yeast. The most appropriate initial therapy from the
list of options is amphotericin B, which has broad activity against both yeast and
fungi. Although natamycin has anti yeast activity, it is more effective against
filamentous molds and its poor aqueous solubility restricts its use as an intrastromal
medication. Moxifloxacin is primarily an antibacterial drug with limited antifungal
activity.
12. d. The large central ulcer strongly suggests the need for culture, according to
published guidelines. Single-drug therapies have poor in vitro activity against
methicillin-resistant Staphylococcus aureus infection, a likely pathogen in an older
nursing home patient.
13. a. Metaplastic epithelial changes can occur in severe ocular surface diseases,
including mucous membrane pemphigoid, Stevens-Johnson syndrome and toxic
epidermal necrolysis, and ocular graft-vs-host disease.
14. c. Corneal neovascularization increases the risk of graft rejection, but not to
such a severe degree. Lymphatic neovessels increase the risk of graft rejection by
facilitating access of donor and host antigen-presenting cells and antigenic material
to regional lymph nodes, thereby accelerating sensitization to graft antigens.
Several animal studies have demonstrated that blocking angiogenesis and/or
lymphangiogenesis can improve graft survival.
Although VEGF inhibitors have been used for the treatment of corneal
neovascularization, no data are yet available on whether their use improves graft
survival in humans.
15. a. Because of the severe ocular surface disease associated with chronic Stevens-
Johnson syndrome and toxic epidermal necrolysis, outcomes after penetrating
keratoplasty are poor. Boston type II and osteo-odonto-keratoprostheses, though
high risk, have been attempted and are described in the literature. An autologous
stem cell transplant would not be a viable option given the bilateral nature of the
condition, with insufficient stem cells available to transplant from the affected
fellow eye.
16. c. Eosinophils are less numerous in atopic keratoconjunctivitis than in vernal
keratoconjunctivitis.
Patients with atopic disease are typically older, they have papillae involving the
upper eyelid, and they may have extensive corneal neovascularization.
19. c. Recurrent ocular surface tumors can be found anywhere on the conjunctiva;
therefore, the entire ocular surface (including the superior fornix) should be
examined at each visit.
Conjunctival melanoma typically spreads to regional lymph nodes, which can be
evaluated by palpation. Squamous cell carcinoma of the conjunctiva results from
sun damage to the ocular surface, which also damages the skin. A dermatologic
evaluation is important for anyone with a diagnosis of an ocular surface tumor.
21. d. Direct pressure from forceps often causes vertical ruptures in Descemet
membrane that can lead to corneal edema, either transient or permanent, and to
permanent vertical striae in the posterior cornea with resulting high astigmatism.
24. a. Most metabolic disorders that affect the cornea are autosomal recessive. Two
exceptions are Hunter syndrome and Fabry disease, which are both X-linked
recessive.
27. c. Pterygia are more common in sunny climates and in people who have spent
significant time outdoors, reflecting exposure to UV light as a significant risk
factor; there is a higher prevalence in men than in women.
32. c. Destruction of limbal stem cells is characterized by the absence of the limbal
palisades of Vogt, abnormal epithelium on the cornea, and vascularization.
33. d. The corneal epithelium is a highly differentiated cell type that is entirely
regeneratedv approximately every 7 days.
Numerous studies have demonstrated that central corneal epithelium is maintained
by continued centripetal movement of peripheral corneal epithelium toward the
visual axis, as well as by anterior movement from the basal epithelial cells.
The source of the peripheral corneal epithelium is believed to be stem cells that
reside in the basal layer of the limbus.
When there is damage to the limbal stem cells, the conjunctival epithelium
resurfaces the cornea.
10. What age group had the highest incidence and prevalence of
uveitis overall in a study population from northern California in the
United States?
a. patients in the first and second decades of life
b. patients in the third and fourth decades of life
c. patients older than age 65 years
d. patients in the fifth decade of life
17. What is the specific concern about using a tumor necrosis factor
(TNF) inhibitor in a 25-year-old woman with intermediate uveitis
and no evidence of tuberculosis or other systemic disease or
infection?
a. congestive heart failure
b. risk of neoplasia
c. lupus like syndrome
d. demyelinating disease
23. The white dot lesions of which disease are least apparent on
fluorescein angiography?
a. serpiginous choroiditis
b. punctate inner choroidopathy (PIC)
c. acute posterior multifocal placoid pigment epitheliopathy (APMPPE)
d. birdshot retinochoroidopathy
24. In patients with VKH syndrome, the presence of diffuse
choroiditis is most likely to be found during which stage of the
disease?
a. recurrent
b. prodromal
c. late (chronic)
d. early (acute uveitic)
35. Which of the following patients is the most likely to have primary
CNS! Intraocular lymphoma?
a. a 40-year-old man with cotton-wool spots and hard exudates
b. a 59-year-old man with hemorrhagic retinitis and retinal vasculitis
c. a 65-year-old woman with dense vitritis, subretinal infiltrates, and
mental confusion
d. a 29-year-old woman with pars plana exudates and retinal vasculitis
36. An individual infected with the human immunodeficiency virus
(HIV) has a necrotizing retinitis. Which of the following tests would
be most helpful in making the diagnosis?
a. blood and urine cultures for herpes viruses, including CMV
b. vitreous biopsy for polymerase chain reaction evaluation, cultures, and
cytologic testing
c. purified protein derivative testing for tuberculosis
d. serologic testing for herpes viruses, including CMV
13. a. The initial management of patients with uveitis and iris bombe
should include laser iridotomy or surgical iridectomy if the laser
procedure is difficult (e.g. due to iris-corneal touch or corneal edema),
glaucoma medications as needed, and intensive application of topical
corticosteroids. Surgical iridectomy may also become necessary if a
patent laser iridotomy cannot be successfully maintained.
