Diseases of the Conjunctiva Practice Questions

Q: All of the following are causes of acute red eye EXCEPT:

Acute macular oedema. ***Acute macular oedema*** - **Macular edema** primarily affects **central vision** and does not typically cause the visible **redness** associated with acute inflammation of the ocular surface or anterior segment. - It involves **fluid accumulation** in the **macula** (the central part of the retina), which is a posterior segment issue and does not present as a red eye. *Conjunctivitis* - **Inflammation** of the **conjunctiva** (the membrane lining the eyelid and sclera) commonly leads to **vasodilatation** and **redness** of the eye. - Often accompanied by **discharge**, **itching**, or a **gritty sensation**. *Acute glaucoma* - An acute rise in **intraocular pressure** (IOP) can cause significant eye **redness** due to **conjunctival injection** and **ciliary flush**. - Other symptoms include **severe eye pain**, **blurred vision**, and **halos around lights**. *Keratitis* - **Inflammation** of the **cornea** typically results in marked **redness**, often with a **ciliary flush** (perilimbal injection) due to perilimbal vascular engorgement. - Associated with **eye pain**, **photophobia**, and potential **vision loss**.

Q: Identify the diagnosis based on the clinical image shown.

Herbert's pits. ***Herbert's pits*** - The image displays characteristic **pits at the limbus**, which are a hallmark of healed follicular conjunctivitis, specifically **Herbert's pits**. - These pits are pathognomonic for **trachoma**, a chronic keratoconjunctivitis caused by *Chlamydia trachomatis*. *Horner-Trantas spots* - These are small, raised, gelatinous white dots found at the limbus, typically containing **eosinophils**. - They are characteristic of **vernal keratoconjunctivitis**, an allergic inflammatory condition, and not seen in the provided image. *Pannus* - **Pannus** refers to the growth of **vascularized connective tissue** onto the cornea. - While pannus is also a feature of trachoma, the image specifically shows distinct limbal pits, rather than diffuse vascularization. *Corneal dystrophy* - **Corneal dystrophies** are a group of inherited, bilateral, and progressive corneal disorders that manifest as opacities or structural changes in the cornea. - The findings in the image, such as pits, are inflammatory in origin and distinct from the typically stromal or epithelial changes seen in corneal dystrophies.

Q: A patient with contact lens use for the past 2 years presents with the ocular findings shown in the image below. What is the most probable diagnosis?

Giant Papillary conjunctivitis. ***Giant Papillary conjunctivitis*** - The image shows **large, elevated papillae** on the **tarsal conjunctiva**, which are characteristic findings of giant papillary conjunctivitis. - This condition is common among **contact lens wearers**, caused by chronic mechanical irritation and an allergic response to lens material or deposits. *Trachoma* - Trachoma is a **chronic infectious disease** caused by *Chlamydia trachomatis*, leading to scarring of the conjunctiva. - It typically presents with **follicles** in the early stages, followed by **scarring** and **pannus formation**, not the large papillae seen here. *Ocular Surface Squamous Neoplasia (OSSN)* - OSSN refers to a spectrum of conditions from **dysplasia to squamous cell carcinoma** affecting the conjunctiva or cornea. - It usually presents as a **gelatinous, fleshy, or leukoplakic lesion**, often at the limbus, which is distinct from the diffuse papillae shown. *Vernal Keratoconjunctivitis* - Vernal keratoconjunctivitis (VKC) is a **severe form of allergic conjunctivitis** but primarily affects children and young adults with a history of atopy. - While it can cause large papillae (cobblestone papillae), it is not specifically associated with contact lens wear and usually has other systemic allergic manifestations.

Q: Identify the correct sequence of staining in dry eyes? 1. Fluorescein stain 2. Lissamine green 3. Rose Bengal stain

iii, ii, i. ***iii, ii, i*** - The correct order for staining in dry eyes is **Rose Bengal, Lissamine Green, and then Fluorescein**. This sequence minimizes the discomfort and potential interference between the dyes. - **Rose Bengal** and **Lissamine Green** stain devitalized or damaged epithelial cells and mucus, while **Fluorescein** stains areas where the epithelium is absent, indicating corneal or conjunctival abrasions or erosions. *i, iii, ii* - This sequence is incorrect because applying fluorescein first could mask the interpretation of epithelial damage by Lissamine Green or Rose Bengal, as it highlights epithelial defects rather than devitalized cells. - The dyes should be applied in an order that optimizes the visualization of different aspects of ocular surface health. *i, ii, iii* - Applying **Fluorescein** first is generally not recommended as it can spread over the ocular surface and potentially interfere with the specific staining patterns of other vital dyes like Lissamine Green or Rose Bengal. - This order does not follow the standard clinical practice for efficient and accurate dry eye assessment. *ii, iii, i* - While Lissamine Green can be used before Fluorescein, placing Rose Bengal after Lissamine Green but still before Fluorescein is not the optimal sequence. - The standard practice aims to assess different layers or types of damage sequentially for a comprehensive evaluation.

Q: Which of the following is true about pterygium?

