FMGE 2025 - Ophthalmology Practice Questions

Q: A patient presents with eyelid crusting and a thready sensation between the cornea and lids. What is the most likely diagnosis?

Chronic Blepharitis. ***Chronic Blepharitis***- This condition is characterized by chronic inflammation of the eyelid margins, leading directly to the observed **eyelid crusting** and debris accumulation at the base of the eyelashes. - The **thready sensation** (often described as a foreign body sensation or stringy mucus) is classic, resulting from poor tear film stability and excessive friction between the chronically inflamed lid margin and the ocular surface.*Dry Eye Syndrome*- While it causes a foreign body sensation, primary uncomplicated dry eye syndrome is less typically associated with significant, persistent **eyelid margin crusting**.- Symptoms are primarily due to inadequate aqueous tear production or excessive evaporation, leading to ocular surface damage, often diagnosed using the **Schirmer test** or tear film breakup time.*Meibomian Gland Dysfunction*- MGD is specifically an obstruction or hypersecretion disorder of the meibomian glands, typically manifesting as poor **lipid layer quality** of the tear film.- Key clinical findings include inspissated gland orifices and telangiectasia on the lid margin, rather than the primary presenting complaint being generalized **eyelid crusting** and debris.*Conjunctivitis*- This typically involves generalized **conjunctival injection** (redness) and discharge (watery, purulent, or mucoid) affecting the entire ocular surface.- While it can cause morning crusting (matting), the chronic presentation focused on the lid margin with persistent **thready sensation** is more characteristic of blepharitis than acute or subacute conjunctival inflammation.

Q: A patient presents with proptosis that increases when bending down. What is the most likely diagnosis?

Orbital Varices. ***Orbital Varices***- This condition involves abnormal orbital veins that swell when orbital venous pressure increases, hence the classic finding of worsening proptosis or **intermittent proptosis** upon bending down or performing the **Valsalva maneuver**.- The proptosis is usually non-pulsatile and often unilateral, resulting from passive congestion of the venous malformation.*Thyroid Eye Disease*- Proptosis in **Thyroid Eye Disease** (**Graves' ophthalmopathy**) is typically caused by chronic inflammation and expansion of **extraocular muscles** and orbital fat, making the proptosis constant.- The severity of proptosis is usually stable and does not fluctuate rapidly or dramatically with maneuvers that increase venous pressure.*Cavernous Sinus Thrombosis*- This condition presents acutely with constant, painful, and progressive proptosis accompanied by **ophthalmoplegia** (due to multiple cranial nerve palsies) and systemic signs like high fever and severe headache.- The clinical picture is typically severe and life-threatening, involving signs of inflammation and infection, not positional congestion.*Orbital Cellulitis*- **Orbital cellulitis** is an acute infectious process characterized by constant, painful, and typically unilateral proptosis, along with severe eyelid swelling (*chemosis*) and **systemic symptoms** (fever).- Proptosis in this condition is fixed and progressive, driven by inflammation and pus formation, and not prone to intermittent worsening simply upon bending down.

Q: What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?

Horner syndrome. No changes were made to the text as none of the provided references reached the relevance threshold of 7/10 for the specific topic of Horner syndrome diagnosis and its differentials. The provided references largely discussed coagulation (mislabeled chapters), neurological signs of intracranial pressure, or general pupillary reflexes without specific diagnostic criteria for Horner syndrome or its differentiating features like anhidrosis.

Q: The finding seen in the image is:

Herbert's pits. ***Herbert's pits*** - These are pathognomonic signs of **cicatricial trachoma**, representing shallow, depressed scars located at the superior corneoscleral junction (limbus). - They are formed by the resolution and scarring of **limbal follicles**, which are characteristic of the active inflammatory stage of trachoma. *Horner-Trantas spots* - These are small, white, gelatinous nodules seen at the limbus, composed of degenerated eosinophils and epithelial cells. - They are a characteristic finding in **vernal keratoconjunctivitis (VKC)**, an allergic eye condition, and are not seen in trachoma. *Pannus* - Pannus refers to the growth of fibrovascular tissue from the limbus onto the peripheral cornea. - While a **superior pannus** is a common finding in trachoma, the specific depressions shown in the image are Herbert's pits, not the pannus itself. *Arlt's line* - This is a horizontal line of scar tissue found on the **tarsal conjunctiva** of the upper eyelid. - It is another sign of cicatricial trachoma but is located on the inner surface of the eyelid, not at the limbus as seen in the image.

Q: A patient with pituitary adenoma compressing the optic chiasma now presents with loss of visual field. What visual field defect will be seen in the patient?