A trabeculectomy or glaucoma implant may later become necessary if
there is a patent laser iridotomy and medically uncontrolled intraocular
pressure. Laser trabeculoplasty is of no benefit in uveitic angle closure or
iris bombe.
21. b. Old, scarred lesions may be present in the newly diagnosed eye.
Funduscopic findings in patients with serpiginous choroidopathy include
characteristic gray-white lesions at the level of the retinal pigment
epithelium (RPE) projecting in pseudopodia! manner from the optic
nerve in the posterior fundus. Less commonly, macular or peripheral
lesions may present without peripapillary involvement. Typically,
disease activity is confined to the leading edge of the advancing lesion; it
may be associated with shallow subretinal fluid. Occasionally, vascular
sheathing has been reported along with RPE detachment and disc
neovascularization. Significant vitritis is distinctly uncommon. Late
findings include atrophy of the choriocapillaris, RPE, and retina, with
extensive RPE hyperpigmentation and subretinal fibrosis; choroidal
neovascularization occurs in some patients at the border of the old scar.
22. b. Acute retinal necrosis presents with a classic triad of retinal
arteriolitis, vitritis, and multifocal yellow-white peripheral retinitis. Early
in the course of the disease, the peripheral retinal lesions are
discontinuous and have a scalloped edge that appears to arise in the
retina. Within days, they coalesce to form a confluent 360 area of
peripheral retinitis that progresses rapidly towards the posterior pole,
leaving full-thickness retinal necrosis in its wake.
24. d. VKH syndrome has been divided into four stages: prodromal,
acute uveitic, convalescent, and chronic recurrent; histologic findings
vary depending upon the stage of the disease. During the acute uveitic
stage, there is a diffuse, non necrotizing, granulomatous inflammation
(virtually identical to that seen in sympathetic ophthalmia) consisting of
lymphocytes and macrophages mixed with epithelioid and multinucleate
giant cells with preservation of the choriocapillaris. The convalescent
stage is characterized by non granulomatous inflammation with uveal
infiltration of lymphocytes and plasma cells and the absence of
epithelioid histiocytes. The number of choroidal melanocytes decreases
with the loss of melanin and pigment, corresponding to the "sunset glow"
fundus seen clinically.
In addition, one sees numerous atrophic depigmented lesions in the
peripheral retina erroneously thought to be Dalen-Fuchs nodules.
The chronic recurrent stage reveals granulomatous choroiditis with
damage to the choriocapillaris.
32. c. Uveitis may be seen in any stage of syphilis but most commonly
occurs in the secondary and tertiary stages of the disease. Thus,
laboratory evaluation for syphilis in patients with uveitis should use
treponemal-specific tests such as FTA-ABS or the
microhemagglutination assay for Treponema pallidum antibodies
(MHA-TP) rather than non treponemal screening tests such as the VD
RL or RPR evaluations.
A chancre is seen at the site of inoculation in primary syphilis. In
secondary syphilis a rash may be seen on the palms. This rash may allow
transfer of the spirochete and should not be touched. Tertiary or latent
syphilis is manifested by gummatous inflammation of the viscera and
neurosyphilis.
33. b. Vitrectomy specimens from suspected cases of intraocular
lymphoma must be processed promptly by an experienced ophthalmic
pathologist in order to preserve the cytology for examination. Prolonged
time between obtaining a specimen and its processing by the pathologist
increases the degeneration of the specimen and greatly reduces its value
for obtaining a diagnosis. It is thus important that the surgeon clearly
communicate to the pathologist the clinical suspicion of lymphoma and
indicate that a specimen will be submitted so that arrangements can be
made for timely evaluation. In addition, depending on the clinical
scenario, the pathologist may want special fixatives to be used to allow
special studies, such as flow cytometry, in addition to cytologic
examination.
3. Which of the following risk factors is probably the least significant for
POAG?
a. myopia
b. race or ethnic origin
c. family history
d. level of IOP
4. All of the following statements regarding the Goldmann equation are true
except:
a. The facility of outflow is inversely related to the level of IOP.
b. F denotes the rate of aqueous formation and is typically 2.0-2.5 liters per
minute.
c. Episcleral venous pressure is normally 8-10 mm Hg and is directly related to
IOP, especially in acute situations.
d. C denotes the facility of outflow and is essentially the same as resistance to
outflow through the trabecular meshwork.
7. Factors that may increase IOP include all of the following except:
a. Valsalva maneuver
b. aerobic exercise
c. ketamine
d. blepharospasm
9. Which one of the following visual field testing strategies may allow an
earlier detection of glaucoma compared with standard automated perimetry?
a. suprathreshold testing
b. optical coherence tomography (OCT)
c. frequency-doubling technology (FDT)
d. confocal scanning laser ophthalmoscopy (CSLO)
16. Which glaucoma is caused by the leakage of lens proteins through the
capsule of a mature or hypermature cataract?
a. phacomorphic glaucoma
b. lens particle glaucoma
c. ectopia lentis
d. phacolytic glaucoma
17. Which is the correct order of normal angle structures viewed anteriorly
to posteriorly during gonioscopy?
a. cornea, non pigmented trabecular meshwork, Schwalbe line, pigmented
Trabecular meshwork, scleral spur, ciliary body band, iris root
b. cornea, scleral spur, non pigmented trabecular meshwork, pigmented trabecular
meshwork, Schwalbe line, ciliary body band, iris root
c. cornea, Schwalbe line, pigmented trabecular meshwork, non pigmented
Trabecular meshwork, scleral spur, ciliary body band, iris root
d. cornea, Schwalbe line, non pigmented trabecular meshwork, pigmented
Trabecular meshwork, scleral spur, ciliary body band, iris root
18. Which of the following is the best method to determine whether a patient
is at risk of angle closure?
a. gonioscopy
b. darkroom prone-position test
c. pharmacologic pupillary dilation
d. darkroom test
20. In an eye with a narrow angle, which of the following most strongly
argues in favor of performing a laser peripheral iridotomy?
a. gonioscopic findings
b. amount of glaucomatous optic nerve cupping
c. amount of glaucomatous visual field loss
d. IOP level
21. A 14-year-old boy with bilateral iris atrophy and corectopia is found to
have elevated IOPs.
