Diseases of the Retina Practice Questions

Q: The test shown below is used for the evaluation of

Macular degeneration. ***Macular degeneration*** - The image shown is an **Amsler grid**, a diagnostic tool used to detect **visual disturbances** caused by changes in the retina, especially the macula. - The straight lines appearing wavy or distorted, as seen in the right panel, are characteristic findings in **macular degeneration** or other macular pathologies. - The Amsler grid is the standard screening tool for **age-related macular degeneration (AMD)** and other macular disorders. *Glaucoma* - Glaucoma primarily affects the **optic nerve** and typically causes **peripheral vision loss**, which is not directly assessed by an Amsler grid. - Visual field tests (perimetry) are used for glaucoma diagnosis, not the Amsler grid. *Cataracts* - Cataracts involve **clouding of the lens** of the eye, leading to blurred vision, glare, and difficulty with night vision. - They do not typically cause the **distortion of straight lines** that an Amsler grid helps to detect. *Retinal detachment* - Retinal detachment usually presents with symptoms like flashes of light, **floaters**, or a curtain-like shadow in the vision. - While it can affect vision, the Amsler grid specifically detects **macular distortion**, which is the hallmark of macular pathology rather than peripheral retinal detachment.

Q: A 75-year-old Englishman living in India presents to OPD with complaints of gradual onset painless, progressive blurring of central vision. He says he could earlier drive to the hospital by himself but is not able to do so now. Slit lamp examination is normal. Fundus examination is given below. What is the diagnosis?

Age-related macular degeneration. ***Age-related macular degeneration*** - The patient's age (75 years), gradual painless progressive blurring of **central vision**, and the presence of **drusen** (small yellow deposits) and a **macular hemorrhage** (red spot) on the fundus exam are all characteristic features of wet age-related macular degeneration. - The inability to drive due to vision loss further points to significant central vision impairment, which is a hallmark of AMD, especially the wet form due to **neovascularization** and hemorrhage. *Central serous retinopathy* - Typically affects younger to middle-aged individuals, often associated with stress or corticosteroid use, contrasting with the patient's age. - Characterized by **serous fluid detachment** of the neurosensory retina, not usually significant hemorrhage as seen in the image. *Cystoid macular edema* - Presents with **cyst-like fluid accumulation** within the retina, often leading to a flower petal-like appearance on imaging, which is not depicted in this fundus image. - Can be associated with various conditions like diabetes, retinal vein occlusion, or inflammation, and while it causes central vision loss, the funduscopic appearance here is more consistent with AMD. *Rhegmatogenous retinal detachment* - Usually presents with sudden vision loss, **floaters**, or **flashes of light**, and a "curtain" coming over the vision, which differs from the gradual onset described. - Fundus examination would typically show a detached, billowing retina, often with a retinal tear, not the macular changes with drusen and hemorrhage seen here.

Q: The given FFA appearance occurs due to accumulation of dye in which of the following layers of retina?

Inner plexiform layer. ***Inner plexiform layer*** - In **cystoid macular edema (CME)**, fluid accumulation occurs in multiple retinal layers, with the **inner plexiform layer** and **inner nuclear layer** being significantly involved. - The characteristic **petaloid (flower-petal) pattern** on fluorescein angiography results from fluid accumulation arranged around the foveal center in a radial pattern. - The **Müller cells**, which span the retina vertically, contribute to the formation of cystoid spaces when their supporting function is disrupted. **Note:** While the **outer plexiform layer (Henle's layer)** is classically described as the primary site of CME in many textbooks due to the radial arrangement of Henle fibers, fluid accumulation also prominently involves the **inner nuclear and inner plexiform layers**, and different imaging modalities and stages of CME may show variable involvement. *Outer plexiform layer* - The outer plexiform layer (also called **Henle's layer** at the macula) is frequently cited as a primary site of fluid accumulation in CME. - The radial arrangement of photoreceptor axons (Henle fibers) in this layer can contribute to the characteristic petaloid pattern. - Modern OCT imaging often shows cystoid spaces involving both outer plexiform and inner nuclear layers. *Ganglion cell layer* - The ganglion cell layer is the most superficial retinal layer containing neuronal cell bodies. - This layer is **not typically involved** in the cystoid fluid accumulation pattern of CME. - Edema here would present differently, potentially obscuring vessels or causing diffuse thickening. *Outer nuclear layer* - The outer nuclear layer contains photoreceptor cell bodies (nuclei of rods and cones). - This layer is **not characteristically involved** in CME's petaloid pattern. - Fluid in this layer is more associated with conditions like **outer retinal edema**, **retinoschisis**, or certain forms of retinal detachment.

