OPTHALMOLOGY MCQs

Q-1
A 67-year-old male patient presents to the ophthalmology emergency department with sudden onset
painless loss of vision in the right eye. He describes it as having a dense shadow over the vision,
progressing from periphery to the centre. He has no past medical history of note.

What is the most likely diagnosis?

A. Retinal detachment
B. Vitreous haemorrhage
C. Central retinal artery occlusion
D. Central retinal vein occlusion
E. Ischaemic optic neuropathy

ANSWER:
A. Retinal detachment

EXPLANATION:
Retinal detachment is a cause of sudden painless loss of vision. It is characterised by a dense shadow
starting peripherally and progressing centrally

Retinal detachment is a cause of sudden painless loss of vision. It is characterised by a dense shadow
starting peripherally and progressing centrally.

Vitreous haemorrhage usually presents with dark spots.

Central retinal artery occlusion and central retinal vein occlusion does not usually present with progressing
dense shadow.

This man's lack of ischaemic risk factors makes ischaemic optic neuropathy less likely.

Please see Sudden Loss of Vision

Q-2
A 54-year-old man with type 2 diabetes mellitus is found on annual review to have new vessel formation
at the optic disc. Visual acuity in both eyes is not affected (6/9). Blood pressure is155/84 mmHg.

HbA1c 68 mmol/mol (8.4%)

What is the most important intervention in this patient?

A. Follow-up ophthalmoscopy in 3 months

B. Add aspirin
C. Blood pressure control
D. Tight glycaemic control
E. Laser therapy
ANSWER:
E. Laser therapy

EXPLANATION:
This patient has proliferative diabetic retinopathy and urgent referral to an ophthalmologist for panretinal
photocoagulation is indicated

Please see Diabetic Retinopathy

Q-3
Which one of the following is not a feature of background diabetic retinopathy?

A. Microaneurysms
B. Blot haemorrhages
C. Cotton wool spots
D. Seen in both type 1 and type 2 diabetes mellitus
E. Hard exudates

ANSWER:
C. Cotton wool spots

EXPLANATION:
Cotton wool spots are seen in pre-proliferative retinopathy

Please see Diabetic Retinopathy

Q-4
A 71-year-old female with dry age-related macular degeneration is reviewed. Unfortunately her eyesight
has deteriorated over the past six months. She has never smoked and is taking antioxidant supplements.
What is the most appropriate next step?

A. Retinal transplant
B. Intravitreal ranibizumab
C. Explain no other medical therapies currently available
D. Photodynamic therapy
E. Photocoagulation

ANSWER:
C. Explain no other medical therapies currently available

EXPLANATION:

Please see Age-Related Macular Degeneration

Q-5
A 73-year-old lady presents with visual loss. She describes sudden onset flashes and floaters in her right
eye.
She is short-sighted and has worn glasses since her early teens. She has a background of hypertension,
recurrent DVTs and osteoporosis.

Medication history includes amlodipine 5mg OD, apixaban 2.5mg BD and alendronic acid 70mg once
weekly.

On examination, visual acuity is 6/12 in the right eye. Fundoscopy is unremarkable with a normal optic
disc and retinal vessels.

What is the most likely diagnosis?

A. Acute angle closure glaucoma

B. Central retinal vein occlusion
C. Giant cell arteritis
D. Posterior vitreous detachment
E. Vitreous haemorrhage

ANSWER:
D. Posterior vitreous detachment

EXPLANATION:
Flashes + floaters are most commonly caused by a posterior vitreous detachment

Flashes and floaters are commonly caused by a posterior vitreous detachment (PVD), where the vitreous
shrinks and pulls away from the retina. About 10% of patients with PVD develop a retinal tear, which is an
important risk factor for a retinal detachment. These patients should therefore be seen by an
ophthalmologist within 24 hours.

Vitreous haemorrhage can be associated with floaters but diffuse haemorrhage in the vitreous cavity is
likely to obscure the view of the retina on fundoscopy.

Central retinal vein occlusion does not typically present with flashes or floaters and vessels on fundoscopy
are likely to appear tortuous with flame-shaped haemorrhages, meaning a PVD is more likely in this
scenario.