His father has a similar condition. Which of the following is the most likely
diagnosis?
a. iridocorneal endothelial syndrome
b. Lowe syndrome
c. Axenfeld- Rieger syndrome
d. Hallermann- Streiff syndrome
22. What anatomical modification is found in increased frequency in primary
congenital glaucoma?
a. increased axial length
b. hyperopia
c. hypoplastic optic nerve
d. decreased corneal diameter
23. Which one of the following is the preferred initial surgical procedure for
an infant with primary congenital (infantile) glaucoma and corneal clouding?
a. goniotomy
b. trabeculectomy
c. cyclophotocoagulation
d. trabeculotomy
24. Mutations in the TIGR/myocilin gene are associated with which of the
following disorders?
a. pigment dispersion syndrome
b. exfoliation syndrome (or pseudoexfoliation)
c. juvenile OAG (JOAG)
d. nanophthalmos
26. Which class of glaucoma medications can induce uterine smooth muscle
contraction and should therefore be avoided during pregnancy?
a. Beta-blockers
b. carbonic anhydrase inhibitors
c. alpha-agonists
d. prostaglandins
27. A 21-year-old woman with JOAG and 7 diopters of myopia complains of
severe blurring of vision after using 1 drop of pilocarpine. What is the most
likely cause of her symptom?
a. increased hyperopia
b. retinal detachment
c. increased myopia
d. a small pupil
2. d. Available data show that, among white populations in the United States and
Europe, the prevalence of primary angle-closure glaucoma (PACG) is
approximately 0.1 %; the prevalence of PACG among the Inuit population of the
Arctic regions is 20 to 40 times higher.
For most Asian population groups, the prevalence of PACG is between that for
whites and that for the Inuit. Groups of African ancestry have a higher prevalence
of OAG.
10. b. Progressive enlargement of the cup is the optic nerve finding most
suggestive of glaucoma.
Although asymmetry of the cups can be a sign of early glaucoma, it can be seen in
individuals without glaucoma as well and is often due to differences in the size of
the neural canal.
Generalized pallor is more commonly a sign of non glaucomatous optic nerve
injury. Exposed lamina cribrosa can be seen in glaucoma, but it is also present in
individuals with physiologic cupping.
11. d.
18. a. Most clinicians find gonioscopy to be the best method for identifying angles
that are potentially at risk for angle closure. Results of provocative testing may
supplement gonioscopic findings, but gonioscopy is considered the gold standard
by most experts.
19. d. Laser iridotomy is useful for treating angle closure when there is an element
of pupillary block (e.g. in phacomorphic glaucoma). Iridotomy is of no benefit
when angle closure is caused by other mechanisms and may exacerbate the
condition if outflow is further diminished by the inflammation inherent in the
procedure.
20. a. In chronic ACG with relative pupillary block, gonioscopic findings are the
key to diagnosis and management. IOP may be normal or elevated. In an eye with
a narrow angle, the presence of elevated pressure alone is not an indication for
laser iridotomy.
In this case, coexisting OAG may be causing the IOP elevation, not the narrow
angle. The extent of visual field loss or optic nerve damage does not indicate
whether an iridotomy is needed.
Patients with appositional angle closure or areas of peripheral anterior synechiae
with relative pupillary block have a high risk of developing chronic angle closure
and should have a laser iridotomy.
24. c. The first OAG gene identified was GLC1A, which was initially mapped in a
large juvenile glaucoma family and has been localized to chromosome l.
Mutations in this gene produce the protein myocilin, which was also found to be
upregulated in trabecular meshwork cells following dexamethasone exposure.
For this reason, the gene was functionally termed trabecular meshwork inducible
glucocorticoid response (TIGR). Mutations in the TIGR/myocilin gene have been
reported in 3% of individuals with adult-onset POAG.
25. b. Brimonidine has been shown to cause systemic hypotension and apnea in
children younger than 2 years.
26. d. Prostaglandins contract uterine smooth muscle and are used therapeutically
to induce labor. They should therefore be avoided in the treatment of glaucoma
during pregnancy, if possible.
27. c. Young, highly myopic patients may have substantially increased myopia
with miotic therapy. This occurs because of a miotic-induced increased convexity
of the lens and forward movement of the lens. Retinal detachment can occur after
miotic therapy, but it would not be the most likely cause of severe visual blurring
in this case.
All patients with a normal iris develop a small pupil on miotic therapy.
This can cause nyctalopia and is more troublesome in older patients with a
cataract or other media opacity.
28. c. Elevation of IOP occurs with plateau iris syndrome without pupillary block
and may occur despite a patent iridotomy.
32. c. The incidence of encapsulated filtering blebs after guarded filtering surgical
procedures without adjunctive antifibrotics is 8% to 28%. When a trabeculectomy
with mitomycin C is performed, the incidence of encapsulation decreases to 2.5%.
Aqueous misdirection can occur following guarded filtering surgery, with an
incidence of2% to 4%. However, aqueous misdirection tends to occur soon after
the surgery and in patients with a history of chronic ACG, hyperopia, or
nanophthalmos or after laser suture lysis or cessation of cycloplegic therapy.
Cystoid macular edema may occur after trabeculectomy, but its incidence
does not appear to be increased with the use of antifibrotic agents. The reported
incidence of bleb-related infections is 5.7% per year, and this percentage increases
significantly with the use of adjunctive antifibrotic therapy.
