Diseases of the Retina Practice Questions

Q: A 60-year-old man with a 10-year history of hypertension and diabetes mellitus presents with reduced vision in one eye. Fundus examination reveals a central bleed in the affected eye, while the fellow eye is normal. What is the most likely diagnosis?

Diabetic retinopathy. **Explanation:** The correct answer is **Diabetic Retinopathy (DR)**. In a patient with a long-standing history of diabetes mellitus (10 years), the most common cause of sudden or subacute vision loss associated with a "central bleed" is proliferative diabetic retinopathy (PDR). The "central bleed" typically refers to a **vitreous hemorrhage** or a **pre-retinal (subhyaloid) hemorrhage** originating from fragile neovascularization at the disc (NVD) or elsewhere (NVE). While the patient also has hypertension, diabetes is a more potent risk factor for significant intraocular bleeding. **Why the other options are incorrect:** * **Retinal tear:** While it can cause vitreous hemorrhage, it is usually associated with symptoms like flashes (photopsia) and floaters, often in myopic eyes or following trauma, rather than a systemic metabolic history. * **Optic neuritis:** This typically presents with painful eye movements, a relative afferent pupillary defect (RAPD), and a pale or swollen disc, but **not** with a retinal or central hemorrhage. * **Hypertensive retinopathy:** While it causes flame-shaped hemorrhages and exudates, it rarely causes a massive "central bleed" unless associated with a secondary branch retinal vein occlusion (BRVO). **NEET-PG High-Yield Pearls:** * **Duration of Diabetes:** This is the single most important risk factor for the development of DR. * **Earliest Sign of DR:** Microaneurysms (located in the inner nuclear layer). * **First Clinically Detectable Sign:** Microaneurysms. * **PDR Hallmark:** Neovascularization (NVD/NVE) due to retinal ischemia (VEGF-mediated). * **Management:** Pan-retinal photocoagulation (PRP) is the gold standard for PDR to regress neovascularization.

Q: Which of the following investigations is contraindicated in retinoblastoma?

FNAC. **Explanation:** **Why FNAC is Contraindicated:** Fine Needle Aspiration Cytology (FNAC) is strictly contraindicated in cases of suspected Retinoblastoma due to the high risk of **extraocular seeding**. Retinoblastoma is a highly malignant intraocular tumor; breaching the globe with a needle can track tumor cells along the needle path, leading to orbital dissemination and transforming a localized intraocular disease into a systemic, life-threatening one. Diagnosis is primarily clinical and radiological. **Analysis of Other Options:** * **CT Scan (A):** Highly useful for detecting **intraocular calcification** (pathognomonic "chalky white" appearance), though it carries a risk of radiation-induced secondary malignancies in patients with the *RB1* germline mutation. * **USG (B):** A non-invasive, first-line tool used to confirm the presence of a mass and detect calcification (seen as high-echo spikes with posterior shadowing). * **MRI (C):** The **investigation of choice** for evaluating optic nerve involvement, extraocular extension, and screening for "Trilateral Retinoblastoma" (associated pinealoblastoma). It avoids ionizing radiation. **Clinical Pearls for NEET-PG:** * **Most common** intraocular tumor of childhood. * **Most common presentation:** Leukocoria (white pupillary reflex), followed by strabismus. * **Pathology:** Flexner-Wintersteiner rosettes (highly specific) and Homer-Wright rosettes. * **Genetics:** Mutation in the *RB1* gene on chromosome **13q14**. * **Calcification:** Present in 90% of cases; its absence should make one reconsider the diagnosis.

Q: A 45-year-old man is diagnosed with diabetes for the first time. When should he visit an ophthalmologist?

