Ophthalmology Exam Master Questions With Already Passed Solutions.

Ophthalmology Exam Master Questions With Already Passed Solutions. A client comes into the clinic with a complaint of flaking and scaling around her lashes, along with itching and burning sensation, occurring over the past year. She has also noted her lid margins are red, and some of her lashes are missing. Her history is significant for seborrheic dermatitis of the scalp, eyebrows, and external ears, and diabetes. What is the most likely diagnosis? Blepharitis Chalazion Conjunctivitis Ectropion Foreign Body Blepharitis Blepharitis may be seborrheic or ulcerative. Seborrheic (non-ulcerative) blepharitis is commonly associated with seborrhea of the face, eyebrows, external ears, and scalp. Inflammation of the eyelid margins occurs, with redness, thickening, and often the formation of scales and crusts or shallow marginal ulcers. Ulcerative blepharitis is caused by bacterial infection (usually staphylococcal) of the lash follicles and the meibomian glands. Removal of crusts, topical antibiotics, and /or oral antibiotics remains the mainstay of treatment. A 64-year-old African-American man presents to the emergency department after he went blind in his right eye "out of the blue" 20 minutes ago. There is no pain associated with his symptoms and he is not nauseated. Past medical history is positive for DMII for the past ten years. The pupil reaction on the left side is normal with pressure of 17mmHg. Right pupil evaluation reveals no reaction to light or accommodation with pressure of 20mmHg. Right eye ophthalmoscopy reveals arteriolar narrowing, vascular stasis, and "boxcar" pattern. What is the most likely diagnosis? Occlusion of the central retinal artery Acute glaucoma attack Subconjunctival hemorrhage Retinal detachment Macular degeneration Occlusion of the central retinal artery The symptoms described above are typical for occlusion of the central retinal artery, which is a branch of the ophthalmic artery, in turn a branch of the internal carotid artery. The "boxcar" pattern is segmentation of the venous blood column, bilateral boxcar ring is a useful sign of circulatory arrest and death. Acute central artery occlusion is an emergency, since it results in permanent blindness if circulation is not restored within 30-60 minutes. A 36-year-old woman presents with a small and irregular right pupil. On exam, you note that the pupil does not respond to direct or consensual light stimuli; however, it becomes smaller during an accommodation testing. What is the most likely diagnosis? Transient ischemic attack (TIA) Retinal artery occlusion Retinal vein occlusion Tertiary syphilis Herpes simplex keratitis Tertiary syphilis The clinical picture is suggestive of tertiary syphilis; more specifically, it is likely tabes dorsalis. The pupil describe here is the Argyll Robertson pupil. The pupil reacts poorly to light, but it reacts well to accommodation. A 27-year-old woman presents with a 3-day history of left eye pain. The patient notes sensitivity to light, and she comments that her eye throbs in pain at night. On physical examination, you note a redness and loss of visual acuity. What would be an appropriate treatment for this patient? Cool compresses and artificial tears Cortisporin ointment Dexamethasone and homatropine ophthalmic drops Oral acyclovir IV acetazolamide Dexamethasone and homatropine ophthalmic drops The clinical picture is suggestive of uveitis. Patients with uveitis usually note redness, pain, photophobia, and visual loss. Treatment is with topical steroids and a dilating agent to relieve the discomfort. There are multiple causes of uveitis, but it is primarily immunogenic. A 1.5-year-old boy presents with a squint in the left eye. His mother informed you that the child's eyes were quite normal until about 2 months ago, when she noticed asymmetric movements of her son's eyes. She also felt that the child could not see properly with his left eye. There is no history of trauma to the eye. Child was born at full term and his growth and development were within normal limits. Eye examination showed both eyeballs were equal in size. There was loss of vision in the left eye and a convergent squint in the same eye. Fundus examination showed absence of red reflex in the left eye, and instead a white pupillary reflex (leukocoria) was seen. X-ray of the skull showed calcification within the globe. What is the most likely diagnosis? Retinal detachment Congenital cataract Retinoblastoma Congenital glaucoma Persistent hyperplastic primary vitreous Retinoblastoma The most likely diagnosis is retinoblastoma, as it is the most common primary ocular tumor in children below 5 years of age. 90% of cases are diagnosed below 3 - 4 years of age. The index case is a 1.5-year-old boy who has presented with a recent appearance of squint and absence of normal red reflex in the left eye, replaced instead by a white pupillary reflex (leukocoria). This is due to reflection of light from the white-colored tumor and loss of vision in that eye. The diagnosis is further supported by calcification seen in the globe in the X-ray of the skull. Fundoscopy may show the tumor as a white mass, which may be small and flat or may be large and protuberant. Orbital inflammation, hyphema, and