Ocular Manifestations of Systemic Disorders Practice Questions

Q: A 30-year-old school teacher presents with complaints of red eye with photophobia. Ocular findings are shown below. All are true about the condition shown except: (Recent NEET Pattern 2016-17)

Muddy iris. ***Muddy iris*** - A "muddy iris" appearance refers to loss of the normal iris architecture and fine details due to **diffuse iris stromal edema** - This is a characteristic feature of **non-granulomatous (acute) anterior uveitis**, not granulomatous uveitis - The images show **granulomatous anterior uveitis** (evidenced by mutton-fat KPs), where muddy iris is typically **absent** or less prominent - **This is the correct answer** as it is NOT a typical feature of the condition shown *Mutton-fat keratic precipitates* - The left image shows large, greasy-looking deposits on the corneal endothelium - These are characteristic **mutton-fat keratic precipitates (KPs)** composed of macrophages and epithelioid cells - These are **pathognomonic for granulomatous uveitis** and are clearly visible in the condition shown *Dalen-Fuchs nodules* - These are yellowish-white collections of lymphocytes and epithelioid cells between **Bruch's membrane and the RPE** in the peripheral fundus - They are a feature of **granulomatous posterior uveitis**, particularly in **Vogt-Koyanagi-Harada (VKH) disease** and sympathetic ophthalmia - While not visible in these anterior segment images, they **can coexist** in patients with granulomatous panuveitis *Aqueous flare* - The right image (slit lamp beam) shows visible **aqueous flare** - cloudiness in the anterior chamber - This indicates **protein leakage** from breakdown of the blood-aqueous barrier - This is a **direct sign of active inflammation** and is commonly seen in both granulomatous and non-granulomatous uveitis

Q: A patient presents with the clinical findings shown in the image. What is the most likely diagnosis?

Herpes zoster ophthalmicus. ***Herpes zoster ophthalmicus*** - The image shows a classic vesicular rash following the **dermatomal distribution** of the trigeminal nerve (V1 branch), affecting the forehead, eyelid, and bridge of the nose. - The involvement of the eye and surrounding tissue, particularly with vesicles on the tip of the nose (**Hutchinson's sign**), indicates potential ocular involvement and confirms Herpes zoster ophthalmicus. *Orbital cellulitis* - Characterized by **painful proptosis**, **ophthalmoplegia**, and **vision loss**, which are not clearly visible or suggested by the skin lesions. - While there is periorbital swelling, the distinctive vesicular rash in a dermatomal pattern is absent in orbital cellulitis. *Angle closure glaucoma* - Presents with a **sudden onset of severe eye pain**, blurred vision, **fixed mid-dilated pupil**, and colored halos, without external skin lesions. - This condition is an intraocular emergency and does not involve the characteristic rash seen in the image. *Subcutaneous emphysema* - Involves **air trapped under the skin**, causing a characteristic **crepitus** on palpation. - It often results from trauma or surgery and does not present with vesicular skin lesions.

Q: A 15-year-old child was diagnosed with Fanconi's syndrome. His school grades have been consistently poor and he has involuntary movements in his hands. Drug screening is negative. Eye finding shows: (APPG 2016)

KF ring. ***KF ring*** - The combination of **Fanconi's syndrome** (renal tubular acidosis), **poor school grades** (neurological deterioration), and **involuntary movements** (extrapyramidal symptoms) is highly suggestive of **Wilson's disease**. - **Kayser-Fleischer (KF) rings** are characteristic ocular findings in Wilson's disease, caused by **copper deposition** in the Descemet membrane of the cornea, which appears as a greenish-brown ring. *Vogt's striae* - **Vogt's striae** are vertical stress lines in the deep stroma and Descemet's membrane of the cornea, typically seen in advanced **keratoconus**. - While keratoconus can be associated with certain syndromes, it is not directly linked to the neurological and renal symptoms described in the patient. *Fleischer ring* - A **Fleischer ring** is a deposition of **iron pigment (hemosiderin)** in the basal epithelial cells of the cornea, often seen at the base of the cone in **keratoconus**. - Like Vogt's striae, it is an indicator of keratoconus and does not align with the systemic symptoms presented. *Stocker line* - A **Stocker line** is a **ferric oxide deposition** that appears as a brown line on the corneal epithelium, typically associated with the advancing edge of a **pterygium**. - This finding is specific to pterygium and is not systemic, thus not explaining the patient's neurological and renal issues.