Giant cell arteritis does not cause flashes or floaters. On fundoscopy, you would expect to see signs of
papilloedema.

Acute angle closure glaucoma does not cause flashes or floaters. It is more likely to present in
hypermetropic (long-sighted) patients.

Please see Posterior Vitreous Detachment

Q-6
A 67-year-old man presents as he has developed a painful blistering rash around his right eye. On
examination a vesicular rash covering the right trigeminal nerve dermatome is seen. Currently he has no
eye symptoms or signs. Which one of the following is most likely to predict future eye involvement?
A. Presence of the rash on the tip of his nose
B. Smoking history
C. Increasing age
D. Previous courses of corticosteroids
E. Presence of the rash in the ear canal

ANSWER:
A. Presence of the rash on the tip of his nose

EXPLANATION:
This is Hutchinson's sign which is strongly predictive for ocular involvement.

Please see Herpes Zoster Ophthalmicus

Q-7
A 64-year-old woman with type 2 diabetes mellitus presents as she has started to bump into things since
the morning. Over the previous two days she had noticed some 'floating spots in her eyes'. Examination
reveals she has no vision in her right eye. The red reflex on the right side is difficult to elicit and you are
unable to visualise the retina on the right side during fundoscopy. Examination of the left fundus reveals
changes consistent with pre-proliferative diabetic retinopathy. What is the most likely diagnosis?

A. Occlusion of central retinal vein

B. Vitreous haemorrhage
C. Proliferative retinopathy
D. Cataract
E. Retinal detachment

ANSWER:
B. Vitreous haemorrhage

EXPLANATION:
The history of diabetes, complete loss of vision in the affected eye and inability to visualise the retina point
towards a diagnosis of vitreous haemorrhage. Please see the table below for help in differentiating retinal
detachment from vitreous haemorrhage.

Please see Sudden Loss of Vision

Q-8
A 45-year-old man presents to the Emergency Department following the sudden onset of pain in the right
side of his face whilst hammering a nail into the wall. The pain is described as severe and constant. On
examination he has a mild right ptosis and small right pupil. What is the most likely diagnosis?

A. Trigeminal neuralgia
B. Glaucoma
C. Carotid artery dissection
D. Syringomyelia
E. Migraine
ANSWER:
C. Carotid artery dissection

EXPLANATION:
This patient has Horner's syndrome caused by a carotid artery dissection. This may be caused by relatively
benign trauma to the neck such as hyperextension whilst doing DIY. Cluster headache would be a
differential diagnosis

Please see Horner's Syndrome

Q-9
Which one of the following best describes the action of latanoprost in the management of primary open-
angle glaucoma?

A. Carbonic anhydrase inhibitor

B. Reduces aqueous production + increases outflow
C. Opens up drainage pores
D. Increases uveoscleral outflow
E. Reduces aqueous production

ANSWER:
D. Increases uveoscleral outflow

EXPLANATION:
Latanoprost is a prostaglandin analog used in glaucoma. It works by increasing uveoscleral outflow
Important for meLess important

Please see Primary Open-Angle Glaucoma: Management

Q-10
A 68-year-old man with a history of type 2 diabetes mellitus presents with worsening eye sight. Mydriatic
drops are applied and fundoscopy reveals pre-proliferative diabetic retinopathy. A referral to
ophthalmology is made. Later in the evening whilst driving home he develops pain in his left eye
associated with decreased visual acuity. What is the most likely diagnosis?

A. Keratitis secondary to mydriatic drops

B. Proliferative diabetic retinopathy
C. Acute angle closure glaucoma
D. Central retinal artery occlusion
E. Vitreous haemorrhage

ANSWER:
C. Acute angle closure glaucoma

EXPLANATION:
Mydriatic drops are a known precipitant of acute angle closure glaucoma. This scenario is more common
in exams than clinical practice.
Please see Acute Angle Closure Glaucoma

Q-11
Which one of the following statements regarding the Holmes-Adie pupil is incorrect?

A. May be associated with absent ankle/knee reflexes

B. Bilateral in 80% of cases
C. It is a benign condition
D. Slowly reactive to accommodation but very poorly (if at all) to light
E. Causes a dilated pupil

ANSWER:
B. Bilateral in 80% of cases

EXPLANATION:
The Holmes-Adie pupil is unilateral, rather than bilateral, in 80% of patients

Please see Holmes-Adie Pupil

Q-12
Which one of the following is not a risk factor for primary open-angle glaucoma?