irregular pupil are seen in advanced stages of the disease. Retinoblastoma gene is a recessive gene located on the chromosome13 at the 13q 14 regions, and the tumor may arise from any of the nucleated layers of the retina. Besides direct observation, ultrasonography or CT scan may help to confirm the diagnosis and demonstrate calcification within the mass. As biopsy can lead to the spread of the tumor, histopathological confirmation of the tumor can be made only after removal of the affected eye A 32-year-old woman presents with a 3-day history of irritation, burning, itching, and redness of both eyelids. She denies fever, visual changes, and photophobia. On physical examination, you note the presence of scales clinging to the eyelids bilaterally. What is the proper management in this case? Daily cleaning with a damp cotton applicator and baby shampoo Short-term oral antibiotic therapy for 7 days Short-term oral corticosteroid therapy for 14 days Topical corticosteroid eye drops for 10 days Prompt ophthalmologist referral Daily cleaning with a damp cotton applicator and baby shampoo The scenario presented above depicts a patient with anterior blepharitis, which is a common disorder seen in primary care; it typically consists of a recurrent bilateral inflammation of the lid margins that involves the eyelid skin, eyelashes, and associated glands. Commonly, the underlying cause is seborrhea, which usually originates in the scalp, eyebrows, or ears. Sometimes, anterior blepharitis can be ulcerative, and the origin in the presented case is staphylococci. Anterior blepharitis can typically be resolved and controlled by cleaning the affected areas daily using a damp cotton applicator, warm water, and a baby shampoo mixture. The object of the daily cleaning is to remove the visible scales as efficiently as possible. A 16-year-old boy was at his team basketball practice when a team member forcefully jabbed his fingers into the 16-year-old's left eye while trying to block his shot. He felt sharp, blinding pain and has had much tearing. He was taken out of practice, ice applied, and sent to you for evaluation. Which examination should always be performed initially following direct eye trauma? Examine globe and sclera for hyphema Observe extraocular movements for symmetry and nystagmus Check pupil size, symmetry, and reaction to light Evaluate visual acuity with corrected vision in place Check for infraorbital nerve injury Evaluate visual acuity with corrected vision in place The initial goal of management is to provide timely recognition of injury to allow for management and stabilization of the condition. On the sidelines, this should always begin with evaluation of visual acuity with corrected vision in place, while taking a thorough history. A 64-year-old Asian man presents with a 1-hour history of severe right eye pain that started while he was watching a movie at the theater. He notes blurred vision and seeing halos around lights when using his right eye. He denies loss of vision, trauma, discharge, and any symptoms in the left eye. Last eye exam was 6 months ago, which resulted in new glasses. Past medical history is negative, and the patient denies any allergies. On physical exam, visual acuity is OS 20/25, OD is 20/70, and OU is 20/40. Pupil on right eye is 7 mm, and left eye is 3 mm. Right pupil is non-reactive to light; left pupil is reactive to light. Right cornea is steamy in appearance, and left cornea is clear. What is the most likely diagnosis? Acute angle-closure glaucoma Chronic glaucoma Cataract Acute uveitis Acute conjunctivitis Acute angle-closure glaucoma Acute angle-closure glaucoma is frequent among the older age group and in Asians. Essential for diagnosis is rapid onset of severe pain and profound vision loss/blurring with halos around lights. On physical exam, a fixed and dilated pupil as well as red eye with a steamy cornea is the hallmark. A 14-year-old girl has had a small, slightly tender swelling in her left upper eyelid for 2 - 3 days that has gradually enlarged, becoming round and painless. There has not been any drainage, visual changes, or itching noted. She has been well otherwise. On exam, vitals are normal, extraocular muscles are intact, and pupils are equal and reactive to light. Her left upper eyelid eyelid has a 1.5 cm round, nontender, swollen mass that is mildly erythematous without any drainage. The underside of the lid is grayish-red. Based on these findings, what is the most likely diagnosis? Chalazion Blepharitis Dacryocystitis Dacryostenosis Hordeolum Chalazion A chalazion is an enlargement of a deep oil gland in the eyelid that results from an obstruction of the gland opening at the edge of the eyelid. Associated factors include immunodeficiency, leishmaniasis, seborrhea, high blood lipid concentrations, acne rosacea, tuberculosis, chronic blepharitis, carcinoma, and viral infections. Most will disappear without treatment after 1 to 3 months. If hot compresses are applied several times a day, it may disappear sooner. Persistent lesions that cause changes in vision should be examined by an ophthalmologist for possible drainage by incision and curettage or intralesional corticosteroid injection. A 22-year-old woman presents with a 1-day history of foreign body