11 - Lens and Cataract
7. The Y-sutures seen in the adult lens are the result of which of the following?
a. the junction of the adult nucleus with the surrounding cortex
b. scarring from the tunica vasculosa lentis
c. the elaboration of the adult nucleus around the fetal nucleus
d. fusion of the embryonic cells within the fetal nucleus
12. A patient presents with a mature lens and secondary glaucoma without
evidence of pupillary block. What is the most likely diagnosis?
a. phacomorphic glaucoma
b. phacolytic glaucoma
c. phacoantigenic uveitis
d. lens particle glaucoma
16. In the developing world, which of the following could apply to a patient
who develops a visually significant cataract?
a. An additional person may be removed from the workforce for care of the patient.
b. The patient must receive prompt attention to have the cataract removed.
c. The patient is at lower risk for falls.
d. The patient is older than 65 years.
17. What did the Beaver Dam Eye Study determine regarding visually
significant cataracts?
a. They occur earlier in men than in women.
b. They interfere with vision only after patients are older than 75 years.
c. They are more likely to be cortical than nuclear.
d. The incidence of visually significant cataract increases slowly from age 54 to 75.
18. If the best -corrected visual acuity for a patient with cataract is 20/100, a
surgeon would be most likely to recommend surgery if
a. pinhole acuity is also 20/100
b. potential acuity meter (PAM) acuity is 20/25
c. laser interferometry reveals that the patient has no ability to recognize the
orientation of the diffraction pattern
d. a Maddox rod test shows multiple interruptions in the red light streak
19. If a patient has a dense white cataract and the posterior pole is not visible,
which of the following would be most helpful for the clinician in deciding
whether to perform surgery?
a. Specular microscopy
b. B-scan ultrasonography
c. laser interferometry
d. Maddox rod test
23. Which one of the following steps would reduce the operative risks of
surgery for a mature, white cataract?
a. placing a small initial incision in the anterior capsule and injecting sufficient
viscoelastic into the lens to expel liquid cortex prior to completing the
capsulorrhexis
b. steepening the dome of the anterior capsule by removing the viscoelastic after
the initial capsule puncture
c. staining the capsule with trypan blue or indocyanine green dye
d. creating numerous radial relaxing incisions in the anterior capsule with long
Vannas scissors
1. c. Lens cells have no mechanism for metabolizing toxins. The lens remains clear
because the lens fibers contain no nuclei or organelles that would scatter light. The
lens refracts light because the relative density of the lens is greater than that of the
fluids (aqueous and vitreous) surrounding it. The lens, until the onset of
presbyopia, remains flexible to provide accommodation in response to the tension
placed on the capsule from the ciliary muscle and zonular fibers.
2. a. With age, the human lens develops an increasingly curved shape, which
results in more refractive power. This change may be accompanied by- and
sometimes offset by-a decrease in the index of refraction of the lens, probably
resulting from an increase in water insoluble proteins.
4. b. Monocular diplopia occurs when the lens is partially dislocated, and light can
pass both through and around the edge of the lens. Pupillary block glaucoma from
anterior dislocation of the lens is a rare event. Aphakic correction is required when
the lens is totally subluxed into the vitreous. When the lens subluxates, it usually
does so superotemporally.
5. c. Glutathione and vitamins A and C are powerful free radical scavengers. They
have no effect on the pH or the corneal endothelium. They actually protect DNA
from being damaged by free radicals.
6. c. The ciliary muscle is a ring, but upon contraction it does not have the effect
that one would intuitively expect of a sphincter. When it contracts, the diameter of
the muscle ring is reduced, thereby relaxing tension on the zonular fibers, allowing
the lens to become more spherical.
7. d. The Y-sutures represent the edges of the secondary lens fibers of the fetal
nucleus. The anterior Y is erect and the posterior one is inverted. They can be seen
in the center of the adult nucleus in a clear lens. The junction of the adult nucleus
and surrounding cortex is invisible until the nucleus develops sclerosis. The tunica
vasculosa lentis surrounds the lens as it grows. The Y-sutures are within the fetal
nucleus, not around it.
11. d. Galactosemia produces an "oil droplet" cataract that appears within the first
few weeks of life. Untreated, galactosemia is rapidly fatal. Crystalline cataracts in
myotonic dystrophy develop a Christmas tree-appearing cortical cataract as well as
posterior subcapsular changes that will lead to complete opacification. The acute
cataract of uncontrolled diabetes has a snowflake appearance in the anterior and
posterior subcapsular region.
12. b. Phacolytic glaucoma occurs when denatured lens protein leaks through an
intact but permeable capsule. In phacomorphic glaucoma, the mature lens causes
pupillary block and secondary angle closure. In phacoantigenic uveitis, leaking of
lens protein produces a granulomatous inflammatory reaction. Lens particle
glaucoma is associated with penetrating lens injury or surgery.
13. c. Increased pigmentation of the trabeculum and reduced outflow occur
frequently in exfoliation syndrome. Exfoliative material has been found in many
bodily organs as well as on the iris and corneal endothelium. Intraocular pressure
may rise as a result of the obstruction of the trabecular meshwork by the exfoliative
material.
14. c. Nuclear cataract is common in patients older than 50 years if vitrectomy has
been used to repair a retinal detachment. Redetachment of the retina is an acute
phenomenon and unlikely 1 year after repair. Steroid therapy after retinal
detachment is usually brief and unlikely to cause nuclear cataract. Phacoantigenic
uveitis produces an inflammatory reaction and is extremely rare.
15. d. Census data confirm that cataracts are the leading cause of reversible
blindness. Cataracts increase in prevalence with increasing age and are a leading
cause of blindness worldwide. They can occur as a congenital condition or as a
result of trauma, metabolic diseases, or medications. Major epidemiologic studies
confirm an increased prevalence in women.