A. Diabetes mellitus
B. Family history
C. Hypertension
D. Afro-Caribbean ethnicity
E. Hypermetropia

ANSWER:
E. Hypermetropia

EXPLANATION:
Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle glaucoma
is associated with myopia
Please see Primary Open-Angle Glaucoma
Q-13
A 34-year-old female presents with fatigue and frequent headaches. On examination of her eyes, you
notice an abnormality during the swinging light test. As the light is moved from the left to the right eye
both pupils appear to dilate. The pupillary response to accommodation is normal bilaterally. Fundoscopy
is also normal bilaterally. Her past medical history includes type one diabetes and hypertension. What is
the most likely explanation for this patients' signs?

A. Raised intracranial pressure

B. Diabetic eye disease
C. Holmes-Adie's pupil on the right
D. Marcus-Gunn Pupil (relative afferent pupillary defect) on the right
E. Argyll Robertson pupil on the right
ANSWER:
D. Marcus-Gunn Pupil (relative afferent pupillary defect) on the right

EXPLANATION:
Marcus Gunn pupil (relative afferent pupillary defect) is diagnosed during the swinging light test. If there
is damage to the afferent pathway (retina or optic nerve) of one eye, the pupil of that affected eye will
abnormally dilate when a light is shone into it. This is because the consensual pupillary relaxation
response from the healthy eye will dominate. Marcus Gunn pupil can be found in patients with multiple
sclerosis. Therefore, given the history, this should be ruled out in this patient.

The history and examination findings in the question are not typical of raised intracranial pressure. Raised
intracranial pressure may present with symptoms such as a headache, vomiting, bilateral blurred vision
and seizures. Patients with increased intracranial pressure often have bilateral papilloedema on
fundoscopy.

Although the history states the female is diabetic, there are typically normal pupillary light responses in
patients with diabetic eye disease. Furthermore, with diabetic eye disease, you would expect to see some
abnormality on fundoscopy.

Holmes-Aide's pupil is a dilated pupil which poorly (if at all) reacts to direct light, however, slowly reacts to
accommodation. This does not correlate to the history.

The information given in the question above does not suggest Argyll Robertson pupil. This is characterised
by a constricted pupil that does not respond to light but responds to accommodation. It is usually bilateral
and is often associated with neurosyphilis.

Please see Relative Afferent Pupillary Defect

Q-14
A 65-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss of
vision in his right eye. On examination of the right eye the optic disc is swollen with multiple flame-shaped
and blot haemorrhages. What is the most likely diagnosis?

A. Diabetic retinopathy
B. Vitreous haemorrhage
C. Ischaemic optic neuropathy
D. Occlusion of central retinal vein
E. Occlusion of central retinal artery

ANSWER:
D. Occlusion of central retinal vein

EXPLANATION:
Central retinal vein occlusion - sudden painless loss of vision, severe retinal haemorrhages on fundoscopy

Please see Central Retinal Vein Occlusion

Q-15
A 15-year-old boy presents to the GP surgery with some skin changes of the neck. The mother reports that
she first noticed a small area of skin changes 3 months ago. Initially, she didn’t think too much about it but
recently noticed that it has been getting bigger and more obvious, now involving the skin covering almost
half of the right side of the neck. On examination, there is a large area of Small, yellow papules of 1-5 mm
in diameter in a reticular pattern and coalescing at places into plaques. The skin has a ‘plucked-chicken’
appearance. The boy reports no problem with his vision.

What would you be the likely finding on fundoscopy?

A. Angioid retinal streaks

B. Lisch nodules
C. Cotton wool spots
D. Neovascularisation
E. Bone spicules

ANSWER:
A. Angioid retinal streaks

EXPLANATION:
Angioid retinal streaks are a feature of pseudoxanthoma elasticum

Angioid streaks are small breaks in Bruch's membrane, an elastic tissue containing membrane of the
retina. It is a feature of pseudoxanthoma elasticum. The earliest sign in pseudoxanthoma elasticum is the
skin changes. This patient likely has pseudoxanthoma elasticum.

