Diseases of the Retina Practice Questions

Q: A 60-year-old man presents with sudden loss of vision in one eye. Fundoscopy shows a cherry-red spot. What is the most likely diagnosis?

Central retinal artery occlusion. ***Central retinal artery occlusion*** - **Sudden, painless loss of vision** in one eye, combined with a **cherry-red spot** on fundoscopy, is the classic presentation of a central retinal artery occlusion (CRAO). - The cherry-red spot is caused by retinal edema making the fovea, which is avascular, appear redder against the pale ischemic retina. *Macular degeneration* - This condition typically causes a **gradual loss of central vision** and metamorphopsia, not sudden and complete vision loss. - Fundoscopic findings include **drusen** and pigmentary changes, not a cherry-red spot. *Retinal detachment* - Characterized by symptoms like **flashing lights**, floaters, and a **curtain-like visual field defect**. - Fundoscopy reveals the detached retina, which appears elevated and often wrinkled, not a cherry-red spot. *Optic neuritis* - Presents with **painful loss of vision** and often **color desaturation**. - Fundoscopy may show a swollen optic disc (papillitis) in some cases, but a cherry-red spot is not a feature.

Q: A 50-year-old female presents with sudden onset painless vision loss in her left eye. Fundoscopy reveals a pale retina with a cherry-red spot at the fovea. Carotid ultrasound shows significant stenosis. What is the most likely diagnosis?

Central retinal artery occlusion. ***Central retinal artery occlusion*** - The classic triad of **sudden, painless vision loss**, a **pale retina** with a **cherry-red spot** at the fovea, and evidence of **carotid stenosis** strongly indicates central retinal artery occlusion. - The **cherry-red spot** is due to the preserved choroidal circulation visibility through the thin foveola against the ischemic, opaque surrounding retina. *Retinal detachment* - Typically presents with symptoms like **flashes of light (photopsia)**, **floaters**, and a **dark curtain or shadow** in the visual field, which are not described. - Fundoscopy would show a **detached retina**, not a pale retina with a cherry-red spot. *Diabetic retinopathy* - Develops gradually and is characterized by **microaneurysms**, **hemorrhages**, **exudates**, and **neovascularization**, usually in patients with a history of diabetes. - While it can cause vision loss, it does not present with sudden, painless loss and a cherry-red spot. *Acute angle-closure glaucoma* - Characterized by **sudden, painful vision loss**, often accompanied by **redness**, **halos around lights**, and a **fixed, mid-dilated pupil**. - Fundoscopy would show **cupping of the optic disc** and not a pale retina with a cherry-red spot.

Q: A 70-year-old man with hypertension and hyperlipidemia has sudden right eye vision loss, described as a 'curtain coming down'. What is the most likely diagnosis?

Retinal detachment. ***Retinal detachment*** - The **classic "curtain coming down"** description is pathognomonic for retinal detachment, representing the progressive separation of the neurosensory retina from the retinal pigment epithelium. - Presents with **sudden, persistent vision loss** (not transient), often accompanied by **photopsia (flashes)** and **floaters** in the prodromal phase. - Risk factors include advanced age (vitreous degeneration), myopia, previous cataract surgery, and trauma. - This is an **ophthalmologic emergency** requiring urgent surgical intervention to prevent permanent vision loss. *Amaurosis fugax* - Describes **transient monocular vision loss** lasting seconds to minutes with **complete resolution**. - Caused by emboli from carotid atherosclerosis causing temporary retinal ischemia. - While the patient has vascular risk factors, the **persistent nature** of vision loss (described in present tense as "has vision loss") excludes this diagnosis. - Patients typically describe it as a "curtain that came down **and lifted**." *Optic neuritis* - Presents with **subacute, painful vision loss** developing over hours to days. - Associated with **pain on eye movement** and commonly linked to demyelinating diseases like multiple sclerosis. - The sudden "curtain" description and lack of pain make this diagnosis unlikely. *Glaucoma* - Acute angle-closure glaucoma can cause sudden vision loss but presents with **severe eye pain**, **red eye**, **halos around lights**, and a **mid-dilated fixed pupil**. - Chronic open-angle glaucoma causes **gradual peripheral vision loss** over months to years. - The "curtain coming down" description is not characteristic of either glaucoma type.