Immediately at the time of diagnosis. The correct answer is **D. Immediately at the time of diagnosis.** **1. Why the correct answer is right:** In **Type 2 Diabetes Mellitus (T2DM)**, the exact onset of hyperglycemia is often asymptomatic and can occur years (typically 5–7 years) before a clinical diagnosis is made. Consequently, microvascular complications like diabetic retinopathy may already be present at the time of diagnosis [2]. Current clinical guidelines (ADA and AIOS) mandate a comprehensive dilated eye examination by an ophthalmologist **at the time of diagnosis** for all T2DM patients to screen for pre-existing damage [2]. **2. Why the incorrect options are wrong:** * **Options A & C:** Waiting until age 50 or any arbitrary age is dangerous, as retinopathy is duration-dependent, not age-dependent. Delaying screening increases the risk of irreversible vision loss [1]. * **Option B:** Diabetic retinopathy is often asymptomatic in its early, treatable stages (Non-Proliferative Diabetic Retinopathy) [2]. Waiting for "dimness of vision" usually means the disease has progressed to advanced stages like Macular Edema or Proliferative Diabetic Retinopathy, where the prognosis is significantly worse [1]. **3. High-Yield Clinical Pearls for NEET-PG:** * **Type 1 Diabetes:** Screening should begin **5 years after diagnosis** (as the onset of hyperglycemia is acute and known). * **Type 2 Diabetes:** Screening begins **at the time of diagnosis.** * **Pregnancy:** Women with pre-existing diabetes planning pregnancy should have an eye exam **pre-conception**, in the **first trimester**, and then be monitored every trimester. (Note: This does not apply to Gestational Diabetes). * **Follow-up:** If the initial exam is normal, repeat screening is generally recommended **annually**.

Q: In retinitis pigmentosa, 'night-blindness' is an early symptom of visual loss. Which of the following explains this phenomenon?

Cones are relatively preserved compared to rods. **Explanation:** **1. Why Option B is Correct:** Retinitis Pigmentosa (RP) is a hereditary dystrophy characterized by the progressive degeneration of photoreceptors. The primary pathology begins in the **rods**, which are concentrated in the mid-periphery of the retina and are responsible for scotopic (low-light) vision. Because rods are affected first and more severely than cones, the earliest clinical symptom is **nyctalopia (night blindness)**. Cones, which handle photopic (daylight) and central vision, are relatively preserved in the early stages, allowing patients to maintain good visual acuity until the disease progresses to the macula. **2. Why Other Options are Incorrect:** * **Options A & C:** Ganglion cells are the third-order neurons in the visual pathway. While they may eventually undergo secondary degeneration in advanced RP, they are not the primary site of pathology. The hallmark of RP is a "photoreceptor-first" degeneration. * **Option D:** While it is true that ganglion cells are relatively preserved compared to rods, this does not explain the specific symptom of *night blindness*. Night blindness is specifically a result of the functional disparity between the two types of photoreceptors (rods vs. cones). **3. High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Most common is Autosomal Recessive; most severe is X-linked. * **Classic Triad (Fundus):** 1. Arteriolar attenuation (narrowing). 2. Bony spicule pigmentation (mid-periphery). 3. Waxy pallor of the optic disc. * **Visual Field:** Characteristically shows a **ring scotoma**, which progresses to "tunnel vision." * **Electroretinogram (ERG):** The most sensitive test for early diagnosis; shows a **reduced or extinguished 'a' and 'b' wave** (scotopic response affected first). * **Associations:** Usher syndrome (deafness), Laurence-Moon-Biedl syndrome (obesity, polydactyly, hypogonadism).

Q: A 32-year-old male presents with unilateral diminished vision in the right eye. On examination, there is mild iritis, vitritis, and a focal necrotic lesion seen at the macula. What is the most likely diagnosis?