17. d. Cataracts begin to interfere with vision in persons aged 43-54 years, and,
from that age range, the incidence increases 13-fold in those aged 75 years or older.
The overall incidence of cataract is greater in women than in men. Nuclear
cataracts are more frequent than cortical cataracts at all ages.
18. b. The potential acuity meter (PAM) projects the equivalent of a Snellen visual
acuity chart into the eye, specifically through clear spaces in the lens, by means of
a beam of light to allow an estimate of macular function. The pinhole test
approximates the PAM; a reduced acuity would signal other ocular conditions that
cataract surgery might not improve.
Laser interferometry usually is beneficial in denser cataracts: the patient's failure to
discern the orientation of the diffraction pattern would indicate reduced visual
potential.
The patient's inability to see a continuous red line on a Maddox rod test would
suggest areas of decreased retinal sensitivity in the macula.
19. b. B-scan ultrasonography is indicated to evaluate for occult tumors, retinal
detachment, and posterior staphyloma or other posterior pathology that could affect
the visual outcome.
Laser interferometry and Maddox rod testing are not reliable with such a dense
cataract. Specular microscopy would be indicated only if signs of corneal
endothelial dysfunction were present.
20. c. The only consideration that would prompt the surgeon to consider operating
would be the inability to evaluate the patient's retina. This would be the case even if
the cataract explained the vision loss and the patient appeared well enough to
undergo surgery. If the patient reports that his vision is adequate for his needs,
surgery should be postponed.
21. c. Careful examination of the retinal periphery may reveal the presence of
lattice degeneration, retinal holes, and other abnormalities that warrant
consideration of preoperative treatment and/or diligent postoperative evaluation.
Lowering the height of the irrigating bottle produces less stress on the zonular
fibers and reduces the risk of posterior capsule tears. All incisions should be
carefully closed to reduce the risk of infection. Myopic patients do need to be
cautioned about anisometropia, and intolerable imbalances may prompt
consideration of second-eye surgery.
22. b. Chronic ciliary body inflammation at the zonular fibers may lead to zonular
laxity similar to that seen in exfoliation syndrome. The technical aspects of cataract
surgery can be more difficult in patients with uveitis. There may be limited access
to the lens because of posterior synechiae, a pupillary membrane, pupillary
sphincter fibrosis, and a floppy iris. Lysing synechiae, excising pupillary
membranes, and using pupil expanders and viscoelastic can counteract and
overcome the effects of an abnormal iris. Rupture of the capsulorrhexis with
extension to the zonular fibers can further complicate the procedure, and capsular
dyes may be necessary to maintain a continuous capsular tear during the rhexis.
23. c. When cataract surgery is performed on a patient with a white lens, there is
little or no red reflection. This makes it difficult to perform a circular
capsulorrhexis. Utilizing a capsular dye improves visualization of the capsule,
facilitating the creation of an anterior capsulorrhexis. The other methods described
increase the operative risks. Steepening the dome of the anterior capsule increases
the propensity for radial anterior capsule tearing and therefore should be avoided.
Maximally filling the anterior chamber with viscoelastic during the capsulorrhexis
can reduce leakage of white lens material into the anterior chamber, improving the
view of the anterior capsule. Creation of numerous radial relaxing incisions is a
method used when the initial capsulorrhexis is unsuccessful; it would not be the
primary step in creation of a capsulorrhexis. A small puncture in the anterior
capsule with injection of viscoelastic to expel liquid cortex prior to the completion
of the capsulorrhexis can be used initially but is not considered necessary with the
advent of capsular dyes.
26. b. A large capsulorrhexis will reduce the risk of phimosis and increased tension
on the weakened zonular fibers of the patient, also reducing the risk of late
posterior dislocation of the intraocular lens. Opacification of the posterior lens
capsule is dependent not on the size of the capsulorrhexis but rather on the anterior
capsule overlapping the edge of the intraocular lens. Postoperative pressure spikes
are not dependent on capsulorrhexis size, although they are more common in
patients with exfoliation. Glare and halos are also not caused by a large anterior
capsulorrhexis.
27. d. Loss of vitreous is not a problem for the eye; vitreous traction is. The goal of
vitreous removal is to reduce the possibility of traction. The clinician may prevent
traction by removing enough vitreous to keep it away from the incision. Therefore,
a Vitrectomy is not complete until all vitreous is removed anterior to the posterior
capsule. This ensures a lower risk of traction, and it is also the best way to decrease
the risk of postoperative cystoid macular edema (CME).
12 - Retina and Vitreous
1. What is a posterior extension of the pars plana epithelium onto the retinal
side of the ora serrata?
a. enclosed ora bay
b. meridional complex
c. dentate process
d. peripheral retinal excavation
9. Which of the following patients has been determined to benefit from Age-
Related Eye Disease Study (AREDS) vitamin supplementation?
a. 40-year-old man with numerous large drusen
b. 14-year-old girl with Stargardt disease
c. 62-year-old man with geographic atrophy in 1 eye
d. 78-year-old patient with previous bilateral CNV
10. Which of the following statements about patients who inherit sickle cell
hemoglobin (Hb SC) is least accurate?
a. "Salmon patch'' lesions, "black sunburst" lesions, and "sea fans" are all signs of
proliferative sickle cell retinopathy.
b. Those with hemoglobin SS have the most severe systemic complications.
c. Those with hemoglobin C and sickle cell thalassemia have the most serious
ocular complications.
d. Sickling of red blood cells occurs under conditions of decreased oxygen
tension.
