Diseases of the Retina Practice Questions

Q: A prematurely born baby at 29 weeks is examined at 42 weeks post-conceptional age and shows stage 2 zone 1 ROP with plus disease in both eyes. How will you manage this patient?

Laser photocoagulation of both eyes. ### Explanation The management of Retinopathy of Prematurity (ROP) is guided by the **ETROP (Early Treatment for ROP) Study** criteria, which defines "Type 1 ROP" requiring urgent treatment. **1. Why Option B is Correct:** The patient has **Stage 2, Zone 1 with Plus disease**. According to the ETROP criteria, **Type 1 ROP** includes: * Zone I: Any stage with plus disease (This patient's case) * Zone I: Stage 3 without plus disease * Zone II: Stage 2 or 3 with plus disease The presence of **Plus disease** (dilatation and tortuosity of retinal vessels) in Zone 1 indicates high risk for progression to retinal detachment. The standard of care is urgent **Laser Photocoagulation** (usually peripheral ablation of the avascular retina) within 48–72 hours to induce regression of the disease. **2. Why Other Options are Incorrect:** * **Option A:** Waiting one week is dangerous. Type 1 ROP is "sight-threatening" and requires treatment within 72 hours. * **Option C:** ROP is a bilateral disease. If both eyes meet the criteria for Type 1 ROP, both must be treated simultaneously to prevent blindness. * **Option D:** Vitreoretinal surgery is reserved for **Stage 4** (partial retinal detachment) or **Stage 5** (total retinal detachment). **3. Clinical Pearls for NEET-PG:** * **Screening Criteria (India):** Birth weight <1750g or Gestational Age <34 weeks. * **First Screening:** Should be done at 4 weeks of life (or 3 weeks if born <28 weeks). * **Plus Disease:** Mandatory for treatment in Zone II, but in Zone I, Stage 3 alone warrants treatment. * **Anti-VEGF (Ranibizumab/Bevacizumab):** An alternative to laser, especially useful in Zone 1 or Aggressive Posterior ROP (AP-ROP), as it allows for continued vessel growth. * **Zone 1:** The most critical area (centered on the disc, twice the distance from the disc to the fovea).

Q: Which of the following statements is FALSE regarding Stargardt's disease?

It is autosomal dominant.. ### Explanation **1. Why Option A is the Correct (False) Statement:** Stargardt’s disease is the most common hereditary macular dystrophy. The underlying medical concept is a mutation in the **ABCA4 gene**, which is inherited in an **Autosomal Recessive (AR)** pattern, not autosomal dominant. This mutation leads to the accumulation of toxic lipofuscin (all-trans-retinal) in the Retinal Pigment Epithelium (RPE), resulting in progressive central vision loss. **2. Analysis of Other Options:** * **Option B (No family history):** Since it is an autosomal recessive condition, it often appears sporadically in a single generation without a prior family history, making this statement clinically plausible. * **Option C (Beaten bronze appearance):** This is the classic pathognomonic description of the macula in advanced Stargardt’s. It is often accompanied by "pisciform" (fish-shaped) yellowish-white flecks at the level of the RPE (Fundus Flavimaculatus). * **Option D (ERG and EOG abnormal):** In the early stages, electrophysiological tests may be normal. However, as the disease progresses and involves the diffuse RPE and photoreceptors, both the **Electroretinogram (ERG)** and **Electro-oculogram (EOG)** become subnormal/abnormal. **3. High-Yield Clinical Pearls for NEET-PG:** * **Silent Choroid:** On Fundus Fluorescein Angiography (FFA), the most characteristic sign is a "dark/silent choroid" due to the masking of background choroidal fluorescence by lipofuscin deposits. * **Presentation:** Typically occurs in the 1st or 2nd decade of life with bilateral, symmetrical decrease in central vision. * **Differential:** Distinguish from Best’s Disease, which is Autosomal Dominant and shows an abnormal EOG with a normal ERG.

Q: A myopic patient presents with complaints of flashes and floaters. On examination, a deep anterior chamber is seen. What is the likely diagnosis?