Q: A 20-year-old college student has visual complaints represented in the image given below. FFA of the patient shows presence of:

Central serous retinopathy. ***Central serous retinopathy*** - The FFA image shows a classic **inkblot or smokestack pattern of leakage** due to choroidal fluid seeping through a defective retinal pigment epithelium, characteristic of central serous retinopathy. - The Amsler grid on the left exhibits **metamorphopsia** (wavy lines) and a **central scotoma** (blurred dark area), indicating macular involvement, consistent with fluid accumulation under the retina in CSR. *Cystoid macular edema* - This condition typically presents with **petaloid leakage patterns** on FFA, due to fluid accumulation within the intraretinal layers, which is not seen here. - While it can cause metamorphopsia and reduced vision, the characteristic "inkblot" leakage on FFA points away from CME. *Age-related macular degeneration* - This condition is more common in older individuals, whereas the patient is a **20-year-old college student**. - Wet AMD typically shows **choroidal neovascularization (CNV)** with associated leakage or bleeding, which is distinct from the serous detachment and RPE leak seen. *Central retinal venous occlusion* - CRVO is characterized by widespread **retinal hemorrhages**, dilated and tortuous veins, and cotton wool spots due to impaired venous outflow. - FFA in CRVO would show delayed venous filling, capillary non-perfusion, and possible neovascularization, none of which are evident in the provided images.

Q: A 60-year-old polycythemia vera patient is having a marked reduction in visual acuity in both eyes. The fundus examination image is shown below. What is the most likely finding?

Central retinal venous occlusion. ***Central retinal venous occlusion*** - The fundus image shows widespread **retinal hemorrhages** (diffuse red areas), **dilated and tortuous retinal veins**, and **optic disc edema**, which are classic signs of a **central retinal venous occlusion (CRVO)**. - The patient's history of **polycythemia vera**, a myeloproliferative disorder causing increased blood viscosity and erythrocyte count, significantly increases the risk of thrombotic events like CRVO. *Cystoid macular edema* - This condition is characterized by fluid accumulation in the macula, forming cyst-like spaces, which would appear as a thickened and somewhat blurry macula, but typically without the widespread hemorrhages seen here. - While macular edema can accompany CRVO, it is not the primary finding describing the diffuse picture of hemorrhages and venous engorgement in the image. *Central retinal artery occlusion* - A **central retinal artery occlusion (CRAO)** typically presents with sudden, profound, painless vision loss and a characteristic **cherry-red spot** in the macula, often with retinal pallor, due to ischemia. - This image does not show retinal pallor or a cherry-red spot, and the widespread hemorrhages are inconsistent with arterial occlusion, which primarily causes ischemic necrosis. *Branched retinal vein occlusion* - A **branched retinal vein occlusion (BRVO)** would present with hemorrhages and venous engorgement limited to a specific quadrant or sector of the retina, corresponding to the distribution of the affected vein branch. - The image demonstrates widespread involvement with hemorrhages appearing throughout the retina, indicating an occlusion of the main central retinal vein rather than a branch.

Q: A 75-year-old patient with carotid artery bruit develops sudden onset, unilateral loss of vision. On examination direct pupillary light reflex is absent and perception of light is absent. What does the given fundus examination show?

Central retinal artery occlusion. ***Central retinal artery occlusion*** - The image shows a **pale retina** with a distinct **cherry-red spot** in the fovea, which is characteristic of CRAO due to retinal ischemia and relative transparency of the foveola. - The patient's history of **sudden unilateral vision loss**, absent pupillary light reflex and perception of light, along with **carotid artery bruit** (indicating atherosclerosis and potential for emboli), are consistent with CRAO. *Central retinal venous occlusion (ischemic)* - Ischemic CRVO typically presents with a **"blood and thunder" fundus**, characterized by widespread retinal hemorrhages, dilated tortuous veins, cotton wool spots, and optic disc edema. - While it causes significant vision loss, the fundus appearance of a pale retina with a cherry-red spot is not typical for CRVO. *Central retinal venous occlusion (non-ischemic)* - Non-ischemic CRVO presents with similar signs to ischemic CRVO but generally less severe, including dilated tortuous veins, retinal hemorrhages, and macular edema, though less extensive than the ischemic form. - It does not present with the diffuse retinal pallor and cherry-red spot seen in the image and described in the clinical scenario. *Central serous retinopathy* - Central serous retinopathy typically presents with **serous detachment of the neurosensory retina** and/or retinal pigment epithelium, often associated with a blurry spot in vision or metamorphopsia. - The fundus features might include localized retinal elevation and sometimes pigment epithelial detachment, but not the widespread retinal pallor and cherry-red spot characteristic of acute arterial occlusion.

Q: What does the following image show?