Conjunctival invasion making a flap over cornea. ***Conjunctival invasion making a flap over cornea*** - A **pterygium** is characterized by the growth of **fibrovascular tissue** from the conjunctiva onto the cornea. - This growth typically forms a **triangular flap**, with its apex extending towards the center of the corneal surface. *Fatty deposition of sclera* - This description is more indicative of **pinguecula**, which is a **yellowish, fatty deposit** on the conjunctiva, usually on the nasal side, but it does not invade the cornea. - Unlike pterygium, a **pinguecula** remains confined to the conjunctiva and does not grow across the limbus onto the cornea. *Inflammation of cornea* - While a pterygium can sometimes cause irritation or inflammation, its primary characteristic is a **degenerative growth of tissue**, not primarily an inflammatory condition of the cornea itself. - **Keratitis** refers to inflammation of the cornea, which can have various causes, but it is not the defining feature of pterygium. *Dead epithelial debris accumulation* - The accumulation of dead epithelial debris is not the principal histological feature of a pterygium. - Pterygium involves **hyperplasia of conjunctival epithelium** and **subepithelial fibrovascular tissue growth**, not merely dead cell accumulation.

Q: Herbert's pits are seen in:

Chlamydial conjunctivitis. ***Chlamydial conjunctivitis*** - **Herbert's pits** are pathognomonic for **trachoma**, a chronic form of chlamydial conjunctivitis caused by *Chlamydia trachomatis* serovars A-C. - They represent healed **follicles** on the superior tarsal conjunctiva, leading to characteristic stellate or linear scarring. *Gonococcal conjunctivitis* - This is an **acute, severe bacterial infection** that typically causes copious purulent discharge and significant edema. - It does not lead to the formation of Herbert's pits, which are sequelae of chronic follicular inflammation. *Vernal conjunctivitis* - A form of chronic allergic conjunctivitis, characterized by **"cobblestone papillae"** on the upper tarsal conjunctiva and **Horner-Trantas dots** at the limbus. - It is not associated with Herbert's pits; its pathophysiology involves mast cell degranulation and allergic inflammation. *Atopic conjunctivitis* - This is often seen in individuals with **atopic dermatitis, asthma, or allergic rhinitis**, presenting with itching, redness, tearing, and sometimes corneal complications. - It does not manifest with follicles or subsequent scarring like Herbert's pits, which are specific to trachoma.

Q: NOT a feature of trachoma:

Chalazion. ***Chalazion*** - A **chalazion** is a **lipogranulomatous inflammation** of a **meibomian gland** and is not directly caused by *Chlamydia trachomatis* infection, though chronic inflammation could theoretically predispose to it. - While chronic inflammation of the eyelids in trachoma can cause various complications, a chalazion is a distinct condition related to meibomian gland dysfunction and is not a direct, defining feature of trachoma. *Entropion* - **Entropion**, the **inward turning of the eyelid margin**, is a severe late complication of trachoma caused by conjunctival scarring and contraction. - This inward turning leads to **trichiasis** (**misdirected eyelashes**), which abrades the cornea. *Corneal opacity* - **Corneal opacity** is a common and serious consequence of chronic trachoma, resulting from repeated **corneal abrasions** by misdirected eyelashes (trichiasis) and chronic inflammation. - This scarring can lead to **severe vision impairment** and **blindness**. *Herbert's pits* - **Herbert's pits** are characteristic depressions on the **limbus** (corneoscleral junction) formed after the resolution of **limbal follicles** in chronic trachoma. - They are a diagnostic sign of past or present trachomatous infection.

Q: Gold standard procedure to reduce recurrence of pterygium after surgical excision is

Conjunctival autograft. ***Conjunctival autograft*** - **Conjunctival autografting** involves transplanting a piece of healthy conjunctiva from the superior bulbar conjunctiva to the bare scleral bed after pterygium excision, acting as a barrier to fibrovascular proliferation. - This technique has consistently shown the **lowest recurrence rates** in comparative studies, making it the **gold standard** for preventing pterygium recurrence due to its high success rate and safety profile. *Thiotepa* - **Thiotepa** is an **antimetabolite** that inhibits DNA synthesis and cell proliferation, used topically post-excision to reduce recurrence by suppressing fibroblast activity. - While it can lower recurrence rates compared to simple excision, its efficacy is generally **less than conjunctival autografting**, and it carries risks of corneal toxicity and limbal stem cell deficiency. *Amniotic membrane grafting* - **Amniotic membrane grafting** involves placing processed amniotic membrane over the scleral bed, which has anti-inflammatory, anti-scarring, and pro-epithelialization properties. - It is an effective option, especially for **large pterygia** or for patients at high risk of recurrence, but its recurrence rates are generally **not as low as those achieved with conjunctival autografting**, and the graft can sometimes detach. *B- radiation* - **Beta-radiation** (strontium-90) is a form of adjuvant therapy applied to the scleral bed immediately after pterygium excision to inhibit fibroblast proliferation and reduce recurrence. - It is effective but associated with potential complications such as **scleral melt**, corneal scarring, and cataract formation, making it a less preferred option than conjunctival autografting, especially in primary cases.