Rhegmatogenous retinal detachment. ***Rhegmatogenous retinal detachment***- The presence of **flashes (photopsia)** and **floaters** signifies acute **vitreoretinal traction** leading to a retinal break (*rhegma*), a classic presentation of RRD, especially in a **myopic** eye.- A **deep anterior chamber** can indicate **hypotony** (low intraocular pressure), which frequently occurs in RRD due to increased uveoscleral outflow from the fluid egress through the retinal break.*Exudative retinal detachment*- This type is caused by underlying processes like inflammation or tumors and is characterized by a lack of **retinal break** and, therefore, typically does **not** cause flashes or floaters associated with vitreous traction.- The subretinal fluid in this condition classically **shifts** upon changing head position, which is a key differentiating feature.*Tractional retinal detachment*- This form is caused by the contraction of **fibrovascular membranes** on the retinal surface, most commonly seen in advanced **proliferative diabetic retinopathy**.- It is usually slowly progressive and does **not** typically present acutely with the prominent **flashes** and **floaters** that suggest a fresh retinal tear.*Central serous retinopathy*- This condition involves fluid accumulation localized beneath the macula, leading to symptoms like **metamorphopsia** and central scotoma, without involving the peripheral retina.- It does **not** cause a generalized retinal detachment, significant **flashes** and **floaters**, or changes in the **anterior chamber depth**.

Q: A patient presents with vision problems and has a history of cataract surgery. OCT finding is shown below. What is the syndrome most likely associated with these findings?

Irvine-Gass Syndrome. ***Irvine-Gass Syndrome*** - This syndrome is defined as the development of **cystoid macular edema (CME)** after intraocular surgery, most commonly **cataract surgery**, which matches the patient's history. - The Optical Coherence Tomography (OCT) image clearly shows characteristic **intraretinal fluid-filled cysts** and thickening in the macular region, which are hallmark signs of CME. *Posner-Schlossman Syndrome* - This condition, also known as glaucomatocyclitic crisis, involves recurrent episodes of **acute unilateral uveitis** and **high intraocular pressure**. - While inflammation can cause CME, it is not the primary feature, and the diagnosis relies on signs of anterior chamber inflammation and pressure spikes, not postoperative macular changes. *Central Serous Retinopathy* - This condition is characterized by the accumulation of **subretinal fluid**, creating a serous detachment of the neurosensory retina, which appears as a large fluid-filled space under the retina on OCT. - The provided OCT shows **intraretinal cysts**, not subretinal fluid, which is the key differentiating feature from CSR. *Elschnig Pearls* - These are a type of **posterior capsule opacification (PCO)**, a common complication of cataract surgery where residual lens epithelial cells proliferate on the posterior capsule. - PCO causes blurry vision by obstructing the visual axis but is a condition of the lens capsule, not the retina, and would not produce the macular edema seen on this OCT.

Q: Fundoscopy findings are shown in the image below. What is the most likely diagnosis?

CRAO. ***CRAO*** - The fundoscopy image shows a pale retina with a characteristic **cherry-red spot** at the macula, which is pathognomonic for Central Retinal Artery Occlusion (CRAO). - This appearance results from ischemia and edema of the inner retinal layers, which makes the retina appear pale, while the fovea, supplied by the choroid, retains its normal reddish color. *CRVO* - Central Retinal Vein Occlusion (CRVO) typically presents with a dramatic “**blood and thunder**” fundus, featuring widespread retinal hemorrhages, dilated tortuous veins, and optic disc swelling, none of which are seen here. - Vision loss in CRVO is usually subacute and variable, unlike the sudden, profound, and painless vision loss characteristic of CRAO. *Diabetic retinopathy* - Key findings in diabetic retinopathy include **microaneurysms**, **dot-and-blot hemorrhages**, **hard exudates**, and **cotton-wool spots**, which are absent in this image. - Proliferative diabetic retinopathy would show signs of **neovascularization**, which is also not present. *Cystoid macular edema* - Cystoid macular edema is characterized by fluid accumulation in the macula, which may appear as a loss of the foveal reflex or macular thickening on fundoscopy, but not the distinct cherry-red spot on a pale background. - It is better visualized with **Optical Coherence Tomography (OCT)**, which shows cystic spaces in the macula, or as a **petaloid pattern** on fluorescein angiography.

Q: Fundoscopy findings are shown in the image below. What is the most likely diagnosis? ![img-41.jpeg](img-41.jpeg)

