A29 year old woman is accidently hit in the eye by her 2 year old

daughter. Her vision was temporarily very blurred but has now
improved to 6/9. The slit lamp appearance is as seen in the
photograph. Which ONE of the following statements is MOST likely

to be TRUE?
Select one:
a. She should be on bed rest until the hyphaema has resolved.
b. A secondary haemorrhage is most likely to occur after 5 to 6
days.
c. Associated pain can be adequately managed with aspirin.
d. The anterior chamber angles should be examined.
The peak incidence of secondary haemorrhages is days 3 to 4 post
injury and is usually due to retraction of the clot and fibrin that has
occluded the traumatised vessel until that time. The risk of
secondary bleeding reduces with age and is highest in children
under 6.

Aspirin has anti-platelet properties and its use is contraindicated as

the risk of secondary bleeding is increased.

There is no evidence that bed rest has any prognostic benefit

particularly for small hyphaemas.

Blunt trauma sufficient to cause a hyphaema may cause angle

recession putting her at risk of secondary glaucoma.
The correct answer is: The anterior chamber angles should be
examined.
A 31 year old woman presents with blurred vision and floaters. On
examination she has a normal anterior segment, acuity of 6/9 and
cells in her vitreous. After pupil dilation clumps of whitish material
are seen in the inferior vitreous. Which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. She has had a posterior vitreous detachment.
b. Retinal detachment is the most common reason for long term
reduced vision.
c. First line treatment is hourly topical prednisolone 1%.
d. Investigation must include serum angiotensin converting
enzyme, a chest X Ray and cranial MRI scan.
Feedback

She has intermediate uveitis, which may be the first evidence that a
patient has an autoimmune disease and may be an initial
manifestation of multiple sclerosis (especially presenting at this
age) or sarcoidosis, so as a bare minimum these should be
excluded.

The commonest cause of permanent visual loss is cystoid macula

oedema

This patient is very young to have a posterior vitreous detachment

although it is no impossible, but the vitreous changes inferiorly
suggest something else.

The mainstay of treatment of intermediate uveitis is steroids

however they should only be used topically if there is an associated
anterior uveitis as they are unable o penetrate into the vitreous in
sufficient concentration to be of any value in the presence of
vitritis. Periocular injection and /or oral steroids are first line
treatment.
The correct answer is: Investigation must include serum
angiotensin converting enzyme, a chest X Ray and cranial MRI
scan.
A 33 year old woman presents with mild ocular discomfort and
slightly reduced vision (6/9). She had a similar episode a year
previously which resolved in 3 days. On examination her eye is
white, there is a faint flare in her anterior chamber but no cells and
there are fine keratic precipitates on the inferior endothelium. The
intraocular pressure is 55mm Hg, she has a normal visual field and
healthy looking optic nerve head. Which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. There will be a family history of open angle glaucoma.
b. She needs an urgent trabeculectomy.
c. A topical mydriatic must be included in the treatment.
d. Treatment is with a topical non-steroidal anti-inflammatory
agent.
Feedback

This patient most likely has a glaucomatocyclitic crisis (Posner-

Schlossman syndrome) in which a very mild uveitis is associated
with a very high IOP (usually 40-60 mm Hg). The level of IOP is
related to the duration of the mild uveitis rather than its severity.

It typically occurs between age 20 and 50 and is almost always

unilateral and is currently thought to be as a result of
cytomegalovirus infection.

Treatment is usually with topical non steroidal anti-inflammatory

agents and topical hypotensives. Peripheral anterior synechiae
rarely form and a mydriatic is unnecessary. Ongoing treatment is
not necessary between episodes.
The correct answer is: Treatment is with a topical non-steroidal
anti-inflammatory agent.

A 68 year old man presents 3 days after cataract surgery with

increasing pain in his eye, mild reduction in vision compared with
the immediate postoperative period and watering. On examination
his visual acuity is 6/12, the eye is slightly injected, the cornea clear
and intraocular pressure 23 mm Hg. There is a 1 mm white
hypopyon significant flare and 2+ cells in the anterior chamber.
There is a clear view of a normal retina. Which ONE of the
following statements is MOST likely to be TRUE?
Select one:
a. He should have an urgent vitreous tap and intravitreous
antibiotics.
b. He should be started on a topical prostaglandin inhibitor.
c. He should use guttae dexamethasone hourly and be reviewed
the following day.
d. He should have an anterior chamber tap to reduce the pressure
and the aspirate sent for microbiological examination.
Feedback

It is important to differentiate between an excessive postoperative

response and infective endophthalmitis in any inflammation
following intraocular surgery.
Endophthalmitis usually presents with severe pain (but not always),
significant redness and the vision is markedly reduced. There is
evidence of inflammatory activity in the vitreous cavity and maybe
an absent red reflex. This patient has mild loss of vision a not
particularly red eye and settled level of white cells in the anterior
chamber which is most likely to be a severe postoperative uveitis
treated by increasing the steroids with or without a topical
hypotensive. It is of course prudent to review the patient early to
ensure this is effectively resolving the problem. High dose topical
steroids are unlikely to have a beneficial impact on
endophthalmitis.
The correct answer is: He should use guttae dexamethasone hourly
and be reviewed the following day.

A 69 year old man complains of loss of vision in his right eye. His
fundal appearance is shown in the photograph. Which ONE of the
following statements is MOST likely to be TRUE?