Lisch nodules are features of neurofibromatosis.

Cotton wool spots and neovascularisation are both features of diabetic retinopathy.

Bone spicules are seen in retinitis pigmentosa.

Please see Angioid Retinal Steaks

Q-16
A 55-year-old male presents to the emergency department with left sided vision loss, headache and scalp
tenderness. On examination, he has a temperature of 38.5°C, jaw claudication and a relative afferent
pupillary defect. A diagnosis of giant cell arteritis is suspected and he is started on high dose prednisone.

Which of the following structural deficits has lead to the relative afferent pupillary defect?

A. Ischaemic optic neuropathy

B. Blindness
C. Optic neuritis
D. Photophobia
E. Corneal opacity
ANSWER:
A. Ischaemic optic neuropathy

EXPLANATION:
Relative afferent pupillary defect indicates an optic nerve lesion or severe retinal disease

Ischaemic optic neuropathy occurs in giant cell arteritis (GCA) as a result of an inflammatory process of the
blood vessels in the head. This optic nerve lesion may manifest in a relative afferent pupillary defect
(RAPD).

Blindness, corneal opacity and photophobia by itself won't necessarily lead to a RAPD.

While optic neuritis may give rise to a RAPD, this won't occur in GCA and may be suggestive of a first
presentation of multiple sclerosis.

Please see Relative Afferent Pupillary Defect

Q-17
A 67-year-old woman presents for review. She has recently been diagnosed with dry age-related macular
degeneration. Which one of the following is the strongest risk factor for developing this condition?

A. Hypertension
B. Poor diet
C. Smoking
D. Diabetes mellitus
E. Alcohol excess

ANSWER:
C. Smoking

EXPLANATION:
Macular degeneration - smoking is risk factor

Having a balanced diet, with plenty of fresh fruits and vegetables may also slow the progression of
macular degeneration. There is still ongoing research looking at the role of supplementary antioxidants
Please see Age Related Macular Degeneration
Q-18
A 25-year-old woman presents with a one-day history of a painful and red left eye. She describes how her
eye is continually streaming tears. On examination she exhibits a degree of photophobia in the affected
eye and application of fluorescein demonstrates a dendritic pattern of staining. Visual acuity is 6/6 in both
eyes. What is the most appropriate management?

A. Topical steroid
B. Perform a lumbar puncture
C. Treat with subcutaneous sumatriptan
D. Topical aciclovir
E. Topical chloramphenicol
ANSWER:
D. Topical aciclovir

EXPLANATION:
This patient has a dendritic corneal ulcer. Topical aciclovir and ophthalmology review is required. Giving a
topical steroid in this situation could be disastrous as it may worsen the infection.

Please see Herpes Simplex Keratitis

Q-19
Which one of the following causes of Horner's syndrome is due to a lesion in the post-ganglionic part of
the nerve supply?

A. Internal carotid aneurysm

B. Stroke
C. Syringomyelia
D. Pancoast's tumour
E. Thyroidectomy

ANSWER:
A. Internal carotid aneurysm

EXPLANATION:
Horner's syndrome - anhydrosis determines site of lesion:
 head, arm, trunk = central lesion: stroke, syringomyelia
 just face = pre-ganglionic lesion: Pancoast's, cervical rib
 absent = post-ganglionic lesion: carotid artery

Please see Horner's Syndrome

Q-20
A 39-year-old woman with a history of rheumatoid arthritis presents with a two day history of a red right
eye. There is no itch or pain. Pupils are 3mm, equal and reactive to light. Visual acuity is 6/5 in both eyes.
What is the most likely diagnosis?

A. Keratoconjunctivitis sicca
B. Scleritis
C. Glaucoma
D. Episcleritis
E. Anterior uveitis

ANSWER:
D. Episcleritis

EXPLANATION:
Scleritis is painful, episcleritis is not painful
Please see Rheumatoid Arthritis: Ocular Manifestations
Q-21
A 65-year-old woman presents to the Emergency Department with visual problems. She has rheumatoid
arthritis, depression and takes medication to control her blood pressure. Over the past few days she has
been getting troublesome headaches and blurred vision but today has noted a marked reduction in vision
in the right eye. On examination her right eye is red, has a sluggish pupil and a corrected visual acuity
6/30. Her medication has recently been changed. Which one of the following drugs is most likely to have
precipitated this event?

