Pediatric Ophthalmology and Strabismus Practice Questions

Q: True about paralytic squint is:

Binocular diplopia. **Explanation:** **1. Why Binocular Diplopia is Correct:** Paralytic squint occurs due to the paralysis of one or more extraocular muscles (cranial nerves III, IV, or VI). This leads to a misalignment of the visual axes. When the patient looks in the direction of the paralyzed muscle, the image of an object falls on the fovea of the fixing eye but on a non-foveal (peripheral) retinal point in the deviated eye. This results in the perception of two images from a single object. Since this occurs only when **both eyes are open**, it is termed **binocular diplopia**. It characteristically disappears when one eye is covered. **2. Why Other Options are Incorrect:** * **Option A (Uniocular diplopia):** This is seen when a single eye perceives two images, usually due to optical issues like subluxated lens, polycoria, or incipient cataract. It does not disappear upon covering the other eye. * **Option C (Cannot use two eyes together):** This is incorrect because patients with paralytic squint *can* often use their eyes together in certain positions of gaze (the field of least deviation) or by adopting a compensatory head posture to maintain binocular single vision. * **Option D (Diminished visual acuity):** Paralytic squint is a motor nerve/muscle issue and does not inherently cause a loss of vision. Unlike concomitant squint in children, paralytic squint usually occurs in adults, so **amblyopia** (lazy eye) is rare. **Clinical Pearls for NEET-PG:** * **Secondary Deviation > Primary Deviation:** In paralytic squint, the deviation of the sound eye (when the paralyzed eye fixes) is greater than the deviation of the paralyzed eye (when the sound eye fixes). * **False Projection (Past-pointing):** The patient points beyond the object in the direction of the paralyzed muscle. * **Compensatory Head Posture:** Patients tilt or turn their head toward the action of the paralyzed muscle to minimize diplopia.

Q: Regarding amblyopia, which of the following is true?

All of the above.. **Explanation:** Amblyopia, commonly known as "lazy eye," is defined as a unilateral or bilateral reduction in best-corrected visual acuity (BCVA) that occurs in the absence of any detectable organic pathology of the eye. It results from abnormal visual experience during the **critical period** of visual development (birth to age 7–8 years). **Why Option D is Correct:** * **Reversible loss of vision (Option A):** Amblyopia is unique because it is functional, not structural. If detected and treated early (within the critical period) using methods like patching (occlusion therapy) or atropine penalization, the vision loss can be reversed. * **Associated with squint (Option B):** **Strabismic amblyopia** is one of the most common types. When the eyes are misaligned, the brain suppresses the image from the deviated eye to avoid diplopia (double vision), leading to amblyopia in that eye. * **Defect in refractive error (Option C):** **Anisometropic amblyopia** occurs when there is a significant difference in refractive error between the two eyes. The brain favors the clearer image from the less ametropic eye, leading to "disuse" of the other. **High-Yield Clinical Pearls for NEET-PG:** 1. **Types of Amblyopia:** Strabismic (most common), Anisometropic, Isoametropic (high bilateral refractive error), and Stimulus Deprivation (e.g., congenital cataract—the most severe form). 2. **Crowding Phenomenon:** Amblyopic patients find it easier to read isolated letters than a row of letters. 3. **Treatment:** The mainstay is **occlusion of the sound (better) eye** to force the brain to use the amblyopic eye. 4. **Eccentric Fixation:** A common finding in long-standing strabismic amblyopia where the patient uses a non-foveal point for fixation.

Q: Which of the following is NOT an action of the superior oblique muscle?

Extorsion. To master extraocular muscle actions for NEET-PG, remember the primary, secondary, and tertiary functions. The **Superior Oblique (SO)** muscle originates from the apex of the orbit but acts via the trochlea, inserting onto the posterior-superior-lateral quadrant of the globe. ### Why "Extorsion" is the Correct Answer The Superior Oblique is an **intortor**. In ophthalmology, the mnemonic **"SIN"** (Superior muscles are Intortors) is high-yield. Both the Superior Oblique and Superior Rectus perform intorsion. Therefore, **extorsion** is the opposite of its physiological action and is primarily performed by the inferior muscles (Inferior Oblique and Inferior Rectus). ### Analysis of Incorrect Options * **Intorsion (Option D):** This is the **primary** action of the SO. * **Depression (Option B):** This is the **secondary** action. The SO is most effective as a depressor when the eye is in an **adducted** position (visual axis aligned with the muscle's pull). * **Abduction (Option C):** This is the **tertiary** action. Because the SO inserts posterior to the equator, its contraction pulls the back of the eye medially, causing the front of the eye (cornea) to move laterally (abduction). ### NEET-PG Clinical Pearls * **Mnemonic for Obliques:** "O's are Abductors" (Both Superior and Inferior Obliques perform abduction). * **Testing Position:** To isolate the SO's depressing action clinically, ask the patient to look **"Down and In."** * **SO Palsy (4th Nerve):** Presents with **hypertropia** and **excylotorsion**. Patients often adopt a compensatory head tilt to the opposite shoulder to minimize diplopia (Bielschowsky Head Tilt Test).