Select one:
a. He has an arcuate visual field defect.
b. Nutritional supplements would have slowed progression.
c. There is a masking defect on fundus fluorescein angiography.
d. The abnormal area is outlined by a halo of autofluorescence.
Feedback

This is a photograph of geographic retinal atrophy which is a form

of dry age related macular degeneration (AMD) producing a well
demarcated area of central atrophy with visible large choroidal
vessels. This appearance can also develop following treated
neovascular AMD

This patient will complain of progressive loss of central vision and

will have a central scotoma. Arcuate scotomas are usually seen with
nerve fibre layer abnormalities at the optic nerve head. A
fluorescein angiogram will show a window defect because of loss
of the retinal layers overlying the choroid.
Retinal autofluorescence increases with age due to accumulation
of lipofuscin. The pattern of autofluorescence at the periphery of
the abnormal area can be used to predict progression.

The age related eye disease study (AREDS) showed and overall
reduction in progression to severe AMD with nutritional
supplements but this was mostly due to reduction in neovascular
AMD with little influence on progression of geographic atrophy
The correct answer is: The abnormal area is outlined by a halo of
autofluorescence.
A 72 year old man presents with left sided headache and sudden
loss of vision in his left eye. Which ONE of the following statements
is MOST likely to be TRUE?
Select one:
a. Treatment with IV steroids should be started immediately.
b. The CRP is likely to be around 2.7mg/dL.
c. The optic nerve head looks normal.
d. A temporal artery biopsy will show intimal thickening.
Feedback

The correct answer is: Treatment with IV steroids should be started

immediately.

A 72 year old man presents with sudden loss of vision in his right
eye. On examination the visual acuity is counting fingers, he has a
relative afferent pupil defect, the intraocular pressure is normal and
his fundus appearance is shown in the photograph. Which ONE of
the following statements is MOST likely to be TRUE?

Select one:
a. This is a non ischaemic central retinal vein occlusion.
b. He is at risk of secondary angle closure glaucoma.
c. An ERG will show increased amplitude of the b wave.
d. He should have an urgent C reactive protein (CRP) measurement.
Feedback

The patient has had a central retinal vein occlusion (CRVO) and the
level of acuity and presence of a relative afferent pupil abnormality
suggests it is likely to be ischaemic. He is therefore at risk of
neovascualrisation of the optic disc, the peripheral retina and the
iris angle leading to secondary glaucoma.

An urgent CRP would be indicated to exclude giant cell arteritis in

the case of a central retinal artery occlusion.

The b wave of the ERG is generated from the inner retina. When
perfusion of the inner retina is reduced as occurs in CRVO the b
wave amplitude is reduced relative to the a wave which is
generated from the outer retina.
The correct answer is: He is at risk of secondary angle closure
glaucoma.

A 73 year old woman presents with epiphora which is worst when

she is outdoors. There are no other symptoms and her eyelid
appearance is shown in the photograph. Which ONE of the
following statements is MOST likely to be TRUE?

Select one:
a. This appearance may be seen following a seventh cranial nerve
(facial) palsy.
b. The abnormality is more common in females than males.
c. The conjunctiva is likely to remain healthy.
d. Epiphora is most likely to be due to functional nasolacrimal duct
obstruction.
Feedback

This is a photograph of a patient with an ectropion in whom the

epiphora is most likely due to the canalicular opening having
moved away from the lacrimal puddle.

Exposure of the tarsal conjunctiva will result in it becoming dry and

keratinized and possibly infected if left untreated.

Because of the larger size of the tarsal plate in men women more
commonly get an entropion and men an ectropion. Loss of tone in
the orbicularis muscle following a seventh nerve palsy commonly
causes an ectropion as well as an inability to close the eye.
The correct answer is: This appearance may be seen following a
seventh cranial nerve (facial) palsy.

A corneal graft performed for which ONE of the following

conditions is at highest risk of disease recurrence in the grafted
tissue?
Select one:
a. Lattice dystrophy.
b. Keratoconus.
c. Post keratitis corneal scarring.
d. Macular dystrophy.
Feedback

It has been shown that the highest risk of recurrence is with

corneal dystrophy of Bowmans membrane followed by lattice
dystrophy and granular dystrophy. Recurrence hardly ever occurs
for macular dystrophy.

There are a number of case reports of recurrence of keratoconus

following keratoplasty
The correct answer is: Lattice dystrophy.

A diagnosis of acute anterior uveitis is made and from the history

you suspect the patient may have systemic lupus erythematosus.
Which ONE of the following investigations is MOST likely to help
confirm the diagnosis?
Select one:
a. Hepatitis B surface antigen.
b. Antineutrophil cytoplasmic antibody.
c. Antinuclear antibody.
d. Human leukocyte antigen typing.
Feedback

Antineutrophil cytoplasmic antibody (ANCA) and Hepatitis B

surface antigen are useful in the diagnosis of polyarteritis nodosa.

HLA typing may show a result raising the possibility of ankylosing

spondylitis, psoriatic arthritis or inflammatory bowel disease.

Postivive antinuclear antibody (ANA) is seen in SLE, progressive

systemic sclerosis and rheumatoid arthritis.
The correct answer is: Antinuclear antibody.

Question 11
I
A pathology report describes areas of tumour cells arranged in a
ring around a central lumen containing cytoplasmic extensions
from the tumour cells. Which ONE of the following is the MOST
likely diagnosis?
Select one:
a. Retinoblastoma.
b. Sebaceous cell carcinoma.
c. Merkel cell tumour.
d. Nevus of Ota.
Feedback

This is a description of Flexner-Wintersteiner rosettes which

indicates a specific type of tumour differentiation. Electron
microscopy would show that the tumour cells have ultrastructural
features of primitive photoreceptors.