A. Methotrexate
B. Doxazosin
C. Amitriptyline
D. Atenolol
E. Bendroflumethiazide

ANSWER:
C. Amitriptyline

EXPLANATION:
Drugs which may precipitate acute glaucoma include anticholinergics and tricyclic antidepressants

Please see Acute Angle Closure Glaucoma

Q-22
A 34-year-old female patient is brought into the emergency department by her husband. Husband reports
that she has been confused in the last 3 days. She has a long-standing history of severe psoriasis but no
other past medical history. Basic observations are all within normal range and a CT head is unremarkable.
A fundoscopy reveals bilateral papilloedema.

What is the likely cause?

A. Encephalitis
B. Brain abscess
C. Primary brain tumour
D. Vitamin A toxicity
E. Hydrocephalus

ANSWER:
D. Vitamin A toxicity

EXPLANATION:
Vitamin A toxicity is a rare cause of papilloedema

Vitamin A toxicity is a rare cause of papilloedema. In this case, she is likely to have been taking retinoids
for psoriasis.

Encephalitis does not usually present with papilloedema.

Brain abscess, brain tumour and hydrocephalus are all less likely with a normal CT head.
Please see Papilloedema

Q-23
An 84-year-old man presents with loss of vision in his left eye since the morning. He is otherwise
asymptomatic and of note has had no associated eye pain or headaches. His past medical history includes
ischaemic heart disease but he is otherwise well. On examination he has no vision in his left eye. The left
pupil responds poorly to light but the consensual light reaction is normal. Fundoscopy reveals a red spot
over a pale and opaque retina. What is the most likely diagnosis?

A. Vitreous haemorrhage
B. Retinal detachment
C. Ischaemic optic neuropathy
D. Central retinal vein occlusion
E. Central retinal artery occlusion

ANSWER:
E. Central retinal artery occlusion

EXPLANATION:

Please see Central Retinal Artery Occlusion

Q-24
Each one of the following is a cause of a mydriatic pupil, except:

A. Third nerve palsy

B. Atropine
C. Holmes-Adie pupil
D. Argyll-Robertson pupil
E. Traumatic iridoplegia

ANSWER:
D. Argyll-Robertson pupil

EXPLANATION:
Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis and is
often said to be the prostitute's pupil - accommodates but doesn't react. Another mnemonic used for the
Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

Features
 small, irregular pupils
 no response to light but there is a response to accommodate

Causes
 diabetes mellitus
 syphilis
Please see Mydriasis
Q-25
A 71-year-old man presents with severe pain around his right eye and vomiting. On examination the right
eye is red and decreased visual acuity is noted. Which one of the following options is the most appropriate
initial treatment?

A. Topical pilocarpine + oral prednisolone

B. Topical pilocarpine + topical steroids
C. Topical steroids
D. Topical pilocarpine + intravenous acetazolamide
E. Topical steroids + intravenous acetazolamide

ANSWER:
D. Topical pilocarpine + intravenous acetazolamide

EXPLANATION:
Treatment of acute glaucoma - acetazolamide + pilocarpine

Please see Acute Angle Closure Glaucoma

Q-26
Which one of the following is least associated with the development of optic atrophy?

A. Tobacco
B. Methanol
C. Vitamin B12 deficiency
D. Lead
E. Zinc deficiency

ANSWER:
E. Zinc deficiency

EXPLANATION:

Please see Optic Atrophy

Q-27
Which one of the following is the most common ocular manifestation of rheumatoid arthritis?

A. Scleritis
B. Episcleritis
C. Keratoconjunctivitis sicca
D. Corneal ulceration
E. Keratitis

ANSWER:
Keratoconjunctivitis sicca
EXPLANATION:
Keratoconjunctivitis sicca is characterised by dry, burning and gritty eyes caused by decreased tear
production

Please see Rheumatoid Arthritis: Ocular Manifestations

Q-28
A 47-year-old female with a history of rheumatoid arthritis presents with a painful and red left eye. Visual
acuity is normal. Fundoscopy is also unremarkable. What is the most likely diagnosis?