Vitreous cells and flare. ***Correct: Vitreous cells and flare*** - The image exhibits **vitreous cells**, seen as tiny dots within the vitreous gel, indicating **inflammatory cells** in the vitreous cavity - **Vitreous flare** is also visible as haziness of the vitreous due to **increased protein content** from breakdown of the blood-aqueous barrier - This combination is characteristic of **intermediate uveitis (vitritis)** and indicates active intraocular inflammation - Seen on **slit-lamp biomicroscopy** with a narrow beam in the vitreous cavity *Incorrect: Asteroid hyalosis* - Would show **yellowish-white, spherical deposits** composed of calcium-lipid complexes - These deposits are typically **asymptomatic** and do not indicate inflammation - Appears as **star-like or asteroid-shaped opacities** that move with eye movement - Usually **bilateral** and associated with aging, not inflammation *Incorrect: Posterior vitreous detachment* - Would show a **Weiss ring** (circular opacity from detached vitreous around the optic disc) - Patient would report **photopsia** (flashes of light) and **floaters** - The vitreous would appear **more mobile** and separated from the retina - No inflammatory cells or protein flare would be present *Incorrect: Vitreous hemorrhage* - Would show **red blood cells** in the vitreous, appearing as **dense red opacity** - The view would be more **obscured** with reduced red reflex - Causes include **trauma, diabetic retinopathy, retinal tears**, or vascular occlusions - No specific cellular inflammatory pattern or protein flare as seen here

Q: During annual medical check-up, a 55-year-old hypertensive corporate executive is found to have ophthalmoscopic findings as shown in the image given below. What is it composed of?

Cholesterol crystals. ***Cholesterol crystals*** - The image depicts **synchysis scintillans**, a condition characterized by numerous tiny, golden-brown, refractile particles often seen in a **liquefied vitreous** humour. These particles are composed of **cholesterol crystals**. - This condition is typically associated with a history of **vitreous haemorrhage** or trauma and is often seen in eyes with retinal detachment or chronic inflammation. The crystals are mobile within the vitreous and "snow" down with eye movement. *Residue of primitive hyaloid vascular system* - Remnants of the **hyaloid artery** or **Mittendorf dot** usually appear as a small, white or grey dense spot on the posterior lens capsule or as a fine strand in the vitreous, not as multiple free-floating crystals. - These are **congenital anomalies** and generally do not resorb or multiply to form widespread vitreous opacities in this manner. *Calcium containing salts* - **Asteroid hyalosis** is composed of **calcium-lipid complexes**, often described as "star-like" or "asteroid" bodies, which are typically yellow-white and tend to remain suspended in the vitreous rather than floating freely. - While both conditions are types of vitreous opacities, synchysis scintillans crystals are more numerous, mobile, and have a distinct golden, shimmering appearance distinct from the static, star-like appearance of asteroid hyalosis. *Degenerated blood in vitreous hemorrhage* - Degenerated blood from a vitreous hemorrhage typically appears as **reddish-brown clumping**, haziness, or strands, which eventually resolve or get resorbed over time. - While synchysis scintillans can follow vitreous hemorrhage, the crystals themselves are a **later development** resulting from the breakdown of blood products and cholesterol, not the blood itself.

Q: All of the following are responsible for the condition shown in the image except:

Kaposi sarcoma. ***Kaposi sarcoma*** - The image depicts **neovascularization of the iris**, also known as **rubeosis iridis**, characterized by abnormal blood vessel growth on the iris surface. - Kaposi sarcoma is a vascular tumor that would typically present as a distinct **raised, reddish-purple lesion** on the iris, NOT as diffuse neovascularization. - **This is the correct answer** as Kaposi sarcoma does NOT cause rubeosis iridis. *Diabetes mellitus* - **Diabetic retinopathy** is one of the most common causes of **rubeosis iridis**, especially in advanced proliferative stages. - Widespread retinal ischemia leads to upregulation of **VEGF (vascular endothelial growth factor)**, stimulating abnormal vessel growth on the iris. - These new vessels can grow into the anterior chamber angle and cause **neovascular glaucoma**, a severe sight-threatening complication. *Central retinal venous occlusion* - **Central retinal venous occlusion (CRVO)** leads to significant **retinal ischemia** and release of **angiogenic factors** (primarily VEGF). - This often results in **rubeosis iridis** within 2-3 months (classic "90-day glaucoma"). - The ischemic retina drives neovascularization as a compensatory but pathological response. *Fuchs heterochromic cyclitis* - **Fuchs heterochromic iridocyclitis (FHI)** is a form of chronic anterior uveitis associated with **heterochromia** (different colored irises) and **stellate keratic precipitates**. - While FHI can show **fine vessels on the iris surface**, these are typically **pre-existing vessels that become visible** due to iris stromal atrophy, NOT true neovascularization. - **True rubeosis iridis is NOT a characteristic feature** of FHI, making this an uncommon association at best.