These rosettes are a classic feature of retinoblastoma but are also

found in pineoblastomas and medulloepitheliomas.
The correct answer is: Retinoblastoma.
Question 12
A patient had this image taken following a review appointment in a
clinic. Which ONE of the following statements is MOST likely to be
TRUE?

Select one:
a. Fluorescein angiography will confirm a healthy optic disc.
b. The patient has had maximal pan retinal photocoagulation.
c. The patient has acute multifocal placoid pigment epitheliopathy.
d. The patient should have their HbA1c checked.
Feedback

A fluorescein angiogram is likely to show leakage from the new

vessels on the optic disc

The peripheral lesions in this photograph are old scars from laser
photocoagulation.

Despite previous treatment there is still active disc

neovasularisation and the patients diabetic control should be
checked with an HbA1c and treatment should be with more laser
photocoagulation.
The correct answer is: The patient should have their HbA1c
checked.
Question 13
In which ONE of the following conditions is a forced duction test
MOST likely to be normal?
Select one:
a. A-pattern esotropia.
b. Healed orbital floor fracture.
c. Browns syndrome.
d. Thyroid associated eye disease.
Feedback

A forced duction test which can be done under local or general

anaesthetic identifies a mechanical reduction in ocular movements
either partial or complete.

The oculomotility problems in thyroid eye disease are mechanical

due to changes in the muscles themselves. There may be residual
adhesions from a healed orbit floor fracture, even in an
asymptomatic patient and Browns syndrome is a mechanical
problem at the superior oblique tendon, trochlea interface.
The correct answer is: A-pattern esotropia.
Question 14
Regarding anterior lenticonus, which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. It is present from birth.
b. Clear lens extraction provides good visual rehabilitation.
c. It is not associated with systemic disease.
d. It is due to an abnormal type II collagen.
Feedback

Anterior lenticonus is due to weakness of type IV collagen in the

basement membrane of the anterior lens capsule.

Posterior lenticonus has no association with systemic disease but

anterior lenticonus is pathognomonic of X-linked Alport syndrome
occurring in 25% of patients although the most common ocular
pathology in that condition is dot and fleck retinopathy which
occurs in 85% of patients.

Anterior lenticonus is not a congenital change but develops over

time manifest as changing vision initially requiring frequent change
of glasses prescription.
The correct answer is: Clear lens extraction provides good visual
rehabilitation.
Question 15
Regarding anterior segment ischaemia following squint surgery,
which ONE of the following statements is MOST likely to be TRUE?
Select one:
a. It is more common following horizontal muscle surgery.
b. Hypotony is a sign of moderate ischaemia.
c. Pupil abnormalities only occur with severe ischaemia.
d. It is due to disruption of the posterior ciliary vessels.
Feedback

Anterior segment ischaemia is a rare complication of squint

surgery and in general the more muscles which are disinserted the
greater the risk however there is a significant reduction in anterior
segment blood flow after vertical muscle surgery.

It is the anterior ciliary vessels which are interrupted when rectus

muscles are disinserted.

Mild cases may only show reduced iris perfusion and pupil
abnormalities but when more severe there may be uveitis,
keratopathy and hypotony.
The correct answer is: Hypotony is a sign of moderate ischaemia.
Question 16
Regarding bleb leaks following trabeculectomy, which ONE of the
following statements is MOST likely to be TRUE?
Select one:
a. They can occur years after the original surgery.
b. It may be associated with a high IOP.
c. They cannot be diagnosed by a Siedel test.
d. There is a lower incidence following use of mitomycin C.
Feedback

The correct answer is: They can occur years after the original
surgery.
Question 17
Regarding carotid-cavernous fistula (CCF), which ONE of the
following statements is MOST likely to be TRUE?
Select one:
a. Orbit ultrasound cannot differentiate a CCF from dysthyroid eye
disease.
b. There is an increased incidence in patients with pseudoxanthoma
elasticum.
c. Treatment requires intracranial surgery.
d. A dural carotid-cavernous fistula may resolve spontaneously.
Feedback

First line treatment is an endovascular intervention using a variety

of materials including balloons, coils or embolic material. However
low flow dural fistuiae may resolve spontaneously and
management can be conservative in low risk cases.

Orbit ultrasound can be used to differentiate a CCF from other

conditions including thyroid eye disease as in addition to muscle
enlargement and orbit congestion the superior ophthalmic vein is
dilated

Causes of CCF include trauma, hypertension, dissection of the

internal carotid artery and Ehlers-Danlos syndrome type IV.
The correct answer is: A dural carotid-cavernous fistula may resolve
spontaneously.
Question 18
Regarding chronic progressive external ophthalmoplegia, which
ONE of the following statements is MOST likely to be TRUE?
Select one:
a. It usually presents with diplopia.
b. It is a mitochondrial myopathy.
c. Somatic muscles are not affected.
d. A tensilon test is positive.
Feedback

A tensilon test is negative and is a good way of differentiating this

condition from myasthenia gravis

The most frequent presentation of chronic progressive external

ophthalmoplegia (CPEO) is progressive ptosis, which may occur
years before the onset of extraocular muscle weakness.

Patients often get progressive weakness of facial and neck and

shoulder muscles although limb involvement is les frequent.
The correct answer is: It is a mitochondrial myopathy.
Question 19
Regarding congenital nasolacrimal duct obstruction, which ONE of
the following statements is MOST likely to be TRUE?
Select one:
a. It is usually due to obstruction at the upper end of the
nasolacrimal duct.
b. It most frequently presents with acute dacryocystitis before age
3 months.
c. There is an increased frequency in babies with trisomy 21 (Downs
syndrome).
d. Probing after the age of 1 year will be unsuccessful.
Feedback

The nasolacrimal duct develops as a solid cord, which canalizes late

in development usually ending at the eighth month but is not
complete at the time of birth in 2-4% of babies. The last part of the
nasolacrimal duct to canalize is the opening into the inferior
meatus of the nose. In symptomatic babies 90% will resolve by age
1 year.
The most frequent presentation is a persistently watery and sticky
eye from the age of around 2 weeks.