Ocular toxoplasmosis. **Explanation:** The clinical presentation of a **focal necrotic retinochoroiditis** associated with inflammatory signs like **iritis** and **vitritis** (often described as a "headlight in the fog" appearance) is a classic hallmark of **Ocular Toxoplasmosis**. 1. **Why Ocular Toxoplasmosis is correct:** It is the most common cause of posterior uveitis worldwide. In young adults, it typically presents as a unilateral, focal, yellowish-white necrotic lesion. The intense vitreous inflammatory reaction (vitritis) overlying the lesion is a key diagnostic feature. While often a reactivation of a congenital infection (near an old pigmented scar), primary acquired cases also present with active necrotizing retinitis. 2. **Why other options are incorrect:** * **Multiple Evanescent White Dot Syndrome (MEWDS):** Typically presents with multiple, very small, fine white dots at the level of the RPE/deep retina. It lacks the intense vitritis and large focal necrotic lesions seen here. * **Multifocal Choroiditis (MFC):** Characterized by multiple, small, punched-out chorioretinal lesions (similar to Histoplasmosis) but with associated vitritis. It does not typically present as a single large focal necrotic macular lesion. * **Ocular Sarcoidosis:** Usually presents with bilateral granulomatous uveitis, "mutton-fat" keratic precipitates, and "string of pearls" vitreous opacities or retinal periphlebitis (candle-wax drippings), rather than a focal necrotic retinal lesion. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Sign:** "Headlight in the fog" (Active retinitis seen through dense vitritis). * **Treatment of Choice:** Triple therapy (Pyrimethamine, Sulfadiazine, and Folinic acid) + Steroids (Steroids are *never* given without anti-parasitic cover). * **Macula involvement:** Toxoplasmosis has a predilection for the posterior pole, making it a common cause of permanent central vision loss.

Q: The 'Sea-Fan' appearance of the retina is characteristic of which condition?

Sickle cell disease. **Explanation:** The **'Sea-fan' appearance** refers to characteristic neovascularization (new vessel growth) seen in **Sickle Cell Retinopathy**, specifically in the proliferative stage. **1. Why Sickle Cell Disease is correct:** In Sickle Cell Disease (most commonly the SC and S-Thal genotypes), sickled erythrocytes cause microvascular occlusion in the peripheral retinal arterioles. This leads to peripheral ischemia, which triggers the release of Vascular Endothelial Growth Factor (VEGF). This results in **Proliferative Sickle Retinopathy (PSR)**, where new vessels grow in a fan-shaped pattern resembling the marine invertebrate *Gorgonia flabellum* (Sea-fan). These vessels usually arise from arteriovenous anastomoses at the junction of the vascular and avascular retina. **2. Why other options are incorrect:** * **CRAO:** Characterized by a **'Cherry-red spot'** at the macula due to retinal edema and opacification, with the underlying choroid shining through the thin fovea. * **SLE:** Typically presents with **Cotton wool spots** (cytoid bodies) and retinal vasculitis, but does not classically produce sea-fan neovascularization. * **Gaucher’s Disease:** May show small, white, well-defined spots (preretinal glia) or cherry-red spots in rare types, but not peripheral neovascularization. **High-Yield Clinical Pearls for NEET-PG:** * **Goldberg’s Classification:** Used to stage Sickle Cell Retinopathy (Stage III is the Sea-fan stage). * **Salmon-patch hemorrhage:** A pre-proliferative sign (intraretinal hemorrhage). * **Black sunburst:** Areas of RPE hypertrophy/pigmentation following the resorption of a hemorrhage. * **Differential for Sea-fan:** Eales disease, ROP, and Branch Retinal Vein Occlusion (BRVO) can also occasionally show similar patterns, but it is most classic for Sickle Cell.

Q: Retinal detachment in Eale's disease is typically which type?