A. Scleritis
B. Episcleritis
C. Glaucoma
D. Anterior uveitis
E. Keratoconjunctivitis sicca

ANSWER:
A. Scleritis

EXPLANATION:
Scleritis is painful, episcleritis is not painful

A key way to discriminate between scleritis and episcleritis is the presence of pain. Keratoconjunctivitis
sicca is usually bilateral and associated more with dryness, burning and itch

Please see Rheumatoid Arthritis: Ocular Manifestations

Q-29
A 53-year-old male who presents to the emergency department with a painful red eye. He has vomited
once since the pain started. He reports seeing haloes around lights.

His immediate management includes latanoprost and pilocarpine, and he requires an urgent
ophthalmology referral.

What is the mode of the action of pilocarpine?

A. Muscarinic receptor agonist

B. Muscarinic receptor antagonist
C. Nicotinic receptor agonist
D. Nicotinic receptor antagonist
E. Adrenergic receptor agonist

ANSWER:
Muscarinic receptor agonist

EXPLANATION:
Pilocarpine is a muscarinic receptor agonist
Pilocarpine is a muscarinic receptor agonist - it increases uveoscleral outflow by constricting the pupil.

Examples of muscarinic receptor antagonists include atropine and hyoscine (scopolamine) - these are not
used in the management of glaucoma.

Nicotinic receptor agonists include nicotine and acetylcholine, therefore this answer is incorrect.

Nicotinic receptor antagonists include succinylcholine, atracurium, vecuronium and bupropion.

Adrenergic receptor agonists include norepinephrine and epinephrine.

Please see Acute Angle Closure Glaucoma

Q-30
A 72-year-old woman presents with a vesicular rash around her left eye. The left eye is red and there is a
degree of photophobia. A presumptive diagnosis of herpes zoster ophthalmicus is made and an urgent
referral to ophthalmology is made.

What treatment is she most likely to be given?

A. Topical aciclovir + topical chloramphenicol

B. Topical aciclovir + topical corticosteroids
C. Oral prednisolone + topical aciclovir
D. Topical aciclovir
E. Oral aciclovir

ANSWER:
E. Oral aciclovir

EXPLANATION:
There is no role for topical antivirals if systemic therapy is given. Topical corticosteroids are sometimes
given to treat secondary inflammation.

Please see Herpes Zoster Ophthalmicus

Q-31
A 49-year-old male patient presents with acute onset loss of vision in the right eye preceded by a 2-hour
history of progressively enlarging dark spots in his vision. He has type-1 diabetes mellitus for over 15 years
and has been poorly controlled.

What is the most likely diagnosis

A. Ocular migraine
B. Retinal detachment
C. Vitreous haemorrhage
D. Ischaemic optic neuropathy
E. Retinal artery occlusion
ANSWER:
C. Vitreous haemorrhage

EXPLANATION:
Vitreous haemorrhage is a cause of sudden painless loss of vision in the context of diabetic retinopathy

Vitreous haemorrhage is a cause of sudden painless loss of vision in the context of diabetic retinopathy. It
usually presents with dark spots (scotoma) in the vision initially. This man is likely to have diabetic
retinopathy.

Ocular migraine does not usually cause visual loss.

Retinal detachment usually presents with dense shadow over vision progressing centrally.

Even though this man has ischaemic risk factors, ischaemic optic neuropathy does not usually present with
dark spots.

Retinal artery occlusion does not usually present with dark spots.

Please see Sudden Loss of Vision

Q-32
A 65-year-old man with a 16 year history of type 2 diabetes mellitus presents complaining of poor eye
sight and blurred vision. Visual acuity measured using a Snellen chart is reduced to 6/12 in the right eye
and 6/18 in the left eye. Fundoscopy reveals a number of yellow deposits in the left eye consistent with
drusen formation. Similar changes but to a lesser extent are seen in the right eye. What is the most likely
diagnosis?