It is general recommended that probing is delayed until 9-12

months of age as the majority will spontaneously resolve in that
time. However even a late presentation can be successfully treated
after the age of 1 years old.

The incidence in babies with Downs syndrome is variably reported

as between 22 and 36%.
The correct answer is: There is an increased frequency in babies
with trisomy 21 (Downs syndrome).
Question 20
Regarding Graves disease, which ONE of the following statements
is MOST likely to be TRUE?
Select one:
a. It is associated with a worsening of diabetic control.
b. There is an association with myasthenia gravis and sarcoidosis.
c. Thyrotropin antibodies do not cross the placenta.
d. 50% of patients who are euthyroid develop thyroid disease
within 18 months.
Feedback

Only 15-20% of patients with euthyroid thyroid eye disease fail to

delvelop abnormal thyroid function within approximately 18
months.

Graves disease is an autoimmune disorder in which thyroid

stimulating immunoglobulins activate thyrotropin receptors. In
some patients Graves disease is just one manifestation of a range
of autoimmune disorders including myasthenia, pernicious
anaemia and inflammatory bowel disease. Although cases have
been reported of sarcoidosis in patients with Graves disease this is
not known to be an autoimmune disease.
Thyrotropin antibodies do cross the placenta and babies can be
born with signs of hyperthyroidism.

Diabetics with active Graves disease are commonly found to have a

high HbA1c
The correct answer is: It is associated with a worsening of diabetic
control.
Question 21
Regarding herpes simplex keratitis, which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. It most commonly presents with raised clear vesicles on the
cornea indicating active viral replication.
b. Papanicolaou stain of a corneal scrape reveals multinucleated
giant cells.
c. Primary herpes simplex infection may manifest as a non-specific
upper respiratory tract infection.
d. It is less common than herpes zoster keratitis.
Feedback

Herpes simplex keratitis in its various forms is a common infective

cause of blindness and much moreso than herpes zoster infection.

The most common presentation is with a classic dendritic ulcer

which stains with fluorescein.

A papanicolaou stain is used to demonstrate intranuclear

eosinophilic inclusion bodies. A giemsa stain is used to identify
multinucleated giant cells.

Primary herpes infection may be asymptomatic, present as

cutaneous lesions or as a non specific upper respiratory tract
infection
The correct answer is: Primary herpes simplex infection may
manifest as a non-specific upper respiratory tract infection.
Question 22
Regarding idiopathic intracranial hypertension, which ONE of the
following statements is MOST likely to be TRUE?
Select one:
a. Lumbar puncture to measure intracranial pressure should be the
first investigation.
b. It may present as horizontal diplopia.
c. Headache typically affects the occipital region.
d. The retinal veins at the optic nerve head will pulsate when
pressure is applied to the eye.
Feedback

Feedback Please justify why the answer is correct

The headache in idiopathic intracranial hypertension (IHI) is
typically non specific varying in location, frequency and type

Raised intracranial pressure may cause a VIth cranial nerve paresis

with loss of lateral rectus function, which may be bilateral.

A lumbar puncture should not be performed until an MRI or at

least a CT scan has ruled out an intracranial lesion or dural sinus
thrombosis. The presence of these conditions is likely to precipitate
acute neurological deterioration due to brain displacement by the
creation of a low pressure shunt at the site of the lumbar puncture.

Typically papilloedema secondary to raised intracranial pressure

stops central retinal vein pulsation even with applied pressure.
The correct answer is: It may present as horizontal diplopia.
Question 23
Regarding infection with mycobacterium tuberculosis, which ONE
of the following statements is MOST likely to be TRUE?
Select one:
a. Large choroidal tubercles have high internal reflectivity on
ultrasonography.
b. Retinal vasculitis with choroidal tubercles is the commonest
ocular manifestation.
c. 80% of patients with ocular infection have diagnosed pulmonary
disease.
d. Primary active infection may occur in the cornea.
Feedback

Up to 60% of patients with extrapulmonary disease do not have

diagnosed lung infection.

Large tubeculomas have moderate to low reflectivity on

ultrasonography

The conjunctive, cornea and sclera can all be sites of primary active
disease. Intraocular involvement is secondary to disease elsewhere
in the body usually from haematogenous spread

The commonest ocular manifestation is posterior uveitis and ocular

disease may be the first manifestation of disease dissemination
from the lungs or elsewhere.
The correct answer is: Primary active infection may occur in the
cornea.
Question 24
Regarding intravitreal injections, which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. Post treatment intraocular pressure measurement is unnecessary.
b. Anterior chamber paracentesis should be performed to keep the
intraocular pressure normal.
c. Povidone iodine must be instilled in the conjunctival sac before
treatment.
d. It must be done with a dilated pupil.
Feedback

Anterior chamber paracentesis is not recommended as it increases

the risk of introducing infection.

There is no concensus on the need to dilate the pupil and many

surgeons perform the procedure without doing this.