sensation in her right eye. She woke up with pain in the right eye, and she immediately had trouble opening her eye. She wears soft contact lenses and does not remember how long the last pair was in for. She removed her contact lenses the night before the pain started. There was no trauma. Visual acuity was 20/40 O.U. without corrective lenses, and extraocular movements were within normal limits. With fluorescein stain, a defect is noted; it is round and found at the center of the cornea. No foreign bodies are noted. What intervention is indicated? Pressure patch Trifluridine drops Ketorolac 0.5% solution Ciprofloxacin 0.3% solution Sulfacetamide 10% solution Ciprofloxacin 0.3% solution The correct answer is ciprofloxacin 0.3%; the patient has a corneal abrasion due to contact lenses. Ciprofloxacin covers pseudomonas, and pseudomonas should always be covered when someone gets a corneal abrasion from contact lenses. A 70-year-old man presents with paralytic strabismus with maximal esotropia as he gazes to the left. Which of the following nerves is most likely affected in this case? Left fourth cranial nerve Left sixth cranial nerve Right fourth cranial nerve Right sixth cranial nerve Right third cranial nerve Left sixth cranial nerve The correct answer is the left sixth cranial nerve. This nerve abducts the eyeball and paralysis of this nerve results in the inability of the left eye to gaze laterally causing maximal esotropia with left gaze. A 34-year-old woman presents to your office to establish care. Her past medical history is significant for gastritis. She has no other medical problems. As part of your new patient assessment, you perform a neurological examination. On confrontation with visual field testing, you note bilateral temporal field defects, specifically a bitemporal non-homonymous hemianopsia. The remainder of your neurological evaluation is unremarkable. What would be your next step in the management of this patient? Refer the patient to the emergency room for evaluation of a possible stroke Order an outpatient MRI of the brain Check thyroid function tests Check an EKG in your office Consult with ophthalmologist for possible glaucoma Order an outpatient MRI of the brain Bitemporal visual field loss localizes to the optic chiasm. In a 34-year-old patient, the most likely cause is a pituitary tumor. The next step in management would be to obtain brain imaging to verify the presence of a lesion and to evaluate its extent. A 62-year-old woman with a history of breast cancer and rheumatoid arthritis presents with stiff neck and severe headache that started a couple of days ago; symptoms are worsening. Upon awakening the morning of presentation, she felt nauseated and vomited twice. Your examination shows right-sided hemiparesis and dilated and nonreactive left pupil. What will be your next step? Fundoscopic examination Lumbar puncture Perform doll's eye maneuver NMR Chest X-ray Fundoscopic examination Having a history of breast cancer and signs of possible intracranial hypertension, your patient may have metastatic tumor in the brain. Right-sided hemiparesis and dilated nonreactive pupil on the left point to the compression from the left side. While in the office, she should should be examined for the presence of papilledema. Papilledema will confirm your suspicion that she has transtentorial herniation, in which brain tissue bulges out of the cranium through the tentorial notch because of the increased intracranial pressure. You should schedule Nuclear Magnetic Resonance (NMR) of the endocranium. While waiting for NMR, a simple fundoscopic examination will contribute to your diagnosis. A 17-year-old baseball player presents to the clinic after being struck in the eye with a baseball. On examination, you note bright red blood in the anterior chamber. What is your initial diagnosis? Corneal abrasion Pinguecula Retinal detachment Hyphema Hypopyon Hyphema The clinical picture is suggestive of a hyphema. Hyphema is defined as hemorrhage into the anterior chamber. A 40-year-old man presents with severe pain in his left eye, decreased vision, nausea, and abdominal pain. On examination, the patient's left pupil is moderately dilated and nonreactive. The cornea is "steamy" in appearance and generally the eye is red. What do you suspect is the cause? Conjunctivitis Acute uveitis Acute angle-closure glaucoma Corneal ulcer Corneal infection Acute angle-closure glaucoma This patient has acute angle-closure glaucoma. The typical characteristics of this condition are all exhibited by this patient (i.e., steamy cornea, severe pain, blurred vision, dilated, and nonreactive pupil). A physical exam finding in a patient with acute uveitis would be a small pupil. In addition to these symptoms, patients may also present with abdominal pain. A corneal infection and corneal ulcer would cause circumcorneal injection and watery or purulent discharge. A 33-year-old man presents with acute left eye pain. He was working in his garage on a woodworking project, and as he hammered in a nail, he felt that something hit him in the left eye. On examination, you note that the left pupil has a teardrop appearance. What diagnostic test/procedure will most likely confirm your diagnosis? Flourescein stain An X-ray of the orbits Test extra