Q: What does the following image show?

Busacca nodules. ***Busacca nodules*** - The image shows multiple, small, translucent nodules scattered across the iris surface, consistent with **Busacca nodules**. - These nodules are collections of **macrophages and epithelioid cells** located in the **stroma of the iris**, typically seen in granulomatous anterior uveitis. *Salzmann's nodular degeneration* - This condition involves elevated, **bluish-white to grayish nodules** usually found in the **mid-peripheral cornea**, often associated with chronic keratitis. - The image displays nodules on the iris, not the cornea. *Koeppe's nodules* - **Koeppe's nodules** are small, grayish-yellow cellular aggregates found at the **pupillary margin**, which are typically less prominent and uniform than what is seen in the image. - While also associated with uveitis, their location is strictly at the pupillary edge, unlike the more widespread distribution in the image. *Cornea guttata* - **Cornea guttata** are small, refractile, wart-like excrescences on the **Descemet's membrane** (innermost layer of the cornea) due to endothelial dysfunction. - They appear as small, dark spots in retroillumination but are not elevated nodules on the iris surface as depicted.

Q: The image shows a child with?

Oculo-cutaneous albinism. ***Oculo-cutaneous albinism*** - The image exhibits signs consistent with **oculocutaneous albinism**, particularly the striking **transillumination defect** of the iris, where light passes through the iris, indicating a lack of melanin. - This condition is characterized by reduced or absent melanin production in the hair, skin, and eyes, leading to symptoms like **photophobia**, nystagmus, and reduced visual acuity. *Telangiectasia* - **Telangiectasia** refers to dilated small blood vessels visible on the skin or mucous membranes, typically appearing as fine red lines. - These are not the primary feature shown in the image; the prominent finding is the lack of iris pigmentation and visible fundus reflex through the iris. *Bitot's spots* - **Bitot's spots** are foamy, triangular patches of keratinized conjunctiva, often seen in the interpalpebral fissure, indicative of **Vitamin A deficiency**. - No such foamy patches are visible in the provided image. *Pterygium* - A **pterygium** is a benign growth of the conjunctiva that extends onto the cornea, typically wedge-shaped and often associated with UV exposure. - The image does not show any corneal encroachment by conjunctival tissue; rather, the underlying issue is related to pigmentation.

Q: Of the following ocular manifestations of Vitamin A deficiency, the first sign that can be clinically seen is:

Conjunctival Xerosis. ***Conjunctival Xerosis*** - This is the **earliest clinical sign** of vitamin A deficiency in the eye, characterized by dryness of the conjunctiva. - It often progresses from a dull, lusterless appearance to the development of **Bitot's spots**. *Bitot's spots* - These are **foamy, triangular patches** of keratinized epithelium on the conjunctiva, usually temporal to the cornea. - While a prominent sign, they appear **after** the initial dryness of conjunctival xerosis. *Nyctalopia* - Also known as **night blindness**, this is a **functional symptom** rather than a visible clinical sign. - It indicates impaired vision in low light conditions due to dysfunction of the **retinal rods**, which is a consequence of vitamin A deficiency. *Corneal Xerosis* - This is a more **advanced stage** of vitamin A deficiency, where the dryness has progressed to affect the cornea. - It appears **after** conjunctival xerosis and can lead to more severe complications like corneal ulceration and keratomalacia.