CRAO. ***CRAO*** - The fundoscopy image shows a classic **cherry-red spot** at the macula, which is pathognomonic for Central Retinal Artery Occlusion (CRAO). This spot appears because the fovea receives its blood supply from the underlying choroid, which remains visible and red against the pale, ischemic retina. - CRAO presents as sudden, profound, and painless monocular vision loss. The diffuse retinal pallor is due to edema and ischemia of the inner retinal layers caused by the occlusion of the central retinal artery, often by an **embolus**. *CRVO* - Central Retinal Vein Occlusion (CRVO) is characterized by a "**blood and thunder**" fundus, featuring widespread **retinal hemorrhages**, dilated and tortuous veins, and cotton-wool spots, none of which are present in the image. - Unlike the arterial occlusion seen here, CRVO is a venous outflow obstruction, leading to venous stasis, ischemia, and hemorrhage rather than diffuse retinal pallor. *Diabetic retinopathy* - The fundoscopic findings of diabetic retinopathy include **microaneurysms**, **dot and blot hemorrhages**, **hard exudates**, and **cotton-wool spots** in its non-proliferative stage. - Proliferative diabetic retinopathy is marked by **neovascularization** (new, fragile blood vessel growth) at the disc or elsewhere, which is absent in this image. *Cystoid macular edema* - Cystoid macular edema involves fluid accumulation in the macula, which on fundoscopy may cause loss of the foveal reflex and macular thickening, but not the diffuse pallor or cherry-red spot seen here. - The characteristic finding is a **petaloid pattern** of leakage on fluorescein angiography or cystic spaces on **Optical Coherence Tomography (OCT)**.

Q: A 62-year-old diabetic patient presents with sudden painless loss of vision in the right eye. Fundoscopy reveals a pale, edematous retina with a cherry-red spot at the macula. Retinal arterioles appear narrowed. Visual acuity is light perception only. What is the most likely diagnosis?

Central retinal artery occlusion. ***Central Retinal Artery Occlusion (CRAO)*** - The presentation of **sudden, painless, severe vision loss** (light perception only) combined with a **pale, edematous retina** and a **cherry-red spot at the macula** is pathognomonic for **CRAO**. - The cherry-red spot occurs because the **fovea** (which is supplied by the **choroid** and not the blocked retinal artery) appears red against the surrounding pale, ischemic retina. - The **narrowed retinal arterioles** further support arterial occlusion. *Central Retinal Vein Occlusion (CRVO)* - While also causing sudden painless vision loss, fundoscopy typically reveals a "**blood and thunder**" appearance with widespread retinal hemorrhages, dilated and tortuous veins, and cotton-wool spots. - Vision loss is usually **not as severe** as in CRAO, rarely limited to only light perception. - Arterioles would not be narrowed; instead, veins are dilated and tortuous. *Vitreous Hemorrhage* - Causes sudden vision loss, but the fundoscopic finding is an inability to clearly visualize the retina due to **blood filling the vitreous cavity**. - There would be **no pale retina** or **cherry-red spot** unless the underlying condition (like proliferative diabetic retinopathy) was the cause, but the hemorrhage itself obscures the view. *Retinal Detachment* - Presents with sudden painless vision loss, often preceded by **flashes** and **floaters**. - Fundoscopy shows a **gray, elevated retina** with a corrugated appearance, not a pale, edematous retina. - There is **no cherry-red spot** at the macula in retinal detachment.

Q: Which of the following investigations allows examination of all layers of the retina?

OCT. ### **Explanation** **Optical Coherence Tomography (OCT)** is the correct answer because it functions as an **"optical biopsy"** of the retina. It uses low-coherence interferometry (near-infrared light) to produce high-resolution, **cross-sectional images**. This allows clinicians to visualize and measure all **ten layers of the retina** individually, from the Internal Limiting Membrane (ILM) to the Retinal Pigment Epithelium (RPE) and even the underlying choroid. #### **Why the other options are incorrect:** * **B-scan Ultrasonography:** This is a two-dimensional acoustic imaging technique. While excellent for detecting gross structural changes (like retinal detachment or intraocular tumors) when the ocular media is opaque (e.g., dense cataract or vitreous hemorrhage), it lacks the resolution to distinguish individual retinal layers. * **Perimetry:** This is a **functional** test (not structural) used to map the visual field. It identifies blind spots (scotomas) but cannot visualize the anatomical layers of the retina. * **Fundus Fluorescein Angiography (FFA):** This is a dynamic study of the **retinal vasculature**. While it is the gold standard for detecting leaks, neovascularization, and capillary non-perfusion, it provides a "top-down" view and cannot differentiate the depth or thickness of specific retinal layers. --- ### **High-Yield Clinical Pearls for INI-CET:** * **OCT Principle:** Based on **Michelson Interferometry**. * **Resolution:** OCT has a resolution of **5–10 microns**, which is significantly higher than B-scan (~150 microns). * **Key Indications:** Best for diagnosing **Macular Hole**, **Epiretinal Membrane**, and **Cystoid Macular Edema (CME)**. * **Inverted Image:** In OCT, the RPE is the most hyper-reflective (brightest) outer band. * **Swept-Source OCT (SS-OCT):** The newest generation that uses longer wavelengths to penetrate deeper into the **choroid**.