11. Which of the following statements does not accurately describe the use of
indirect ophthalmoscopy to screen for retinopathy of prematurity (ROP)?
a. Screening should be performed on all premature neonates of less than 30 weeks
gestation.
b. Screening should be repeated biweekly on neonates who demonstrate ROP on
initial examination.
c. Screening should be performed before hospital discharge or by 4- 6 weeks of
age.
d. Screening should be performed on all premature neonates with a birth weight
<1500 g.
12. Which of the following factors is an important risk factor for ocular
toxoplasmosis?
a. consumption of undercooked meat
b. exposure to ticks
c. exposure to mosquitoes
d. living in the Ohio River Valley
14. What is a clinical feature of the multiple evanescent white dot syndrome
(MEWDS)?
a. RPE scarring
b. gray-white, poorly demarcated, patchy, outer-retinal lesions
c. severe vitreous cellular reaction
d. gray, granular pigmentation of the fovea
15. The parents of a 2-year-old girl report that she has had "bobbing eyes"
and light sensitivity since birth. In your office, the girl shows good visual
attention but has bilateral pendular nystagmus and squints in bright light.
The retina appears normal, but the foveal reflex is blunted. Dark-adapted
scotopic ERG responses are normal, but light-adapted photopic signals are
greatly diminished. No relatives are similarly affected. What condition does
this patient most likely have?
a. Stargardt disease
b. congenital stationary night blindness
c. Leber congenital amaurosis
d. achromatopsia
17. Which of the following tests most often yields a normal result in Best
disease?
a. optical coherence tomography (OCT)
b. ERG
c. fluorescein angiography
d. EOG
22. An atypical form of CME may be seen as an adverse effect of which of the
following medications?
a. sildenafil
b. amiodorone
c. hydroxychloroquine
d. niacin
35. What parameter increases the risk of Bruch membrane ruptures during
application of laser photocoagulation?
a. small spot size
b. long duration
c. low intensity
d. green wavelength
9. c. Patients at the time of enrollment into the Age-Related Eye Disease Study
(AREDS) was 55-80 years old.
The AREDS showed a 25% reduction in the risk of progression to advanced
AMD for patients with advanced unilateral AMD who were randomly assigned to
the combination supplement group.
10. a. "Salmon patch" and iridescent spot lesions represent areas of intraretinal
hemorrhage, while "black sunburst" lesions are localized areas of intra- and
subretinal hemorrhage and arise from hyperplasia and intraretinal migration of the
RPE.
"Sea fans" are fronds of neovascularization that extend from the retina into the
vitreous and are therefore signs of proliferative retinopathy.
A prospective clinical trial has demonstrated the efficacy of argon laser scatter
photocoagulation therapy for proliferative sickle cell retinopathy. Prolonged loss
of visual acuity and vitreous hemorrhage were reduced in treated eyes compared
with control eyes. Scatter photocoagulation proved to be effective and safe in the
treatment of patients with sea fan neovascularization.
11. b. Several risk factors have been associated with the development of
retinopathy of prematurity (ROP) in premature neonates, including low birth
weight, low gestational age, oxygen therapy apnea, sepsis, and others. Premature
infants with a birth weight of 1500 g or less, of gestational age of 30 weeks or
less, or who require supplemental oxygen are particularly at risk of developing
ROP.
Initial examination of the peripheral retina by indirect ophthalmoscopy in these
neonates is recommended before hospital discharge, or by 4-6 weeks of postnatal
age (or within the 31st to 33rd week of post conceptional or postmenstrual age,
whichever is later).
Retinal examinations are repeated every 1- 2 weeks until the retina becomes fully
vascularized or ROP is noted.
If ROP develops, weekly examinations should be performed to watch for possible
progression to threshold disease.
15. d. The early onset of photophobia and nystagmus points to a congenital cone
dysfunction.
The loss of photopic ERG response, including photopic flicker response, and the
patient's essentially normal rod function confirm the generalized cone
abnormality.
Although congenital stationary night blindness (CSNB) can reduce visual acuity
and cause nystagmus, the congenital loss of night vision from rod system
abnormalities would cause an abnormal scotopic ERG response.
CSNB is frequently an X-linked recessive trait that affects males.
In Leber congenital amaurosis, overall vision is very limited because of
generalized retinal dysfunction that causes loss of both rod and cone ERG
responses.
Stargardt disease often becomes evident during the grade school and teenage
years and typically shows a nearly normal rod and cone ERG response.
Achromatopsia causes total color blindness as a result of a congenital absence of
cone photoreceptors.
It has an autosomal recessive inheritance pattern, and its appearance in more than
the current generation is rare.
Ultimate visual acuity ranges from 20/100 to 20/200 and is best in dimmer light or
with sunglasses.
16. a. Acetazolamide has been shown to reduce CME in patients with hereditary
retinal degeneration (retinitis pigmentosa).
CME caused by a central retinal vein occlusion can be treated with intravitreal
injections of steroids or anti-vascular endothelial growth factor drugs.
Underlying causes of hypotony should be treated to reduce CME.
In patients with CME caused by vitreomacular traction, surgery may be indicated
to relieve the traction on the retina.
17. b. In patients with Best disease, the optical coherence tomogram and
fluorescein angiogram can help delineate the structure of vitelliform lesions, and
the EOG is often abnormal.
The ERG pattern, however, does not usually reveal any characteristic defects.
18. a. EOG is most helpful in identifying patients with, or carriers of, Best
disease. Results of optical coherence tomography, ERG, and fluorescein
angiography are typically normal in carriers of the disease.
19. c. AMD, Stargardt disease, and cone dystrophy can all cause RPE changes
similar to those found in chloroquine and hydroxychloroquine toxicity.
Tay-Sachs disease typically causes a cherry-red-spot appearance of the macula,
related to intraretinal storage of ganglioside.
20. d. The coexistence of renal and/or hepatic disease represents a risk factor for
the development of hydroxychloroquine maculopathy; youth, lean body weight,
and northern European ancestry do not.