The intraocular pressure should be measured post treatment and

can be used with subjective vision as to the likeliehood that the
central retinal artery has been temporarily occluded

The most important steps to take are those that minimize the risk
of infection including minimal lid manipulation, use of a face mask,
hand washing and using gloves.
Povidone iodine is a very effective antiseptic agent and is probably
the most effective prophylaxis against the development of
endophthalmitis (as it is before cataract surgery).
The correct answer is: Povidone iodine must be instilled in the
conjunctival sac before treatment.
Question 25
Regarding multiple sclerosis, which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. The diagnosis can be made after a single episode of a suggestive
neurological disorder.
b. It is an autoimmune disease.
c. Computerised tomography (CT) is more sensitive than magnetic
resonance imaging (MRI) in identifying active plaques.
d. Visual evoked potential is only helpful in diagnosis after an
episode of optic neuritis.
Feedback

MRI scanning is the most sensitive imaging technique

demonstrating lesions in 90-95% of patients with multiple sclerosis

The exact aetiology of multiple sclerosis (MS) is unknown but it is

thought that multiple factors both environmental and genetic are
responsible

The McDonald criteria are the basis on which a diagnosis of

multiple sclerosis can be made and in the 2010 revision diagnosis
was made possible after a single episode providing certain criteria
are met. This has advantages in that there is some evidence that
early treatment can reduce disability.

A visual evoked potential can identify sub-clinical disease of the

optic nerve although it is non-specific for MS.
The correct answer is: The diagnosis can be made after a single
episode of a suggestive neurological disorder.
Question 26
Regarding primary congenital glaucoma, which ONE of the
following statements is MOST likely to be TRUE?
Select one:
a. It commonly presents with epiphora.
b. Accurate intraocular pressure measurement can be done with a
hand held tonometer in clinic.
c. Haab striae are also seen in congenital megalocornea.
d. It is always bilateral.
Feedback

In congenital megalocorneal the corneal diameter increases to

greater than 13mm but the cornea is of normal thickness and
structure. Haab striae result from splits in the descemet membrane
due to the raised intraocular pressure.

Congenital glaucoma is bilateral in 75% of patients and presents

with epiphora, photophobia and blepharospasm.

Although intraocular pressure can be measured in an infant with a

hand held tonometer it is unlikely to be accurate as the baby
strains and fights the procedure.
The correct answer is: It commonly presents with epiphora.
Question 27
Regarding ptosis, which ONE of the following statements is MOST
likely to be TRUE?
Select one:
a. A dilated pupil indicates a sympathetic nerve supply problem.
b. If due to a third nerve paresis the patient presents with diplopia.
c. Congenital ptosis is due to improper development of the levator
muscle.
d. The most common cause of adult onset ptosis is contact lens
wear.
Feedback

The ptosis in a third nerve palsy is usually sufficiently low to

occlude that eye and prevent diplopia

Ageing is the most common cause of adult onset ptosis, other

causes include contact lens use, trauma, ocular surgery and much
less commonly neurological abnormalities (third nerve /
sympathetic)

Horners syndrome due to a sympathetic lesion presents as a mild

ptosis in association with miosis as the sympathetic nerves supply
dilator pupillae
The correct answer is: Congenital ptosis is due to improper
development of the levator muscle.
Question 28
Regarding retained lens fragments following cataract surgery,
which ONE of the following statements is MOST likely to be TRUE?
Select one:
a. They incite a T cell mediated delayed hypersensitivity reaction.
b. Retinal detachment is less likely if the fragments are removed at
the time of the primary procedure.
c. Early removal leads to better long term visual outcomes.
Feedback

Studies have not shown any difference in long term visual

outcomes between early and late removal of fragments.

Retained fragments can block the trabecular meshwork and a rise

in intraocular pressure should be treated and may need an anterior
chamber paracentesis.

Retinal detachment is a recognized complication with a higher

incidence if an anterior segment surgeon attempts removal of the
fragments by manipulating the vitreous during the primary
procedure.

The small amount of lens protein normally found in the anterior

chamber does not incite an inflammatory reaction because of the
immune privileged environment in the anterior chamber. However
this is overcome by large amounts of material and it is thought
that the subsequent inflammation is T cell mediated with a
preponderance of macrophages.
The correct answer is: They incite a T cell mediated delayed
hypersensitivity reaction.
Question 29
Regarding retinitis pigmentosa which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. A patient may have profound neurosensory deafness.
b. 25% of cases occur in patients with no family history.
c. It predominantly affects retinal cones.
d. Patients complain of peripheral field loss before worsening night
vision.
Feedback

Retinitis pigmentosa (RP) can be inherited by all types of

inheritance but 50% of patients have no known family history.

Ushers syndrome is typical changes of retinitis pigmentosa

associated with neurosensory deafness which may be profound or
moderate.

Retinitis pigmentosa is a rod cone dystrophy in which it is

predominantly the rods which become apoptotic and die.
The most common presenting symptom is difficulty of performing
tasks in poor light because of loss of rod function. Loss of the
peripheral field is generally asymptomatic until it is very advanced.
The correct answer is: A patient may have profound neurosensory
deafness.
Question 30
Question text

Regarding Steven-Johnson syndrome, which ONE of the following

statements is MOST likely to be TRUE?
Select one:
a. Conjunctival biopsy shows plasma cells and helper T cells.
b. Non steroidal anti-inflammatory drugs are the commonest drug
cause.
c. It is a type II hypersensitivity reaction.
d. Once symblepharon have formed they cannot be treated.
Feedback

Stevens-Johnson is a type IV allergic reaction affecting the skin and

mucous membranes.

Drugs are the most common agents blamed for the development
of Stevens-Johnson most commonly antibiotics and specifically
penicillin and sulfa compounds. Other causes reported include
infective and malignancy related but 25-50% are idiopathic.