Q: A 45-year-old AIDS patient was started on anti-retroviral therapy following which he develops decrease in visual acuity. Fundus examination was done. All are used for management of the patient except?

CMV hyperimmunoglobulin. ***CMV hyperimmunoglobulin*** - CMV hyperimmunoglobulin is typically used for prevention or treatment of CMV disease, particularly in transplant recipients or immunocompromised individuals, but **not as a primary treatment for established CMV retinitis**. - Its role is minimal in direct management of vision-threatening retinitis where antiviral agents are the mainstay. *Ganciclovir intraocular pellets* - **Ganciclovir intraocular pellets** are a form of localized therapy directly implanted into the eye to provide sustained release of the antiviral drug. - This method ensures high local drug concentrations, effective against **CMV retinitis**, especially in cases where systemic treatment is problematic or retinitis is severe. *Valganciclovir* - **Valganciclovir** is an oral prodrug of ganciclovir, which is commonly used as a systemic treatment for **CMV retinitis** due to its good bioavailability. - It is effective in both the induction and maintenance phases of treatment for CMV retinitis. *Foscarnet* - **Foscarnet** is an antiviral agent effective against **CMV**, particularly useful in cases of ganciclovir resistance or intolerance due to its different mechanism of action. - It is administered intravenously and is a well-established treatment option for **CMV retinitis**.

Question 1

A prematurely born baby at 29 weeks is examined at 42 weeks post-conceptional age and shows stage 2 zone 1 ROP with plus disease in both eyes. How will you manage this patient?

Accepted Answer

Laser photocoagulation of both eyes

Answer

Examine the patient after 1 week

Answer

Laser photocoagulation of the worse eye, follow up of the other eye

Answer

Vitreoretinal surgery

Question 2

Which of the following statements is FALSE regarding Stargardt's disease?

Accepted Answer

It is autosomal dominant.

Answer

There is no family history.

Answer

It is characterized by a 'beaten bronze' appearance of the fundus.

Answer

Both ERG and EOG are abnormal.

Question 3

A myopic patient presents with complaints of flashes and floaters. On examination, a deep anterior chamber is seen. What is the likely diagnosis?

Accepted Answer

Rhegmatogenous retinal detachment

Answer

Central serous retinopathy

Answer

Tractional retinal detachment

Answer

Exudative retinal detachment

Question 4

A patient presents with vision problems and has a history of cataract surgery. OCT finding is shown below. What is the syndrome most likely associated with these findings?

Accepted Answer

Irvine-Gass Syndrome

Answer

Central Serous Retinopathy

Answer

Posner-Schlossman Syndrome

Answer

Elschnig Pearls

Question 5

Fundoscopy findings are shown in the image below. What is the most likely diagnosis?

Accepted Answer

CRAO

Answer

CRVO

Answer

Cystoid macular edema

Answer

Diabetic retinopathy

Question 6

Fundoscopy findings are shown in the image below. What is the most likely diagnosis? ![img-41.jpeg](img-41.jpeg)

Accepted Answer

CRAO

Answer

Diabetic retinopathy

Answer

CRVO

Answer

Cystoid macular edema

Question 7

A 62-year-old diabetic patient presents with sudden painless loss of vision in the right eye. Fundoscopy reveals a pale, edematous retina with a cherry-red spot at the macula. Retinal arterioles appear narrowed. Visual acuity is light perception only. What is the most likely diagnosis?

Accepted Answer

Central retinal artery occlusion

Answer

Retinal detachment

Answer

Central retinal vein occlusion

Answer

Vitreous hemorrhage

Question 8

Which of the following is seen in proliferative diabetic retinopathy?

Accepted Answer

Tractional retinal detachment

Answer

No retinal detachment

Answer

Exudative retinal detachment

Answer

Rhegmatogenous retinal detachment

Question 9

Which of the following investigations allows examination of all layers of the retina?

Accepted Answer

OCT

Answer

B-scan ultrasonography

Answer

Perimetry

Answer

Fundus fluorescein angiography

Question 10

A 45-year-old AIDS patient was started on anti-retroviral therapy following which he develops decrease in visual acuity. Fundus examination was done. All are used for management of the patient except?

Accepted Answer

CMV hyperimmunoglobulin

Answer

Ganciclovir intraocular pellets

Answer

Valganciclovir

Answer

Foscarnet

Diseases of the Retina — MCQs

Diseases of the Retina — MCQs

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