Q: A 6-month-old child with retinoblastoma is brought with the following presentation in the right eye. The presentation shown is known as:

Pseudohypopyon. ***Pseudohypopyon*** - The image exhibits a visible layer of white material settled at the bottom of the anterior chamber, which in a retinoblastoma patient, represents a collection of **tumor cells** that have seeded into the anterior chamber. This is referred to as **pseudohypopyon**. - A true **hypopyon** consists of white blood cells (pus) from an inflammatory or infectious process, whereas **pseudohypopyon** in retinoblastoma is composed of shed neoplastic cells. - This is a well-recognized but less common presentation of advanced retinoblastoma when tumor cells gain access to the anterior chamber. *Adherent leucoma* - An **adherent leucoma** is an opaque scar on the cornea that has become adhered to the iris when there has been a perforation and prolapse of the iris. It is not depicted in this image. - This lesion leads to a **fixed and distorted pupil (corectopia)** due to the corneal-iris adhesion which is not seen here. *Keratic precipitates* - **Keratic precipitates (KPs)** are deposits of inflammatory cells on the inner surface of the cornea (endothelium), typically seen in uveitis. - They appear as small, often triangular or stellate, white or pigmented dots on the corneal endothelium and do not form a distinct layering like the material in the image. *Corneal ulcer* - A **corneal ulcer** is an open sore on the surface of the cornea, typically caused by infection, trauma, or inflammation. - It involves a break in the corneal epithelium and often presents with pain, redness, photophobia, and blurred vision, and would appear as a visible defect on the corneal surface, which is not what is shown.

Question 1

The test shown below is used for the evaluation of

Accepted Answer

Macular degeneration

Answer

Glaucoma

Answer

Cataracts

Answer

Retinal detachment

Question 2

A 75-year-old Englishman living in India presents to OPD with complaints of gradual onset painless, progressive blurring of central vision. He says he could earlier drive to the hospital by himself but is not able to do so now. Slit lamp examination is normal. Fundus examination is given below. What is the diagnosis?

Accepted Answer

Age-related macular degeneration

Answer

Central serous retinopathy

Answer

Cystoid macular edema

Answer

Rhegmatogenous retinal detachment

Question 3

The given FFA appearance occurs due to accumulation of dye in which of the following layers of retina?

Accepted Answer

Inner plexiform layer

Answer

Outer plexiform layer

Answer

Ganglion cell layer

Answer

Outer nuclear layer

Question 4

A 20-year-old college student has visual complaints represented in the image given below. FFA of the patient shows presence of:

Accepted Answer

Central serous retinopathy

Answer

Cystoid macular edema

Answer

Central retinal venous occlusion

Answer

Age-related macular degeneration

Question 5

A 60-year-old polycythemia vera patient is having a marked reduction in visual acuity in both eyes. The fundus examination image is shown below. What is the most likely finding?

Accepted Answer

Central retinal venous occlusion

Answer

Cystoid macular edema

Answer

Central retinal artery occlusion

Answer

Branched retinal vein occlusion

Question 6

A 75-year-old patient with carotid artery bruit develops sudden onset, unilateral loss of vision. On examination direct pupillary light reflex is absent and perception of light is absent. What does the given fundus examination show?

Accepted Answer

Central retinal artery occlusion

Answer

Central retinal venous occlusion (ischemic)

Answer

Central retinal venous occlusion (non-ischemic)

Answer

Central serous retinopathy

Question 7

What does the following image show?

Accepted Answer

Vitreous cells and flare

Answer

Asteroid hyalosis

Answer

Posterior vitreous detachment

Answer

Vitreous hemorrhage

Question 8

During annual medical check-up, a 55-year-old hypertensive corporate executive is found to have ophthalmoscopic findings as shown in the image given below. What is it composed of?

Accepted Answer

Cholesterol crystals

Answer

Residue of primitive hyaloid vascular system

Answer

Calcium containing salts

Answer

Degenerated blood in vitreous hemorrhage

Question 9

All of the following are responsible for the condition shown in the image except:

Accepted Answer

Kaposi sarcoma

Answer

Diabetes mellitus

Answer

Central retinal venous occlusion

Answer

Fuchs heterochromic cyclitis

Question 10

A 6-month-old child with retinoblastoma is brought with the following presentation in the right eye. The presentation shown is known as:

Accepted Answer

Pseudohypopyon

Answer

Adherent leucoma

Answer

Keratic precipitates

Answer

Corneal ulcer

Diseases of the Retina — MCQs

Diseases of the Retina — MCQs

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