21. d. The other medications can also cause pigmentary retinopathy. Thus, the
recommendation is to discontinue thioridazine as soon as toxicity is suspected.
Late atrophic changes of the macula can occur after discontinuation.
22. d. Niacin can cause a form of CME in which no late leakage is apparent on the
fluorescein angiogram. The other medications listed are not associated with an
atypical CME.
25. c. Retinal detachments from giant retinal tears, tears of greater than 90, have
a high redetachment rate due to proliferative vitreoretinopathy.
Because of the high risk of failure, the preferred approach would usually include
pars plana vitrectomy, use of perfluorocarbon liquid, laser photocoagulation
demarcation, and complete fluid-gas exchange.
The other options, performed alone, would not be likely to temporarily t1atten or
reattach the retina.
26. d. Repair for acute retinal detachment soon after diagnosis is important to
optimize outcome. Retrospective studies have shown a worsened prognosis in
cases for which surgery was delayed for about 7 days or more from the time of
diagnosis.
However, compared with emergency (same-day) surgery, scheduled surgery has
been associated with similar outcomes and complication rates, and with lower
cost. Nevertheless, because no prospective randomized studies have addressed
this topic, clinical judgment must be exercised.
Eyes with attached maculae or recently detached maculae may benefit from
earlier surgery. In addition, detachments associated with acute giant retinal tears
or superior bullous detachments with the macula remaining attached should be
repaired as soon as possible.
A good peripheral examination at diagnosis of retinal detachment is important to
assess for these factors.
28. b. The staging system applies only to idiopathic macular holes, not traumatic
or disorder associated macular holes.
A stage 2 macular hole is defined as a perifoveal or "can opener" -like hole.
A stage 3 idiopathic macular hole is characterized by an adjacent annulus of
subretinal fluid without a posterior vitreous separation.
A stage 4 macular hole is a full -thickness hole with a posterior vitreous
separation.
Occasionally, idiopathic macular holes that have been repaired surgically will
reopen spontaneously or in relation to cataract surgery.
However, hole reopening is not included in the staging system.
29. b. Vitrectomy for removal of epiretinal membranes is a highly successful
surgery.
The procedure is associated with improvement in visual acuity, reduction in
metamorphopsia, and low rates of recurrent membrane formation. Accelerated
cataract development is the most common complication after vitrectomy for
epiretinal membrane removal.
Other postoperative risks include atrophy, hypertrophy, and migration of RPE
cells, macular edema, glaucoma, and retinal breaks.
Hypotony is a rare postoperative complication. However, when present, it is
usually due to decreased aqueous production or a wound leak rather than
increased trabecular filtration.
RPE disturbances are reported after successful vitrectomy and membrane peeling.
Indistinguishable RPE changes may develop after long-standing venous occlusive
disease.
Cautioning the patient regarding these postoperative complications would be
appropriate given the clinical setting.
33. a. The red laser penetrates through nuclear sclerotic cataracts better than other
wavelengths.
It is minimally absorbed by xanthophyll, possibly reducing the risk of thermal
damage in the treatment of CNV adjacent to the fovea.
It causes deeper burns with a higher rate of patient discomfort and a higher risk of
a "pop effect:'
34. a. Macular xanthophyll readily absorbs blue but minimally absorbs yellow,
red, and infrared wavelengths.
Therefore, the blue wavelength should be avoided during macular laser
photocoagulation in order to minimize thermal retinal damage.
35. a. Small spot size, high intensity, and short duration of laser applications all
increase the risk of a Bruch membrane rupture.
The red laser causes deeper burns with a higher risk of inhomogeneous choroidal
absorption and focal disruption.
7. What is the most common indication for the use of intrastromal corneal ring
segments?
a. hyperopia
b. keratoconus
c. Fuchs dystrophy
d. astigmatism
11. When considering a patient for excimer laser surgery, most surgeons
prefer what minimum safe thickness for the residual stromal bed?
a. 150 m
b. 225 m
c. 200 m
d. 250 m
12. What is the risk of cutting a laser in situ keratomileusis (LASIK) flap with
a mechanical microkeratome on a cornea flatter than 40.00 D?
a. larger than expected diameter flap, with increased risk for a "buttonhole"
b. larger than expected diameter flap, with increased risk for a free cap
c. smaller than expected diameter flap, with increased risk for a "buttonhole"
d. smaller than expected diameter flap, with increased risk for a free cap
13. What is the principal mechanism by which collagen cross linking stabilizes
the cornea?
a. keratocyte apoptosis
b. compaction of stromal lamellae
c. collagen polymerization
d. covalent bonding
15. Which one of the following statements about corneal cross linking is true?
a. It was shown to be safe and effective in post-refractive surgery patients in US
Food and Drug Administration (FDA) trials.
b. It cannot be combined with insertion of intrastromal ring segments.
c. It is an option for patients with keratoconus who have a corneal thickness of
275 m.
d. It may be utilized as a treatment for infectious keratitis.
18. What preoperative test is most crucial for determining the available
strategies for astigmatism correction in the evaluation of a patient for
refractive lens exchange?
a. manual keratometry
b. simulated keratometry from an autorefactor or topographer
c. topography for pattern evaluation
d. Scheimpflug measurement of lenticular astigmatism
19. A 42-year-old man with diabetes mellitus reports worsening distance vision
for 6 months; his findings are as follows: most recent hemoglobin A1c
(HgbA1J value, 9.5; corrected distance visual acuity (CDVA, also called best-
corrected visual acuity), 20/15 in each eye (OD, -2.50 sphere; OS, -2.00 sphere);
and normal ophthalmologic evaluation.