Q: Which of the following is a common cause of floaters in patients with diabetes?

Vitreous hemorrhage. ***Vitreous hemorrhage*** - In diabetic patients, **neovascularization** (abnormal new blood vessel growth) due to **diabetic retinopathy** is fragile and prone to bleeding into the vitreous humor. - This bleeding manifests as **floaters** or a sudden decrease in vision as blood obstructs light transmission. *Retinal detachment* - While floaters can be a symptom of **retinal detachment**, it's more commonly associated with a **curtain-like vision loss** or flashing lights. - Though diabetic retinopathy can lead to **tractional retinal detachment**, vitreous hemorrhage is a more direct and frequent cause of floaters specifically. *Cataract* - Cataracts cause **blurry vision** or **decreased vision** due to clouding of the lens, rather than discrete floaters. - While common in diabetics, cataracts typically do not present with the sensation of moving spots or cobwebs characteristic of floaters. *Optic neuritis* - Optic neuritis involves **inflammation of the optic nerve**, causing sudden **painful vision loss** and diminished color perception. - It does not typically cause floaters, which are visual phenomena originating from opacities within the vitreous.

Q: A 60-year-old male presents with sudden vision loss and floaters. Fundus examination reveals retinal hemorrhages and cotton wool spots. What is the likely diagnosis?

Central retinal vein occlusion. ***Central retinal vein occlusion*** - **Sudden vision loss**, **floaters**, and characteristic fundus findings of **retinal hemorrhages** and **cotton wool spots** are classic signs of CRVO. - This condition is caused by a blockage in the central retinal vein, leading to blood and fluid leakage into the retina, creating the typical "blood and thunder" appearance. - CRVO is more common in **older patients** (>50 years) with risk factors like hypertension, diabetes, and glaucoma. *Hypertensive retinopathy* - While it can manifest with **retinal hemorrhages** and **cotton wool spots**, hypertensive retinopathy typically presents with additional findings like **arteriolar narrowing**, **arteriovenous nicking**, and sometimes **papilledema** in severe cases. - The sudden profound vision loss with floaters is more characteristic of **vascular occlusion** rather than hypertensive changes. - Hypertensive retinopathy is typically **bilateral** and develops gradually with chronic hypertension. *Diabetic retinopathy* - This condition is a complication of **diabetes mellitus** and usually develops over a long period, causing **gradual rather than sudden** vision loss. - Although it can present with hemorrhages and cotton wool spots, the **sudden onset** and lack of other diabetic retinopathy features (microaneurysms, hard exudates) make it less likely. - Diabetic retinopathy is typically **bilateral** and progressive. *Retinitis pigmentosa* - This is a group of **genetic disorders** characterized by progressive degeneration of the retina, leading to **night blindness** and **peripheral vision loss** over many years. - It does not cause sudden vision loss, floaters, or the specific fundus findings of retinal hemorrhages and cotton wool spots. - Classic findings include **bone spicule pigmentation**, **attenuated retinal vessels**, and **waxy disc pallor**.

Q: A patient with a history of myopia presents with new floaters and flashes of light. Fundoscopy reveals a retinal tear. What is the initial management?

Laser photocoagulation. ***Laser photocoagulation*** - **Laser photocoagulation** is the **preferred initial management** for a **retinal tear** without retinal detachment, as it creates a chorioretinal adhesion around the tear, preventing fluid from passing through. - This procedure aims to seal the edges of the tear, thereby **preventing progression to retinal detachment**. - It is **preferred** due to its **precision, minimal inflammation, and ability to treat posterior tears** with excellent visualization. *Vitrectomy* - **Vitrectomy** is generally reserved for more complex cases, such as **retinal detachment with vitreous hemorrhage** or significant vitreous traction. - It involves removing the vitreous gel, which is a more invasive procedure than laser photocoagulation. *Scleral buckle* - A **scleral buckle** is typically used to repair a **retinal detachment** by indenting the sclera and bringing the choroid into contact with the detached retina. - It is not the primary treatment for an isolated retinal tear without detachment. *Cryotherapy* - **Cryotherapy** is an **alternative** to laser photocoagulation for **retinal tears**, especially useful when the view to the tear is obstructed, for **anterior peripheral tears**, or when laser equipment is unavailable. - While equally effective at creating chorioretinal adhesion, laser photocoagulation is **more commonly used** in modern practice due to better control, less inflammation, and superior results for posterior tears.