Mechanical symblepharon lysis is effective in limiting conjunctival

shrinkage.
The correct answer is: Conjunctival biopsy shows plasma cells and
helper T cells.
Question 31
Regarding the assessment of a patient complaining of epiphora,
which ONE of the following statements is MOST likely to be TRUE?
Select one:
a. A hard stop when a cannula is inserted into the inferior punctum
indicates a patent common canaliculus.
b. A Jones I test distinguishes complete from partial obstruction of
the lacrimal drainage system.
c. Lacrimal scintillography is unhelpful in the identification of
functional epiphors.
d. Lacrimal sac stones cannot be identified on dacryocystography.
Feedback

A hard stop means the cannula has passed into the lacrimal sac
and come up against the solid lacrimal bone.

The Jones 1 test involves putting fluorescein in the conjunctival sac

and 5 monutes later a cotton bud is placed under the inferior
turbinate. If it comes out stained with dye the test is positive and
there is no obstruction. This test can distinguish between
oversecretion of tears and partial obstruction of the drainage
system.

A dacryocystogram (DCG) can identify the site of an obstruction in

the lacrimal drainage system as well as filling defects such as
tumours or stones in the lacrimal sac.

Lacrimal scintillography and the Jones 1 test are the only tests
conducted under physiological conditions. Any investigation that
involves syringing through the lacrimal drainage system may
overcome a partial obstruction and therefore not always give an
accurate result. Functional epiphora is generally due to
malposition of the punctum or lower lid laxity from a variety of
causes and the isotope will not even be seen in the canaliculi..
The correct answer is: A hard stop when a cannula is inserted into
the inferior punctum indicates a patent common canaliculus.
Question 32
Regarding the diagnosis of the lesion in the photograph, which
ONE of the following statements is MOST likely to be TRUE?

Select one:
a. The other eye is likely to be normal.
b. Active necrotizing retinitis may occur adjacent to the scar.
c. This is retinal scarring from toxocara infection.
d. Active inflammation requires a depot sub conjunctival steroid
injection.
Feedback

This is a congenital toxoplasma retinochoroidal scar, 85% of which

are bilateral. Only a small percentage of patients with acquired
toxoplasmosis have ocular involvement.
Reactivation of live tissue cysts at the edge of the scar produces
necrotizing retinitis adjacent to the scar and requires treatment.

Topical steroids may be required for anterior segment

inflammation but a depot steroid injection is contraindicated as it
is thought this overwhelms the local host immune response
resulting in rampant necrosis and ultimately phthisis.

Toxocariasis is an acquired infection due to ingestion of the larvae

of a round worm found in dogs and cats and produces granulomas
and chorioretinitis progressing to retinal fibrosis and detachment
The correct answer is: Active necrotizing retinitis may occur
adjacent to the scar.
Question 33
Regarding the lesion on this eyelid, which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. The lesion is a keratoacanthoma.
b. The patient should be examined for pre-auricular nodes.
c. Treatment with cryotherapy will ensure the lesion does not recur.
d. Histological examination will show islands of basaloid cells with
peripheral palisading.
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This lesion has the clinical appearance of an ulcerated basal cell

carcinoma which on histological examination shows well
circumscribed islands of proliferating basal cells with frequent
mitotic figures. At the edge of the islands the cells are arranged as
a palisade.
The correct answer is: Histological examination will show islands of
basaloid cells with peripheral palisading.
Question 34
Regarding the lesion seen in this photograph, which ONE of the
following statements is MOST likely to be TRUE?

Select one:
a. Left untreated this lesion commonly invades the orbit.
b. This condition is seen most commonly in pre-menopausal
women.
c. This is a pre-malignant lesion.
d. On histological examination the epidermis is acanthotic with
patchy hyperkeratosis.
Feedback

This is a squamous papilloma, a benign tumour of epithelial origin.

There is no known cause (viral aetiology is as yet unproven) and it
is the commonest benign skin tumour. Although it becomes
increasingly common with age there is no gender or race
predominance.

It does not undergo malignant change

The correct answer is: On histological examination the epidermis is
acanthotic with patchy hyperkeratosis.
Question 35
Regarding the management of amblyopia, which ONE of the
following statements is MOST likely to be true?
Select one:
a. Hypermetropia should be under-corrected by 1 dioptres.
b. Atropine penalisation is not as effective as patching in moderate
amblyopia.
c. Once the visual acuity has improved it does not subsequently
worsen.
d. Patching for two hours a day is as effective as full time patching
in moderate amblyopia.
Feedback

The correct answer is: Patching for two hours a day is as effective
as full time patching in moderate amblyopia.
Question 36
Regarding the medical management of glaucoma, which ONE of
the following statements is MOST likely to be TRUE?
Select one:
a. Topical carbonic anhydrase inhibitors should not be used in
patients with advanced renal disease.
b. Alpha agonists are safe to use in children.
c. A prostaglandin analogue should not be prescribed following
uneventful cataract surgery.
Feedback

Prostaglandin analogues are contraindicated following cataract

surgery in which the posterior capsule has been breached because
of the risk of increasing the likelihood of cystoid macula oedema.

Alpha agonists are contraindicated in children because of the risk

of central nervous system side effects.

Topical carbonic anhydrase inhibitors have no contraindications

other than allergy, but taken systemically they are contraindicated
in those with severe renal disease and sulfonamide allergy.
Question 37
Regarding the symptoms experienced by people with developing
cataract, which ONE of the following statements is MOST likely to
be TRUE?
Select one:
a. Glare when driving is most commonly due to peripheral cortical
spokes.
b. A need for frequent changes in glasses prescription indicates
posterior subcapsular cataract.
c. Nuclear cataract causes loss of the blue part of the visual
spectrum.
d. An emmetropic patient developing nuclear cataract has
improved distance vision in the early stages.
Feedback

A nuclear cataract increases the power of the lens due to

increasing refractive index. For some time an emmetropic patient
may find they can read without their reading glasses although
obviously this will be at the expense of their distance vision. In the
early stages these patients will need regular prescription changes
to get the best visual acuity.