Q: The most common ocular lesion peculiar to HIV infection in early stage is :

Soft exudates in retina. ***Soft exudates in retina*** - **Soft exudates**, also known as **cotton wool spots**, are the most common early ocular manifestation in HIV infection. - They represent ischemia of the nerve fiber layer due to microvascular occlusion and do not generally affect vision significantly. *Retinal necroses* - **Retinal necroses**, such as those seen in **progressive outer retinal necrosis (PORN)** or **acute retinal necrosis (ARN)**, are typically severe and rapidly progressive. - They are usually associated with advanced HIV infection (low CD4 count) and viral etiologies like **CMV retinitis** or **VZV**, not early stage HIV. *Retinal hemorrhages* - **Retinal hemorrhages** can occur in HIV, but they are often associated with systemic conditions like **thrombocytopenia** or **anemia**, or advanced opportunistic infections. - They are not considered the *most common* lesion peculiar to early HIV itself. *Kaposi's sarcoma* - **Kaposi's sarcoma** is a vascular tumor caused by **HHV-8 infection** and is associated with advanced immunosuppression in HIV. - While it can affect the conjunctiva or eyelids, primary intraocular involvement is rare and typically presents in later stages, not early HIV.

Q: In patients with systemic hypertension, the characteristic haemorrhage seen on ophthalmoscopy is

Flame-shaped haemorrhage. ***Flame-shaped haemorrhage*** - **Flame-shaped hemorrhages** are superficial, linear hemorrhages occurring in the **nerve fiber layer** of the retina, characteristic of **hypertensive retinopathy**. - They result from the rupture of superficial capillaries due to **elevated intravascular pressure** in systemic hypertension. *Wet sponge haemorrhage* - This term is not a standard description for retinal hemorrhage types. - Retinal hemorrhages are typically categorized by their shape and depth, such as dot-and-blot, flame-shaped, or subretinal. *Suprachoroidal haemorrhage* - **Suprachoroidal hemorrhages** occur between the choroid and the sclera, often due to trauma or surgical complications. - They are much deeper than retinal hemorrhages and are typically not a direct, primary manifestation of chronic systemic hypertension on routine ophthalmoscopy. *Dot haemorrhage* - **Dot haemorrhages** are deep, punctate hemorrhages occurring in the **inner nuclear** or **outer plexiform layers** of the retina. - While they can be seen in various conditions including diabetic retinopathy, they are not the most characteristic type of hemorrhage seen specifically in systemic hypertension.

Q: Consider the following : 1. Night blindness 2. Corneal xerosis 3. Conjunctival xerosis 4. Keratomalacia What is the correct sequence of the above in the progress of clinical presentation of vitamin A deficiency blindness?

1-3-2-4. ***1-3-2-4*** - This is the **correct sequence** according to WHO classification of xerophthalmia in vitamin A deficiency. - **Night blindness (XN)** is typically the **earliest clinical manifestation**, resulting from impaired rod photoreceptor function due to insufficient rhodopsin synthesis. - This is followed by **conjunctival xerosis (X1A)**, characterized by dryness and thickening of the bulbar conjunctiva, often accompanied by Bitot's spots (X1B) - foamy triangular patches of keratinized epithelium. - As deficiency progresses, **corneal xerosis (X2)** develops, with dryness extending to the corneal surface, creating a hazy, lusterless appearance. - The final and most severe stage is **keratomalacia (X3)**, involving corneal softening, ulceration, and potential perforation leading to irreversible blindness. *2-1-4-3* - This sequence incorrectly places **corneal xerosis** before **night blindness**. - Night blindness is a functional symptom that appears early, while corneal xerosis is a later structural change. - The progression also illogically places keratomalacia before conjunctival xerosis. *1-2-3-4* - This sequence incorrectly suggests **corneal xerosis** precedes **conjunctival xerosis**. - In vitamin A deficiency, xerosis (dryness) affects the **conjunctiva first**, then progresses to involve the **cornea**. - The conjunctiva is more susceptible to early changes than the cornea. *1-3-4-2* - This sequence incorrectly places **keratomalacia** before **corneal xerosis**. - Keratomalacia represents corneal softening and melting, which cannot occur before the cornea becomes xerotic (dry). - Corneal xerosis is a **prerequisite** for the development of keratomalacia.

Q: A patient presented with dryness in the eye with a gritty sensation along with corneal softening. What is the most probable cause?