Q: Cotton wool spots on fundoscopic examination are characteristically seen in all of the following EXCEPT:

Glaucoma. ***Glaucoma*** - Glaucoma is characterized by **optic nerve damage** with **optic disc cupping** and **pallor**, along with visual field defects. - **Cotton wool spots are NOT a feature** of glaucoma; the primary pathology involves elevated intraocular pressure causing optic neuropathy. - Fundoscopic findings include increased **cup-to-disc ratio** (>0.5), vertical elongation of the cup, and **RNFL defects**. *Hypertensive retinopathy* - Cotton wool spots are a hallmark of **grade III-IV hypertensive retinopathy**, resulting from **ischemic infarction** of the nerve fiber layer. - They appear as **white, fluffy patches** and indicate severe hypertension with arteriolar occlusion. - Associated with flame-shaped hemorrhages, arteriovenous nicking, and copper/silver wiring. *Diabetic retinopathy* - Cotton wool spots are commonly seen in **severe NPDR and PDR**, indicating **capillary non-perfusion** and ischemia. - They result from **focal retinal ischemia** due to microvascular occlusion from chronic hyperglycemia. - Other features include microaneurysms, dot-blot hemorrhages, hard exudates, and neovascularization. *Retinal detachment* - **Central retinal vein occlusion (CRVO)**, which can lead to retinal detachment, classically presents with cotton wool spots. - Cotton wool spots can be seen in **ischemic CRVO** along with extensive retinal hemorrhages ("blood and thunder" appearance). - True rhegmatogenous retinal detachment presents with flashes, floaters, and visual field defects but may have preceding vascular changes.

Q: What is the primary function of the macula in terms of visual field?

Central vision. ***Central vision*** - The **macula** is a small, specialized area within the retina responsible for **sharp, detailed central vision** necessary for tasks like reading and recognizing faces. - It has a high concentration of **cone photoreceptors**, which are essential for high-acuity vision in the **central visual field**. - The macula, particularly the **fovea centralis**, provides the highest visual acuity in the retina. *Peripheral vision* - Peripheral vision detects objects and movement outside the direct line of sight and is primarily mediated by the **peripheral retina** with its rod photoreceptors. - Damage to the macula typically spares peripheral vision, whereas damage to the peripheral retina affects this type of vision. - Conditions like **age-related macular degeneration** demonstrate how macular damage causes central vision loss while preserving peripheral vision. *Night vision* - **Night vision** is primarily mediated by **rod photoreceptors**, which are highly sensitive to low light levels. - The macula is dominated by **cone photoreceptors**, which function best in bright light conditions (photopic vision). - Rods are concentrated in the peripheral retina, not the macula. *Color vision* - While **color vision** is indeed mediated by **cone photoreceptors** concentrated in the macula, this is a **functional characteristic** rather than a **spatial/field function**. - The question asks about the macula's role in terms of visual field distribution, where it specifically serves **central vision**. - Color perception occurs throughout the visual field wherever cones are present, though it's most acute in the macula.

Q: What is the most common cause of blindness in patients with diabetes?

Diabetic retinopathy. ***Diabetic retinopathy*** - It is the leading cause of blindness in patients with diabetes due to **microvascular complications**, leading to retinal damage [1]. - Symptoms often progress from mild non-proliferative changes to severe **proliferative diabetic retinopathy**, impacting vision significantly [1]. *Cataract* - While cataracts are common in diabetics and can lead to **blurred vision**, they are not the primary cause of **blindness** in this population. - Cataracts can be surgically managed, whereas diabetic retinopathy often leads to irreversible vision loss [1]. *Age-related macular degeneration* - Although this condition causes blindness, it is more prevalent in the **aging population** and is not specifically linked to diabetes. - The primary mechanism is related to **age**, rather than the diabetic state, making it less relevant here. *Glaucoma* - Glaucoma can cause blindness but is less common compared to diabetic retinopathy in diabetic patients [2]. - It often presents with **increased intraocular pressure**, which differs from the vascular issues seen in diabetic retinopathy [2].