The most likely cause of glare, usually manifest as difficulty at night

time when lights are lit or when driving, is posterior subcapsular
cataract.
The correct answer is: Nuclear cataract causes loss of the blue part
of the visual spectrum.
Question 38
Regarding this visual field, which ONE of the following statements
is MOST likely to be TRUE?

Select one:
a. A caeco-central scotoma is identified.
b. The patient probably has an inferiorly abnormal optic disc.
c. The most likely reason for low test reliability is the duration of
the test.
d. It is a left visual field.
Feedback

This image is of an arcuate scotoma

It is the right visual field because the blind spot is on the right

Multiple false positives and negatives are the likeliest reason that a
field test is unreliable.
The correct answer is: The patient probably has an inferiorly
abnormal optic disc.
Question 39
Regarding traumatic optic neuropathy, which ONE of the following
statements is MOST likely to be TRUE?
Select one:
a. Blunt head trauma induces shearing forces which disrupts the
vascular supply to the optic nerve.
b. It cannot be diagnosed in an unconscious patient.
c. It is most commonly caused by a penetrating injury to the orbit.
d. It can be diagnosed by direct ophthalmoscopy of the optic nerve
head after a recent injury.
Feedback

In most cases traumatic optic neuropathy is due to indirect trauma

to the optic nerve within the optic canal and as such in the early
stages the optic nerve head appears normal only becoming
atrophic after 3 to 5 weeks. The nerve is most susceptible to
damage within the confined space of the optic canal, which is why
blunt trauma particularly in road traffic incidents or assault is a
major risk.

Even though it is not possible to assess the acuity or field in an

unconscious patient, there is likely to be a relative or total afferent
pupil defect and optic nerve damage can be confirmed by a visual
evoked potential (VEP) if this is possible. A VEP can also give a
useful guide as to the likely recovery or not of vision. However a
patient who has had trauma sufficient to render them unconscious
is likely to have more urgent medical needs.
The correct answer is: Blunt head trauma induces shearing forces
which disrupts the vascular supply to the optic nerve.
Question 40
Which ONE of the following conditions is a secondary open angle
glaucoma?
Select one:
a. Aqueous misdirection syndrome.
b. Pigmentary glaucoma.
c. Iridocorneal endothelial syndrome.
d. Ciliary body cysts.
Feedback

Aqueous misdirection syndrome follows intraocular surgery or

even suture lysis and is thought to be due to a blockage to
aqueous flow at the ciliary body with impermeability at the anterior
hyaloid. It is associated with a shallow or flat anterior chamber,
usually a patent peripheral iridectomy and high pressure.

If sufficiently large and numerous, ciliary body cysts cause a

mechanical angle closure by pushing the iris anteriorly

Iridocorneal endothelial syndrome is a spectrum of disorders with

an abnormal corneal endothelium which forms a membrane over
the angle and anterior iris.

Pigmentary glaucoma is caused by iris pigment obstructing the

trabecular meshwork but the angle itself remains open
The correct answer is: Pigmentary glaucoma.
Question 41
Which ONE of the following conditions is MOST likely to be the
cause of a poorly dilating pupil prior to cataract surgery?
Select one:
a. Pseudoexfoliation syndrome.
b. Horners syndrome.
c. Long-standing type 2 diabetes.
d. Use of systemic calcium channel blockers.
Feedback

The most likely reasons for a poorly dilating pupil are mechanical
including posterior synaechiae, fibrotic pupil margin and
pseudoexfoliation. The use of tamsulosin for the symptoms of
benign prostatic hypertrophy is becoming an increasing reason for
a poorly dilating atonic pupil.
The correct answer is: Pseudoexfoliation syndrome.
Question 42
Which ONE of the following criteria is included in the World Health
Organisation requirements for a screening programme?
Select one:
a. Facilities for diagnosis and treatment must be available.
b. The diagnostic test need only be done for a defined period in a
population.
c. Any disease can be subject to a screening program.
d. The screening test should have a high specificity but low
sensitivity.
Feedback

The WHO criteria for screening can easily be found on-line.

Screening should be an ongoing process to identify a disease
which is an important health problem and fully understood, in a
latent or asymptomatic phase using a readily deliverable test which
is acceptable to the population and which is cost effective to
administer in relation to the burden of disease. There must in
addition be an effective treatment.

The screening test should have a high sensitivity, which means

there are few false negatives and few cases are missed.
The correct answer is: Facilities for diagnosis and treatment must
be available.
Question 43
Which ONE of the following is a kinetic visual field assessment?
Select one:
a. Goldman visual field.
b. Esterman visual field.
c. Humphrey 10.2 program.
d. Humphrey SITA program.
Feedback

Static visual field assessment is more sensitive in detecting field

defects in glaucoma than kinetic (dynamic) assessments.

In kinetic perimetry a target is moved from an unseen area until it

becomes visible. In static perimetry the target appears in a known
location for a standard time and can be varied by size and
luminance to identify a threshold for that part of the visual field.
The stimulus does not move.

An Esterman visual field is a static field performed binocularly and

is particularly used for a binocular visual field e.g. for driving.