Vitamin A deficiency. Vitamin A deficiency - **Dry eyes** with a **gritty sensation (xerophthalmia)** and **corneal softening (keratomalacia)** are classic signs of severe vitamin A deficiency [1], [2]. - This condition can lead to blindness if not treated promptly, as vitamin A is crucial for the health of the **cornea** and **retina** [1], [2]. *Follicular conjunctivitis* - Characterized by the presence of **lymphoid follicles** on the conjunctiva, often due to viral infections like **adenovirus** or **chlamydia**. - While it can cause dryness, it does not typically lead to **corneal softening** or the severe vision-threatening complications seen with vitamin A deficiency. *Viral Keratitis* - Involves inflammation of the **cornea** due to a viral infection, commonly by **herpes simplex virus**. - Symptoms include pain, redness, blurred vision, and sensitivity to light, but **generalized dryness** and **corneal softening** as the primary presentation are less characteristic. *Riboflavin Deficiency* - Also known as **ariboflavinosis**, this deficiency can cause ocular symptoms like **photophobia**, **corneal vascularization**, and **conjunctivitis**. - However, it typically does not present with **severe dry eyes** or **corneal softening (keratomalacia)** as seen in vitamin A deficiency.

Question 1

A 30-year-old school teacher presents with complaints of red eye with photophobia. Ocular findings are shown below. All are true about the condition shown except: (Recent NEET Pattern 2016-17)

Accepted Answer

Muddy iris

Answer

Mutton-fat keratic precipitates

Answer

Dalen-Fuchs nodules

Answer

Aqueous flare

Question 2

A patient presents with the clinical findings shown in the image. What is the most likely diagnosis?

Accepted Answer

Herpes zoster ophthalmicus

Answer

Orbital cellulitis

Answer

Angle closure glaucoma

Answer

Subcutaneous emphysema

Question 3

A 15-year-old child was diagnosed with Fanconi's syndrome. His school grades have been consistently poor and he has involuntary movements in his hands. Drug screening is negative. Eye finding shows: (APPG 2016)

Accepted Answer

KF ring

Answer

Vogt's striae

Answer

Fleischer ring

Answer

Stocker line

Question 4

What does the following image show?

Accepted Answer

Busacca nodules

Answer

Salzmann's nodular degeneration

Answer

Koeppe's nodules

Answer

Cornea guttata

Question 5

The image shows a child with?

Accepted Answer

Oculo-cutaneous albinism

Answer

Telangiectasia

Answer

Bitot's spots

Answer

Pterygium

Question 6

Of the following ocular manifestations of Vitamin A deficiency, the first sign that can be clinically seen is:

Accepted Answer

Conjunctival Xerosis

Answer

Bitot's spots

Answer

Nyctalopia

Answer

Corneal Xerosis

Question 7

The most common ocular lesion peculiar to HIV infection in early stage is :

Accepted Answer

Soft exudates in retina

Answer

Retinal necroses

Answer

Retinal hemorrhages

Answer

Kaposi's sarcoma

Question 8

In patients with systemic hypertension, the characteristic haemorrhage seen on ophthalmoscopy is

Accepted Answer

Flame-shaped haemorrhage

Answer

Wet sponge haemorrhage

Answer

Suprachoroidal haemorrhage

Answer

Dot haemorrhage

Question 9

Consider the following :

1. Night blindness

2. Corneal xerosis

3. Conjunctival xerosis

4. Keratomalacia
What is the correct sequence of the above in the progress of clinical presentation of vitamin A deficiency blindness?

Accepted Answer

1-3-2-4

Answer

2-1-4-3

Answer

1-2-3-4

Answer

1-3-4-2

Question 10

A patient presented with dryness in the eye with a gritty sensation along with corneal softening. What is the most probable cause?

Accepted Answer

Vitamin A deficiency

Answer

Follicular conjunctivitis

Answer

Viral Keratitis

Answer

Riboflavin Deficiency

Ocular Manifestations of Systemic Disorders — MCQs

Ocular Manifestations of Systemic Disorders — MCQs

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