Bitemporal hemianopia. ***Bitemporal hemianopia*** - A **pituitary adenoma** most commonly compresses the **optic chiasma**, where the nasal retinal fibers from both eyes decussate (cross over). - Damage to these crossing fibers specifically leads to the loss of the **temporal visual fields** in both eyes, which is the definition of bitemporal hemianopia. *Homonymous anopia* - This is a less specific term. **Homonymous** defects refer to the loss of the same side of the visual field in both eyes (e.g., the left side in both eyes). - These types of defects are caused by lesions located **posterior** (behind) the optic chiasma, not at the chiasma itself. *Homonymous hemianopia* - This defect describes the loss of the same half (either left or right) of the visual field in both eyes. - It results from a lesion in the visual pathway **posterior** to the optic chiasma, such as in the **optic tract**, **optic radiations**, or the **visual cortex**. *Superior quadrantanopia* - This refers to the loss of vision in the upper quadrant of the visual field, often described as a "pie in the sky" defect. - This is typically caused by a lesion affecting the contralateral **temporal lobe** (damaging **Meyer's loop** of the optic radiation), not the optic chiasma.

Q: A patient presents with complaints of eye strain. The given image shows the focus of light rays in different meridians in the eye. Which refractive error is present in this patient?

Astigmatism. ***Astigmatism*** - The image illustrates that light rays passing through different meridians (vertical and horizontal) of the eye are focused at two separate points, which is the defining feature of **astigmatism**. - This refractive error, typically caused by an irregularly shaped **cornea** or lens, results in the formation of a **conoid of Sturm** (the interval between the two focal lines), causing blurred vision and symptoms like **eye strain**. *Amblyopia* - **Amblyopia**, or lazy eye, is a neurodevelopmental condition where vision is reduced in one eye because the eye and the brain are not working together properly; it is not a refractive error itself. - It can be caused by untreated refractive errors (like severe astigmatism) or **strabismus** during early childhood, but the diagram depicts an optical-physical phenomenon, not a neurological one. *Hypermetropia* - In **hypermetropia** (farsightedness), parallel light rays from all meridians would focus at a single point **behind the retina**, not at two different points as shown. - The image's depiction of two distinct focal lines for vertical and horizontal planes is inconsistent with the uniform focusing seen in simple hypermetropia. *Presbyopia* - **Presbyopia** is the age-related loss of **accommodation**, which is the eye's ability to change focus for near objects due to hardening of the **lens**. - It does not involve different refractive powers in different meridians and therefore is not represented by the optical diagram shown.

Q: A myopic patient presents with complaints of flashes and floaters. On examination, a deep anterior chamber is seen. What is the likely diagnosis?

Rhegmatogenous retinal detachment. ***Rhegmatogenous retinal detachment***- The presence of **flashes (photopsia)** and **floaters** signifies acute **vitreoretinal traction** leading to a retinal break (*rhegma*), a classic presentation of RRD, especially in a **myopic** eye.- A **deep anterior chamber** can indicate **hypotony** (low intraocular pressure), which frequently occurs in RRD due to increased uveoscleral outflow from the fluid egress through the retinal break.*Exudative retinal detachment*- This type is caused by underlying processes like inflammation or tumors and is characterized by a lack of **retinal break** and, therefore, typically does **not** cause flashes or floaters associated with vitreous traction.- The subretinal fluid in this condition classically **shifts** upon changing head position, which is a key differentiating feature.*Tractional retinal detachment*- This form is caused by the contraction of **fibrovascular membranes** on the retinal surface, most commonly seen in advanced **proliferative diabetic retinopathy**.- It is usually slowly progressive and does **not** typically present acutely with the prominent **flashes** and **floaters** that suggest a fresh retinal tear.*Central serous retinopathy*- This condition involves fluid accumulation localized beneath the macula, leading to symptoms like **metamorphopsia** and central scotoma, without involving the peripheral retina.- It does **not** cause a generalized retinal detachment, significant **flashes** and **floaters**, or changes in the **anterior chamber depth**.

Q: Identify the ocular condition shown in the image.

Herbert's pits. ***Herbert's pits*** - The image displays shallow, scalloped depressions at the superior corneoscleral junction (limbus), which are characteristic of **Herbert's pits**. - These pits are pathognomonic for **trachoma**, representing the cicatricial remains of resolved limbal follicles. *Horner-Trantas spots* - These are distinct gelatinous nodules or dots at the limbus composed of degenerated epithelial cells and **eosinophils**. - They are a hallmark sign of **vernal keratoconjunctivitis (VKC)**, an allergic eye disease, and do not appear as pitted scars. *Pannus* - Pannus is the ingrowth of fibrovascular tissue and **neovascularization** onto the cornea, typically from the superior limbus. - While pannus is also a sign of **trachoma**, the image specifically highlights the pitted scarring of Herbert's pits, not a sheet of blood vessels. *Arlt's line* - This refers to a line of scarring on the **tarsal conjunctiva**, which is the inner surface of the eyelid. - It is a sign of cicatricial **trachoma** but would only be visible upon eversion of the eyelid, not on the globe itself as shown in the image.