Q: Which of the following tests measures stereoacuity?

Randot stereoacuity test. **Explanation:** Stereoacuity is the measurement of **stereopsis**, which is the ability to perceive depth based on the slight disparity between the images received by each eye (binocular vision). **Correct Option: C. Randot stereoacuity test** The Randot test is a clinical standard for measuring stereoacuity. It utilizes **random-dot stereograms** and polarized glasses to eliminate monocular cues. The patient must identify shapes (like circles or animals) that appear to "pop out" from the background. It measures depth perception in seconds of arc; a lower number indicates finer stereoacuity. **Incorrect Options:** * **A. Ishihara:** This is the gold standard screening test for **color vision** deficiencies, specifically red-green defects. It uses pseudoisochromatic plates. * **B. Pelli-Robson chart:** This measures **contrast sensitivity**. Unlike the Snellen chart, which uses decreasing sizes of letters, this chart uses letters of the same size but with decreasing contrast against the background. * **D. Snellen’s chart:** This is the most common method for measuring **visual acuity** (the ability to resolve fine detail at a distance). **High-Yield Clinical Pearls for NEET-PG:** * **Normal Stereoacuity:** Usually considered to be **40 seconds of arc** or better. * **Other Stereopsis Tests:** Titmus Fly test (uses a large fly for gross stereopsis), TNO test (uses red-green goggles), and the Lang test (does not require glasses, useful for children). * **Prerequisite:** Good stereopsis requires bifoveal fixation and roughly equal visual acuity in both eyes. It is often absent in patients with **strabismus** or **amblyopia**.

Q: Which of the following drug classes is used in the management of accommodative esotropia?

Miotics. **Explanation:** **Accommodative Esotropia** occurs due to an over-convergence of the eyes triggered by the effort to accommodate (usually to compensate for hyperopia). The management of choice is typically full cycloplegic refraction and corrective glasses. However, **Miotics** (Option A) serve as a pharmacological alternative or adjunct. **Why Miotics are Correct:** Miotics, such as **Echothiophate iodide** or **Pilocarpine**, act by stimulating the ciliary muscle directly. This produces "peripheral accommodation," which reduces the need for central accommodative effort (mediated by the 3rd cranial nerve). By decreasing the central drive to accommodate, the associated **accommodative convergence** is also reduced, thereby straightening the eyes. They are particularly useful in "High AC/A ratio" esotropia. **Why Other Options are Incorrect:** * **B. Mydriatics:** These drugs (like Atropine) paralyze accommodation (cycloplegia). While used for diagnosis (refraction), chronic use would blur near vision and potentially worsen the sensory adaptation to the squint. * **C. Steroids:** These are used for inflammatory conditions (uveitis, episcleritis) and have no role in correcting ocular alignment or innervation. * **D. Antibiotics:** These treat ocular infections and do not affect the extraocular muscles or the accommodative reflex. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** Long-acting cholinesterase inhibitors like **Echothiophate iodide (0.125%)** are the most common miotics used for this condition. * **Side Effect:** A classic exam-favorite side effect of long-term miotic use in children is the formation of **Iris Cysts** (at the pupillary margin). These can be prevented by co-administering **Phenylephrine (2.5%)**. * **Surgical Note:** Surgery is only indicated in accommodative esotropia if there is a "residual deviation" despite full hyperopic correction.

Q: The Hirschberg test measures which of the following conditions?