What is the most appropriate refractive treatment?
a. contact lens fitting
b. eyeglass correction
c. repeat refraction in 3- 6 weeks
d. laser refractive surgery
20. What is the best initial therapy for a 53-year-old woman with intermittent
blurred vision and corneal punctate epitheliopathy who underwent
uncomplicated bilateral LASIK 6 weeks previously?
a. antibiotic drops
b. corticosteroid drops
c. non steroidal anti-inflammatory drops
d. preservative-free artificial tear drops
21. A 22-year-old man is referred for a LASIK evaluation. He has noted
worsening visual acuity over the past 3 years that has required several
eyeglass prescription changes. He states that he had good vision with soft
contact lenses as a teenager but that he cannot see well with his current soft
contact lens prescription. A manifest refraction reveals 3.00 D of non
orthogonal astigmatism, and manual keratometry shows irregular mires.
What is the most appropriate test for establishing a diagnosis of forme fruste
keratoconus?
a. corneal pachymetry
b. corneal topography
c. cycloplegic refraction
d. slit-lamp photography
6. d. The longer the incision, deeper the incision, and smaller the optical zone, the
greater the astigmatic correction.
11. d. Leaving a residual stromal bed of less than 250 m thickness puts the patient
at risk for corneal ectasia.
12. d. Corneas flatter than 40.00 D are more likely to have smaller-diameter flaps
and are at increased risk for creation of a free cap. Remember that cutting a flap
with the same blade in a second eye usually results in a thinner (not thicker) flap.
13. d. Corneal collagen cross linking combines riboflavin (vitamin B2), which is a
naturally occurring photosensitizer found in all human cells, and ultraviolet A
(UVA) light to strengthen the biomechanical properties of the cornea via covalent
bonding of the collagen fibrils. Although there may also be a slight flattening of the
cornea, the most important effect of the cross linking is that it stabilizes the corneal
curvature and prevents further steepening and bulging of the corneal stroma.
14. b. The UVA light used to activate riboflavin in the cross linking procedure is
toxic to corneal endothelial cells. In the presence of riboflavin, approximately 95%
of the UVA light irradiance is absorbed in the anterior 300 m of the corneal
stroma.
Therefore, most studies require a minimal corneal thickness of 400 m after
epithelial removal to prevent corneal endothelial damage and secondary corneal
edema by the UVA irradiation.
Thinner corneas may be thickened temporarily with application of a hypotonic
riboflavin formulation prior to UVA treatment.
15. d. Corneal collagen cross linking has had good results in stabilizing ectasia and
reducing both myopia and astigmatism resulting from post- refractive surgical
causes as well as naturally occurring conditions such as keratoconus; it has not yet
been approved by the FDA as safe and effective.
Some investigators have combined cross linking with other refractive modalities
(such as intrastromal rings) with promising early results. Patients with thin corneas
are not candidates for this procedure because of the endothelial toxicity of the UVA
irradiation.
Interestingly, there have been reports of collagen cross linking employed
successfully to treat fungal and bacterial infections of the cornea.
This use may represent a potential new application of this technology.
18. c. Manual keratometry and simulated keratometry values can both provide
information on the amount of regular corneal astigmatism present.
However, neither evaluation can determine irregular corneal astigmatism or
identify a corneal ectatic disorder such as keratoconus or pellucid marginal
degeneration.
Such disorders must be recognized preoperatively in order to decide what treatment
options are available for any residual astigmatism.
Whereas patients with regular astigmatism are potential candidates for a variety of
treatment strategies, including toric IOLs or multifocal IOLs with bioptics
(utilizing LASIK or PRK postoperatively), patients with significant irregular
astigmatism are not candidates for bioptics and may not be suitable for toric IOLs if
the irregularity is too great.
19. c. Elective ocular surgery should not be performed in a diabetic patient with
poor or erratic blood glucose control.
The blood sugar of a patient with diabetes mellitus must be well controlled at the
time of examination to ensure an accurate refraction, as the refractive error may
fluctuate with changes in the blood glucose level.
For this reason, it is also not advised to prescribe eyeglasses or contact lenses in
patients with diabetes mellitus whose blood glucose control is labile.
20. d. Dry eye symptoms after LASIK and PRK (advanced surface ablation) are the
most common adverse effects of refractive surgery.
Corneal nerves are severed when the flap is made, and the cornea overlying the flap
is significantly anesthetic for 3-6 months and even as long as 1 year
postoperatively.
As a result, most patients experience a decrease in tear production. Patients who
had dry eyes prior to surgery or whose eyes were marginally compensated before
surgery may experience more severe symptoms afterward. In addition, patients who
develop dry eyes after LASIK or surface ablation have an abnormal tear film and a
poor ocular surface, leading to reports of fluctuating vision between blinks
intermittently throughout the day.
Frequent application of preservative-free artificial tears often alleviates symptoms.
Additional treatments include topical cyclosporine, lubricant ointments, and
punctal occlusion.
22. c. There are numerous ways to perform IOL calculations in eyes that have
undergone refractive surgery.
Unfortunately, none is perfect. Small, effective central optical zones after refractive
surgery (especially after RK) can lead to inaccurate measurements, because
keratometers and Placido disk-based corneal topography units measure the corneal
curvature several millimeters away from the center of the cornea.
Also, the relationship between the anterior and posterior corneal curvatures may be
altered after refractive surgery (especially after laser ablative procedures), leading
to inaccurate results.
Historical methods and rigid contact lens over refractions are often fairly accurate.
Manual keratometry is often less accurate than automated keratometry. Currently,
the best option for calculation of IOL powers in post-refractive surgery patients is
probably the American Society of Cataract and Refractive Surgery (ASCRS)
Online Post-Refractive IOL Power Calculator. This resource is available on the
websites of the ASCRS and the American Academy of Ophthalmology (AAO) and
is updated with new formulas and information as they become available.