Q: A 70-year-old man presents with gradual, painless vision loss and a history of smoking. What is the most likely diagnosis?

Age-related macular degeneration. ***Age-related macular degeneration*** - **Gradual, painless vision loss** in an older individual, especially with a history of **smoking**, is highly suggestive of **age-related macular degeneration** (AMD) - AMD specifically affects the **macula**, leading to loss of **central vision** and difficulty with tasks like reading and recognizing faces - **Smoking is the most significant modifiable risk factor** for developing AMD *Cataracts* - While cataracts also cause gradual, painless vision loss and are common in older adults, they typically present with **cloudy or blurry vision**, problems with glare, and reduced night vision - Smoking is a risk factor for cataracts, but the specific pattern of **central vision loss** points more strongly to AMD *Glaucoma* - Glaucoma is characterized by **optic nerve damage** and is typically associated with **elevated intraocular pressure**, leading to **peripheral vision loss** first - The patient's presentation of painless, gradual vision loss, particularly without mention of tunnel vision, is less typical for glaucoma *Diabetic retinopathy* - **Diabetic retinopathy** occurs in individuals with **diabetes mellitus** and can lead to blurred vision, floaters, or sudden vision loss due to macular edema or retinal hemorrhage - The patient's history does not mention diabetes, making this diagnosis less likely in the absence of that key risk factor

Question 1

A 60-year-old man presents with sudden loss of vision in one eye. Fundoscopy shows a cherry-red spot. What is the most likely diagnosis?

Accepted Answer

Central retinal artery occlusion

Answer

Macular degeneration

Answer

Retinal detachment

Answer

Optic neuritis

Question 2

A 50-year-old female presents with sudden onset painless vision loss in her left eye. Fundoscopy reveals a pale retina with a cherry-red spot at the fovea. Carotid ultrasound shows significant stenosis. What is the most likely diagnosis?

Accepted Answer

Central retinal artery occlusion

Answer

Retinal detachment

Answer

Diabetic retinopathy

Answer

Acute angle-closure glaucoma

Question 3

A 70-year-old man with hypertension and hyperlipidemia has sudden right eye vision loss, described as a 'curtain coming down'. What is the most likely diagnosis?

Accepted Answer

Retinal detachment

Answer

Amaurosis fugax

Answer

Optic neuritis

Answer

Glaucoma

Question 4

Which of the following is a common cause of floaters in patients with diabetes?

Accepted Answer

Vitreous hemorrhage

Answer

Retinal detachment

Answer

Cataract

Answer

Optic neuritis

Question 5

A 60-year-old male presents with sudden vision loss and floaters. Fundus examination reveals retinal hemorrhages and cotton wool spots. What is the likely diagnosis?

Accepted Answer

Central retinal vein occlusion

Answer

Hypertensive retinopathy

Answer

Diabetic retinopathy

Answer

Retinitis pigmentosa

Question 6

A patient with a history of myopia presents with new floaters and flashes of light. Fundoscopy reveals a retinal tear. What is the initial management?

Accepted Answer

Laser photocoagulation

Answer

Vitrectomy

Answer

Scleral buckle

Answer

Cryotherapy

Question 7

Cotton wool spots on fundoscopic examination are characteristically seen in all of the following EXCEPT:

Accepted Answer

Glaucoma

Answer

Hypertensive retinopathy

Answer

Diabetic retinopathy

Answer

Retinal detachment

Question 8

What is the primary function of the macula in terms of visual field?

Accepted Answer

Central vision

Answer

Peripheral vision

Answer

Night vision

Answer

Color vision

Question 9

What is the most common cause of blindness in patients with diabetes?

Accepted Answer

Diabetic retinopathy

Answer

Cataract

Answer

Glaucoma

Answer

Age-related macular degeneration

Question 10

A 70-year-old man presents with gradual, painless vision loss and a history of smoking. What is the most likely diagnosis?

Accepted Answer

Age-related macular degeneration

Answer

Cataracts

Answer

Glaucoma

Answer

Diabetic retinopathy

Diseases of the Retina — MCQs

Diseases of the Retina — MCQs

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