Strabismus. **Explanation:** The **Hirschberg test**, also known as the **Corneal Light Reflex test**, is a simple, non-invasive clinical method used to estimate the presence and magnitude of **strabismus** (ocular misalignment). **Why Strabismus is the Correct Answer:** The test is performed by shining a light source (penlight) into the patient's eyes from a distance of about 33 cm while the patient fixates on the light. The clinician observes the position of the light reflection (reflex) on the cornea relative to the pupil: * **Normal (Orthophoria):** The reflex is centered or slightly nasal in both pupils. * **Abnormal:** If the reflex is displaced, it indicates a deviation. For every **1 mm** of displacement from the center, there is approximately **7 degrees (or 15 prism diopters)** of ocular deviation. * *Temporal displacement* indicates Esotropia (inward turn). * *Nasal displacement* indicates Exotropia (outward turn). **Why Other Options are Incorrect:** * **Cataract:** Diagnosed via slit-lamp biomicroscopy or distant direct ophthalmoscopy (looking for a red reflex defect). * **Refractive Error:** Measured using retinoscopy or automated refractometry. * **Glaucoma:** Assessed via tonometry (IOP), gonioscopy (angle), and fundoscopy (optic disc cupping). **High-Yield Clinical Pearls for NEET-PG:** * **Krimsky Test:** A modification of the Hirschberg test where prisms are used to center the displaced reflex to quantify the deviation more accurately. * **Pseudo-strabismus:** A common "distractor" in exams; a wide epicanthal fold may make a child look cross-eyed, but a **normal Hirschberg test** (central reflex) confirms the eyes are actually aligned. * **Bruckner Test:** Uses a direct ophthalmoscope to view red reflexes simultaneously; asymmetry suggests strabismus or anisometropia.

Q: Which of the following is NOT an ocular feature of congenital rubella syndrome?

Iritis. **Explanation:** **Congenital Rubella Syndrome (CRS)**, caused by the rubella virus crossing the placenta during the first trimester, presents with a classic triad of **Cataract, Cardiac defects (PDA), and Deafness**. **Why Iritis is the correct answer:** While CRS involves significant ocular inflammation, it characteristically presents as **Chronic Uveitis** or **Iris Hypoplasia** (leading to a lack of pupillary dilation), rather than acute Iritis. The ocular features of CRS are primarily structural and pigmentary rather than acute inflammatory episodes. **Analysis of Incorrect Options:** * **Nuclear Cataract:** This is the most common ocular finding in CRS. The virus persists in the lens fiber for years, typically causing a "pearly white" nuclear opacification. * **Salt and Pepper Retinopathy:** This is the most common *retinal* manifestation. It consists of mottled areas of pigment epithelial hyperpigmentation and atrophy. Importantly, it usually does not affect vision. * **Microphthalmos:** This is a hallmark feature of CRS, often occurring alongside cataracts. The eye is abnormally small due to interference with gestational development. **High-Yield Clinical Pearls for NEET-PG:** * **Gregg’s Triad:** Cataract, Sensorineural hearing loss, and PDA (Patent Ductus Arteriosus). * **Glaucoma:** Infantile glaucoma (buphthalmos) can occur in CRS, but it is less common than cataracts. * **Management Tip:** If a child with CRS has a cataract, surgery should be performed early, but surgeons must be cautious as the **live virus** can remain in the lens for up to 3 years, potentially causing post-operative endophthalmitis. * **Microcornea** is also a frequent finding associated with the microphthalmic eye in these patients.

Q: Which of the following is the most common cause of chronic iridocyclitis in children?

Juvenile idiopathic arthritis. **Explanation:** **Juvenile Idiopathic Arthritis (JIA)** is the most common systemic association and cause of chronic anterior uveitis (iridocyclitis) in the pediatric population. The uveitis associated with JIA is typically **nongranulomatous, chronic, and characteristically asymptomatic** (white-eyed/quiet eye), making it particularly dangerous as it can lead to irreversible vision loss before diagnosis. It is most frequently seen in the **Oligoarticular** subtype, especially in young girls who are **ANA (Antinuclear Antibody) positive**. **Analysis of Incorrect Options:** * **Systemic Lupus Erythematosus (SLE):** While SLE can cause ocular manifestations, it more commonly presents with posterior segment involvement (retinal vasculitis or cotton wool spots) rather than chronic iridocyclitis. * **Sjögren's Syndrome:** This primarily affects the lacrimal glands, leading to **Keratoconjunctivitis Sicca** (dry eye). It is rare in children and does not typically cause primary iridocyclitis. * **Behçet's Disease:** This causes a classic "cold" **hypopyon uveitis**. While it is a cause of uveitis, it is less common in children compared to JIA and usually presents as acute recurrent episodes rather than a primary chronic course. **High-Yield Clinical Pearls for NEET-PG:** * **The "Triad" of JIA Uveitis:** Iridocyclitis, Band-shaped keratopathy, and Complicated cataract. * **Screening:** ANA positivity is the strongest predictor for the development of uveitis in JIA patients. * **Treatment:** Topical steroids and cycloplegics are first-line; Methotrexate is the preferred steroid-sparing agent for chronic cases. * **Key Fact:** Because the eye is often asymptomatic ("White Eye"), periodic slit-lamp screening is mandatory for all children diagnosed with JIA.