ocular movements (EOMs) Check visual acuity Test intraocular pressure An X-ray of the orbits The clinical picture is suggestive of an intraocular foreign body or penetrating injury to the eye. This is commonly seen in individuals with a history of pounding on metal or using grinding equipment. The patient may give a history of "something hitting my eye" or "something was pulled out of my eye. His pupil is teardrop shaped, indicating penetration of the globe. An X-ray or CT scan of the orbit should be ordered to rule out radiopaque foreign bodies. Referral to an ophthalmologist is recommended. A 68-year-old woman presents with episodic, monocular blindness lasting typically less than 5 minutes described as a curtain moving vertically over her visual field. She denies pain or other related vision symptoms. Fundoscopic exam reveals no significant abnormality. What is the most likely cause of the condition described? Detached retina Retinal artery emboli Retinal vein occlusion Papilledema Macular degeneration Retinal artery emboli The answer is retinal artery emboli, as the diagnosis for this patient is amaurosis fugax. Amaurosis fugax is characterized by brief episodes of monocular blindness caused by retinal artery emboli, often from ipsilateral carotid disease. Carotid stenosis is best evaluated using intra-arterial angiography. To reduce stroke risk in patients with carotid disease who experience transient vision loss, an anti-platelet drug such as aspirin should be used. A 23-year-old man presents 2 hours after being involved in a road traffic accident in which he sustained right-sided periorbital injuries. He is seeing double; he denies headache, vomiting, and loss of consciousness. On examination, he is alert and oriented in time, space, situation, and person. His right eye is deviated downwards and temporally. What finding would you also expect to find in this patient? Loss of the corneal reflex Ptosis Pupillary constriction Corneal anesthesia Eye adduction Ptosis The clinical picture is suggestive of injury to the oculomotor nerve, which is the 3rd cranial nerve. Patients usually present with diplopia, which is also known double vision. They may also mention the inability to see with 1 eye if the ptosis is severe enough to cover the pupil. They may also mention blurred vision and a glare in bright lights due to the mydriasis. A 25-year-old male medical resident presents with 'acute red eyes' with copious watery discharge. He also notes some aversion to bright light. While rubbing his left eye, he describes a sensation of a 'gritty' foreign body. Other than the aversion to bright light, he denies any visual disturbance or pain. On physical exam, the conjunctiva of both eyes are injected and mildly edematous. The remainder of the exam is within normal limits. What is the most likely diagnosis? Allergic conjunctivitis Bacterial conjunctivitis Chlamydial conjunctivitis Contact lens abuse Hyperacute conjunctivitis Allergic conjunctivitis Allergic conjunctivitis is almost always secondary to environmental allergens; therefore, it usually presents with bilateral symptoms. The other hallmark symptom would be pruritus, which might be suggested by the rubbing of his eye. A 12-year-old boy presents with fatigue and jaundice. History obtained from the patient and his mother is negative for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On eye examination using a slit-lamp, you note brown-yellow rings encircling the iris in the rim of the cornea bilaterally. You order a serum ceruloplasmin level, which is reported as low. What is this diagnostic corneal pigmentation known as? Fleischer's rings Kayser-Fleischer rings Rust rings Arcus juvenilis Pinguecula Kayser-Fleischer rings The correct answer is Kayser-Fleischer rings, which are the result of accumulation of copper in the cornea and the most unique sign of Wilson's disease. A 48-year-old Caucasian man presents with acute onset of blurring of vision and severe pain in the left eye that began 1/2 hour ago. He notes seeing halos with his left eye; he is also experiencing nausea and vomiting; those symptoms started at the same time as the pain. The patient reports that he was relaxing on his porch when the pain started. His vital signs are: temp. 36.9 C, pulse 90/min, BP 130/90 mm Hg, and resp. 20/min. Physical examination reveals a shallow anterior chamber, a hazy cornea, a fixed, moderately dilated pupil, and ciliary injection. What would be the next step in the management of this patient? Lumbar puncture X-ray to rule out a foreign body Topical atropine to the eye to facilitate ophthalmoscopy Tonometry Discharge with topical antibiotic drops for the eye Tonometry The history and physical examination of this patient are suggestive of acute angle-closure glaucoma, which can be easily confirmed by measuring the intraocular pressure using a tonometer (e.g., the Schiötz tonometer). Acute angle-closure glaucoma develops in individuals with pre-existing anatomic narrowing of the anterior chamber, which is seen mainly in hypermetropes. The condition usually develops in the twilight hours, which is when the pupil is dilated in response to the low level of illumination. It may also occur with pupillary dilation for ophthalmoscopy, so topical atropine would be contraindicated.