Q: Treatment of gonococcal ophthalmia neonatorum does not include:

IV bacitracin. ***IV bacitracin*** - **Bacitracin is NEVER administered intravenously** due to significant nephrotoxicity risk. - It has **no role** in the treatment of gonococcal ophthalmia neonatorum, neither systemically nor as standard topical therapy. - This is the **correct answer** to what is NOT included in treatment. *Topical bacitracin* - While topical bacitracin **can be used as adjunct therapy** in neonatal conjunctivitis, it is not the primary or preferred topical agent. - Standard topical therapy typically uses **erythromycin or tetracycline ointment** rather than bacitracin. - However, it may still be employed in some treatment protocols, making it part of potential treatment options. *Ceftriaxone IM* - **Ceftriaxone 50 mg/kg IM (maximum 125 mg) as a single dose** is the **first-line systemic treatment** for gonococcal ophthalmia neonatorum. - This provides adequate bactericidal levels against *Neisseria gonorrhoeae* and prevents complications including corneal perforation and systemic dissemination. - This is **definitely included** in standard treatment protocols. *Topical atropine* - **Atropine** is a cycloplegic agent with **no antibacterial activity**. - It is NOT part of the standard treatment protocol for gonococcal ophthalmia neonatorum. - While it might be considered if severe iritis develops as a complication, it is not a routine component of treatment.

Q: A 22-year-old Air-force test pilot presents after flying a sortie. He reports no pain or vision changes. Eye examination reveals a localized red patch on the sclera. What is the most likely diagnosis?

Subconjunctival hemorrhage. ***Subconjunctival hemorrhage*** - A **localized red patch on the sclera** with no pain or vision changes, especially after activities that can increase venous pressure (like flying a sortie or straining), is characteristic of a **subconjunctival hemorrhage**. - It results from the rupture of small blood vessels beneath the conjunctiva, causing blood to pool. *Hyphema* - This involves blood in the **anterior chamber of the eye**, usually visible as a fluid level and often causing pain or blurred vision. - It typically results from **trauma** and is not described as a localized red patch on the sclera. *Keratitis* - **Keratitis** is inflammation of the cornea, causing pain, redness, photophobia, and often blurred vision. - The patient has no pain or vision changes, and the presentation is a localized scleral patch, not diffuse corneal involvement. *Allergic conjunctivitis* - Presents with **redness**, itching, tearing, and often bilateral involvement, sometimes with discharge. - The description of a solitary, localized red patch without other allergic symptoms makes this diagnosis unlikely.

Question 1

All of the following are causes of acute red eye EXCEPT:

Accepted Answer

Acute macular oedema

Answer

Conjunctivitis

Answer

Acute glaucoma

Answer

Keratitis

Question 2

Identify the diagnosis based on the clinical image shown.

Accepted Answer

Herbert's pits

Answer

Horner-Trantas spots

Answer

Pannus

Answer

Corneal dystrophy

Question 3

A patient with contact lens use for the past 2 years presents with the ocular findings shown in the image below. What is the most probable diagnosis?

Accepted Answer

Giant Papillary conjunctivitis

Answer

Trachoma

Answer

Ocular Surface Squamous Neoplasia (OSSN)

Answer

Vernal Keratoconjunctivitis

Question 4

Identify the correct sequence of staining in dry eyes?

1. Fluorescein stain
2. Lissamine green
3. Rose Bengal stain

Accepted Answer

iii, ii, i

Answer

i, iii, ii

Answer

i, ii, iii

Answer

ii, iii, i

Question 5

Which of the following is true about pterygium?

Accepted Answer

Conjunctival invasion making a flap over cornea

Answer

Fatty deposition of sclera

Answer

Inflammation of cornea

Answer

Dead epithelial debris accumulation

Question 6

Herbert's pits are seen in:

Accepted Answer

Chlamydial conjunctivitis

Answer

Gonococcal conjunctivitis

Answer

Vernal conjunctivitis

Answer

Atopic conjunctivitis

Question 7

NOT a feature of trachoma:

Accepted Answer

Chalazion

Answer

Entropion

Answer

Corneal opacity

Answer

Herbert's pits

Question 8

Gold standard procedure to reduce recurrence of pterygium after surgical excision is

Accepted Answer

Conjunctival autograft

Answer

Thiotepa

Answer

Amniotic membrane grafting

Answer

Beta-radiation

Question 9

Treatment of gonococcal ophthalmia neonatorum does not include:

Accepted Answer

IV bacitracin

Answer

Topical bacitracin

Answer

Ceftriaxone IM

Answer

Topical atropine

Question 10

A 22-year-old Air-force test pilot presents after flying a sortie. He reports no pain or vision changes. Eye examination reveals a localized red patch on the sclera. What is the most likely diagnosis?

Accepted Answer

Subconjunctival hemorrhage

Answer

Hyphema

Answer

Keratitis

Answer

Allergic conjunctivitis

Diseases of the Conjunctiva — MCQs

Diseases of the Conjunctiva — MCQs

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