Q: A patient presents with a painless ulcer in the eye. On examination, a long, branching ulcer with desquamated epithelium is seen on the cornea. What is the most likely diagnosis?

Neurotrophic ulcer. ***Neurotrophic ulcer***- The defining feature of a **neurotrophic ulcer** is the **painless** nature of the epithelial defect, resulting from damage to the **trigeminal nerve** (CN V1) leading to loss of corneal sensation.- The ulcer morphology, described as a persistent epithelial defect (ulcer) with a desquamated, **geographic** or long-branching appearance, is characteristic of the poor healing seen in the setting of chronic denervation.*Fungal ulcer*- Fungal ulcers typically cause marked pain, photophobia, and conjunctival injection, which contrasts sharply with the painless presentation in this patient.- Morphologically, they are often characterized by elevated, gray-white ulcers with **feathery borders** and commonly exhibit satellite lesions or an underlying **immune ring**.*Dendritic ulcer*- A **dendritic ulcer** is pathognomonic for **Herpes Simplex Virus (HSV) keratitis** and is usually associated with significant pain and foreign body sensation.- While it is branching, it stains vividly, and its key features are **terminal bulbs** at the ends of the branches, differentiating it from the desquamated, geographic type of defect seen in neurotrophic disease.*Bacterial corneal ulcer*- Bacterial corneal ulcers are extremely painful, rapidly progressive, and associated with profound inflammation, ciliary injection, and often significant **anterior chamber reaction (hypopyon)**.- They usually present as dense, whitish-yellow **stromal infiltrates** with an overlying epithelial defect, not a painless, superficially desquamated pattern.

Question 1

A patient presents with eyelid crusting and a thready sensation between the cornea and lids. What is the most likely diagnosis?

Accepted Answer

Chronic Blepharitis

Answer

Meibomian Gland Dysfunction

Answer

Dry Eye Syndrome

Answer

Conjunctivitis

Question 2

A patient presents with proptosis that increases when bending down. What is the most likely diagnosis?

Accepted Answer

Orbital Varices

Answer

Orbital Cellulitis

Answer

Cavernous Sinus Thrombosis

Answer

Thyroid Eye Disease

Question 3

What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?

Accepted Answer

Horner syndrome

Answer

Argyll Robertson pupil

Answer

Marcus Gunn pupil

Answer

Adie's tonic pupil

Question 4

The finding seen in the image is:

Accepted Answer

Herbert's pits

Answer

Arlt's line

Answer

Pannus

Answer

Horner-Trantas spots

Question 5

A patient with pituitary adenoma compressing the optic chiasma now presents with loss of visual field. What visual field defect will be seen in the patient?

Accepted Answer

Bitemporal hemianopia

Answer

Superior quadrantanopia

Answer

Homonymous hemianopia

Answer

Homonymous anopia

Question 6

A patient presents with complaints of eye strain. The given image shows the focus of light rays in different meridians in the eye. Which refractive error is present in this patient?

Accepted Answer

Astigmatism

Answer

Presbyopia

Answer

Amblyopia

Answer

Hypermetropia

Question 7

A myopic patient presents with complaints of flashes and floaters. On examination, a deep anterior chamber is seen. What is the likely diagnosis?

Accepted Answer

Rhegmatogenous retinal detachment

Answer

Central serous retinopathy

Answer

Tractional retinal detachment

Answer

Exudative retinal detachment

Question 8

Identify the ocular condition shown in the image.

Accepted Answer

Herbert's pits

Answer

Arlt's line

Answer

Pannus

Answer

Horner-Trantas spots

Question 9

An elderly female presents with sudden onset of pain, redness, and decreased vision. On examination, hazy cornea, fixed mid-dilated pupil, and shallow anterior chamber are noted. What is the diagnosis?

Accepted Answer

Acute congestive glaucoma

Answer

Central retinal artery occlusion

Answer

Acute conjunctivitis

Answer

Acute uveitis

Question 10

A patient presents with a painless ulcer in the eye. On examination, a long, branching ulcer with desquamated epithelium is seen on the cornea. What is the most likely diagnosis?

Accepted Answer

Neurotrophic ulcer

Answer

Bacterial corneal ulcer

Answer

Fungal ulcer

Answer

Dendritic ulcer

FMGE 2025 — Ophthalmology