Tractional RD. **Explanation:** **Eales’ Disease** is an idiopathic inflammatory peripheral perivasculitis (primarily affecting the venules) that leads to peripheral retinal ischemia and neovascularization. **Why Tractional RD is the correct answer:** The hallmark of Eales’ disease is peripheral retinal neovascularization (sea-fan neovascularization). These new vessels are accompanied by fibrous proliferation. As this fibrovascular membrane contracts, it exerts mechanical pull on the retina, leading to a **Tractional Retinal Detachment (TRD)**. This is the most common type of RD seen in the proliferative stage of the disease, similar to the mechanism in Proliferative Diabetic Retinopathy (PDR). **Why other options are incorrect:** * **Exudative RD:** While Eales’ disease involves inflammation and vascular leakage, the primary sight-threatening complication in advanced stages is due to fibrosis and traction, not massive subretinal fluid accumulation. * **Rhegmatogenous RD:** This is caused by a retinal break or tear. While a tractional detachment can occasionally lead to a secondary tear (Tractional-Rhegmatogenous), it is not the primary or typical mechanism in Eales’ disease. **Clinical Pearls for NEET-PG:** * **Demographics:** Typically affects young adult males (20–40 years). * **Association:** Strongly associated with hypersensitivity to **Tuberculoprotein** (Mantoux test is often positive). * **Presentation:** Sudden painless loss of vision most commonly due to **Vitreous Hemorrhage** (the most common complication). * **Stages:** Perivasculitis (sheathing) → Peripheral Ischemia → Neovascularization → Vitreous Hemorrhage/Tractional RD. * **Treatment:** Laser photocoagulation for ischemia; Vitrectomy for non-resolving vitreous hemorrhage or TRD.

Question 1

A 60-year-old man with a 10-year history of hypertension and diabetes mellitus presents with reduced vision in one eye. Fundus examination reveals a central bleed in the affected eye, while the fellow eye is normal. What is the most likely diagnosis?

Accepted Answer

Diabetic retinopathy

Answer

Retinal tear

Answer

Optic neuritis

Answer

Hypertensive retinopathy

Question 2

Which of the following investigations is contraindicated in retinoblastoma?

Accepted Answer

FNAC

Answer

CT

Answer

USG

Answer

MRI

Question 3

A 62-year-old poorly controlled diabetic presents with sudden painless loss of vision. There is no history of floaters. He also complains of a visual field defect which has been progressively worsening over the past few months. He has a history of similar complaints in the other eye, for which vitrectomy was performed. What is the next step in management?

Accepted Answer

Pars plana vitrectomy

Answer

Pan-retinal photocoagulation

Answer

Scleral buckling

Answer

Pneumatic retinopexy

Question 4

Vitreous hemorrhage is commonly caused by which of the following conditions?

Accepted Answer

Retinal vein occlusion

Answer

Retinal artery occlusion

Answer

Retinitis pigmentosa

Answer

Retinoblastoma

Question 5

A 45-year-old man is diagnosed with diabetes for the first time. When should he visit an ophthalmologist?

Accepted Answer

Immediately at the time of diagnosis

Answer

On his 50th birthday

Answer

When dimness of vision starts

Answer

Before his 50th birthday

Question 6

In retinitis pigmentosa, 'night-blindness' is an early symptom of visual loss. Which of the following explains this phenomenon?

Accepted Answer

Cones are relatively preserved compared to rods

Answer

Cones are relatively preserved compared to ganglion cells

Answer

Ganglion cells are relatively preserved compared to cones

Answer

Ganglion cells are relatively preserved compared to rods

Question 7

A 32-year-old male presents with unilateral diminished vision in the right eye. On examination, there is mild iritis, vitritis, and a focal necrotic lesion seen at the macula. What is the most likely diagnosis?

Accepted Answer

Ocular toxoplasmosis

Answer

Multiple evanescent white dot syndrome

Answer

Multifocal choroiditis

Answer

Ocular sarcoidosis

Question 8

The 'Sea-Fan' appearance of the retina is characteristic of which condition?

Accepted Answer

Sickle cell disease

Answer

Central retinal artery occlusion (CRAO)

Answer

Systemic lupus erythematosus (SLE)

Answer

Gaucher's disease

Question 9

Neovascularization in uveal tissue is most commonly caused by?

Accepted Answer

Diabetic Retinopathy

Answer

Central Retinal Vein Occlusion (CRVO)

Answer

Central Retinal Artery Occlusion (CRAO)

Answer

Choroidal melanoma

Question 10

Retinal detachment in Eale's disease is typically which type?

Accepted Answer

Tractional RD

Answer

Exudative RD

Answer

Rhegmatogenous RD

Answer

All of the above

Diseases of the Retina — MCQs

Diseases of the Retina — MCQs

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