The Humphrey field analyser is a static assessment and specifically

the SITA (Swedish interactive threshold algorithm) has been
developed to reduce the test time and the 10.2 program gives a
more detailed assessment of the central 10 degrees of the visual
field.

The Goldman analyser has both static and kinetic components and
needs an experienced technician to produce good results. Gross
defects can be identified with static use then the size of the defect
explored kinetically.
The correct answer is: Goldman visual field.
Question 44
Which ONE of the following is an absolute contraindication to
performing an MRI scan of the orbit?
Select one:
a. Titanium clip to a berry aneurysm.
b. Cochlear implant.
c. Gold implant for lagophthalmos.
d. Claustrophobia.
Feedback

Claustrophobia is only a relative contraindication to MRI scanning

and many patients with sympathetic help can be talked through
the procedure or can have it done under general anaesthetic if it is
the investigation most likely to be useful.

Previously aneurysm clips could be dislodged by the magnetic

used for the scan however more recently clips are made of
titanium and if this is definitely known to be the case, an MRI can
be done.

Gold implants in the lid like metallic orbit floor implants develop a
fibrous coat, which prevents them moving under the influence of
the scanner.
The correct answer is: Cochlear implant.
Question 45
Which ONE of the following is a water-borne organism causing
ocular disease?
Select one:
a. Vibrio cholera.
b. Histoplasma capsulatum.
c. Chlamydia trachomatis.
d. Leptospira.
Feedback

Leptospira are excreted through the kidneys of affected rodents,

cattle and others so contaminating water where they can survive
for several months infecting humans through damaged skin and
intact mucosa. Ocular manifestations of infection include non-
granulomatous anterior uveitis, cataract, interstitial keratitis, retinal
vasculitis and papillitis.

Chlamydia is transmitted by direct contact.

Ocualr histoplasmosis results from inhalation of the fungal spore
Vibrio cholerae is transmitted through infected water but does not
cause ocular infection.
The correct answer is: Leptospira.
Question 46
Select one:
a. Episcleritis.
b. Optic neuritis.
c. Posterior scleritis.
d. Orbital myositis.
Feedback

The correct answer is: Episcleritis.

Question 47
Which ONE of the following primary tumours is MOST likely to
metastasise to the orbit?
Select one:
a. Gastric adenocarcinoma.
b. Prostate adenocarcinoma.
c. Transitional cell carcinoma.
d. Cutaneous melanoma.
Feedback

The most frequent primary sites to metastasise to the orbit are

breast, lung and prostate.

Orbit metastases only account for 5-10% of orbit tumours and only
occur in 2-3% of patients with cancer.
The correct answer is: Prostate adenocarcinoma.
Question 48
Which ONE of the following procedures is MOST effective in the
prevention of post cataract surgery endophthalmitis?
Select one:
a. Thorough lid cleaning for a week prior to surgery.
b. Correct placement of the surgical drapes.
c. Topical antibiotics for 24 hours pre-operatively.
d. Putting povidone iodine into the conjunctival sac 5 minutes
before the procedure.
Feedback

Two potential sources of infection during cataract surgery are

direct insertion of microbes from the instruments used and transfer
from the flora existing on the lid margins and in the conjunctival
sac.
Povidone iodine is a powerful bacteriostatic agent after 1 minute
of contact and has minimal toxicity. Its use is supported by
prospective comparative studies and laboratory evidence.

Not included in this question but many centres now use

intracameral antibiotics at the end of the procedure as there is
increasing evidence that this is a safe and effective prophylaxis if
used at the correct dosage.
The correct answer is: Putting povidone iodine into the conjunctival
sac 5 minutes before the procedure.
Question 49
Which ONE of the following signs is the earliest ocular
manifestation of malignant hypertension?
Select one:
a. Peripapillary cotton wool spots.
b. Clustered microaneurysms at the posterior pole.
c. Periarteriolar transudates around the larger arterioles.
d. Blot retinal haemorrhages.
Feedback

Blot haemorrhages do not appear early nor are they a particularly

prominent feature.

Periarteriolar transudates are seen as small white focal oval lesions

deep in the retina around the major arterioles and are one of the
earliest signs of malignant hypertension

Cotton wool spots are usually found at the posterior pole

The correct answer is: Periarteriolar transudates around the larger
arterioles.
Question 50
You receive a letter from a urological colleague who wants to start
a patient on oxybutynin for urgency of micturition. His patient has
glaucoma and he wants to know if it is safe to prescribe. In which
ONE of the following conditions should oxybutynin be avoided?
Select one:
a. A 72 year old with poorly controlled open angle glaucoma
refusing surgery.
b. A 70 year old who had a peripheral iridectomy for angle closure
glaucoma the previous year but refused treatment in the
asymptomatic eye.
c. A 57 year old with a previous left anterior ischaemic optic
neuropathy.
d. A 78 year old with pseudoexfoliative glaucoma a flat drainage
bleb and an intraocular pressure of 28mmHg resistant to
treatment.
Feedback

Oxybutynin is an anticholinergic drug used frequently by urologists

to try and control symptoms of urgency, frequency and
incontinence by reducing the muscle spasms associated with the
overactive bladder syndrome. The anticholinergic activity can cause
pupil dilation and in susceptible eyes, ie. those with shallow
anterior chamber angles, can precipitate angle closure and a
pressure rise. A patient who has had angle closure in one eye is at
high risk of developing it in the other in the absence of treatment.
An eye which has been treated with a peripheral iridectomy is no
longer at risk from anticholinergic drugs.
The correct answer is: A 70 year old who had a peripheral
iridectomy for angle closure glaucoma the previous year but
refused treatment in the asymptomatic eye.