Q: Pseudoesotropia is associated with which of the following?

Negative angle kappa. **Explanation:** **Pseudoesotropia** is a clinical condition where the eyes appear to be crossed (turned inward) despite being orthophoric (perfectly aligned). This false impression of esotropia is primarily caused by facial anatomy or optical axes. **Why Negative Angle Kappa is the Correct Answer:** Angle Kappa is the angle between the **visual axis** (line from the object to the fovea) and the **pupillary axis** (line through the center of the pupil). * In a **negative angle kappa**, the fovea is situated nasal to the pupillary axis. To align the visual axis with an object, the eye must shift slightly outward (temporally). * When the eye shifts outward, the light reflex appears to fall on the temporal side of the cornea, making the eye look as if it is turned inward (esotropia). **Analysis of Incorrect Options:** * **A. Hypertelorism:** This refers to an increased distance between the bony orbits. It is typically associated with **pseudoxantropia** (pseudoexotropia), as the wide-set eyes give the appearance of an outward deviation. * **C. Positive Angle Kappa:** This occurs when the fovea is temporal to the pupillary axis (common in hypermetropes). It causes the eye to shift inward to fixate, making the light reflex appear nasal. This results in **pseudoexotropia**. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most Common Cause:** The most common cause of pseudoesotropia in infants is **prominent epicanthal folds** (which hide the nasal sclera) and a **broad, flat nasal bridge**. 2. **Diagnosis:** The **Cover-Uncover Test** is the gold standard; in pseudo-strabismus, there is no corrective movement of the eyes. 3. **Hirschberg Test:** In pseudoesotropia, the corneal light reflex is central or slightly temporal, whereas in true esotropia, it is displaced temporally. 4. **Positive Angle Kappa** is associated with **Hypermetropia**; **Negative Angle Kappa** is associated with **High Myopia**.

Question 1

True about paralytic squint is:

Accepted Answer

Binocular diplopia

Answer

Uniocular diplopia

Answer

The person cannot use the two eyes together

Answer

Diminished visual acuity

Question 2

Regarding amblyopia, which of the following is true?

Accepted Answer

All of the above.

Answer

It is a reversible loss of vision.

Answer

It is associated with squint.

Answer

It is a defect in refractive error.

Question 3

Which of the following is NOT an action of the superior oblique muscle?

Accepted Answer

Extorsion

Answer

Depression

Answer

Abduction

Answer

Intorsion

Question 4

Which of the following tests are appropriate for visual testing in a child?

Accepted Answer

Visual evoked potential and Teller's acuity card test

Answer

Visual evoked potential

Answer

Visual evoked potential and Keratometry

Question 5

Which of the following tests measures stereoacuity?

Accepted Answer

Randot stereoacuity test

Answer

Ishihara

Answer

Pelli-Robson contrast sensitivity chart

Answer

Snellen's chart

Question 6

Which of the following drug classes is used in the management of accommodative esotropia?

Accepted Answer

Miotics

Answer

Mydriatics

Answer

Steroids

Answer

Antibiotics

Question 7

The Hirschberg test measures which of the following conditions?

Accepted Answer

Strabismus

Answer

Cataract

Answer

Refractive error

Answer

Glaucoma

Question 8

Which of the following is NOT an ocular feature of congenital rubella syndrome?

Accepted Answer

Iritis

Answer

Nuclear cataract

Answer

Salt and pepper retinopathy

Answer

Microphthalmos

Question 9

Which of the following is the most common cause of chronic iridocyclitis in children?

Accepted Answer

Juvenile idiopathic arthritis

Answer

Systemic lupus erythematosus

Answer

Sjögren's syndrome

Answer

Behçet's disease

Question 10

Pseudoesotropia is associated with which of the following?

Accepted Answer

Negative angle kappa

Answer

Hypertelorism

Answer

Positive angle kappa

Answer

None of the above

Pediatric Ophthalmology and Strabismus — MCQs

Pediatric Ophthalmology and Strabismus — MCQs

On this page

Practice by Chapter

Want unlimited practice?