A. Wet age-related macular degeneration

B. Pre-proliferative diabetic retinopathy
C. Chronic open angle glaucoma
D. Proliferative diabetic retinopathy
E. Dry age-related macular degeneration

ANSWER:
E. Dry age-related macular degeneration

EXPLANATION:
Drusen = Dry macular degeneration

Please see Age Related Macular Degeneration

Q-33
An 83-year-old female presented to her GP with complete loss of vision in her right eye which occurred
suddenly. The episode lasted for 10 minutes and she denies any pain in her eye. Her past medical history
includes hypercholesterolaemia, diet controlled, and hypertension for which she takes amlodipine.

Eye examination and fundoscopy are normal. Her blood pressure is 145/80 mmHg.
What medication are you going to give first?

A. Aspirin 300mg
B. Aspirin 75mg
C. Simvastatin 20mg
D. Apixaban 5mg BD
E. Enoxaparin 40mg

ANSWER:
A. Aspirin 300mg

EXPLANATION:
Monocular transient painless loss of vision (amaurosis fugax) should be treated as a TIA

Sudden painless loss of vision with a normal fundoscopy examination is an amaurosis fugax and thus
treated as a transient ischaemic attack (TIA). NICE guidance states that 300mg of aspirin should be given
immediately and admission if ABCD2 score >3 or crescendo TIA, otherwise an immediate TIA clinic referral
is required.

Option 2 is the correct medication but incorrect dose.

Option 3 is likely to be added later but aspirin is the first initial plan.

Apixaban is usually given for cardiovascular disease and enoxaparin 40mg is the dose given for deep vein
thrombosis prophylaxis with normal renal function.

Please see Sudden Loss of Vision

Q-34
Which one of the following features is not characteristic of optic neuritis?

A. Eye pain worse on movement

B. Relative afferent pupillary defect
C. Poor discrimination of colours, 'red desaturation'
D. Sudden onset of visual loss
E. Central scotoma

ANSWER:
D. Sudden onset of visual loss

EXPLANATION:
Visual loss typically occurs over days rather than hours. Sudden visual loss due to optic neuritis is very
unusual.

Please see Optic Neuritis

Q-35
A 62-year-old man presents with sudden visual loss in his right eye. He is otherwise asymptomatic. Which
one of the following conditions is least likely to be responsible?

A. Ischaemic optic neuropathy

B. Occlusion of the central retinal vein
C. Occlusion of the central retinal artery
D. Optic neuritis
E. Vitreous haemorrhage

ANSWER:
D. Optic neuritis

EXPLANATION:
Whilst optic neuritis can present with sudden loss, in this 62-year-old man it is the least likely option.
Typically there is a unilateral decrease in visual acuity over hours or days. There may be poor
discrimination of colours and eye pain on movement

Please see Sudden Loss of Vision

Q-36
A 19-year-old male presents to the emergency department with a 1-day history of redness around the left
eye associated with puffiness of the eye and pain on eye movement. Overnight he reports feeling feverish.
His vision is restricted due to an inability to open the eye. On examination, there is oedema surrounding
upper and lower eyelids with erythema and proptosis. The eye itself appears normal with normal pupil
reflexes but pain on eye movements. There is mildly raised intraocular pressure. He is normally fit and
well but has recently been taking intranasal corticosteroid for sinusitis.

What is the most appropriate management?

A. Refer for urgent (within 1 week) ophthalmology appointment

B. Admit for intravenous antibiotics
C. Refer for emergency (within 24 hours) ophthalmology appointment
D. Discharge home with oral antibiotics
E. Discharge home with topical antibiotics

ANSWER:
B. Admit for intravenous antibiotics

EXPLANATION:
Patients with orbital cellulitis require admission to hospital for IV antibiotics due to the risk of cavernous
sinus thrombosis and intracranial spread

The correct answer here is to admit for intravenous antibiotics. This patient has orbital cellulitis which is a
medical emergency due to risk or optic nerve damage, cavernous sinus thrombosis and intracranial
spread. The systemic upset and pain on eye movements are clues pointing towards orbital as opposed to
periorbital cellulitis. As the condition progresses patient can develop proptosis, relative afferent pupillary
defect and raised intraocular pressure. There may also be globe displacement with resistance to
retropulsion. Recent sinus infection or sinusitis is a risk factor for orbital cellulitis and points towards the
diagnosis. In some hospitals, suitable patients may be ambulated with intravenous antibiotics as an
alternative to admission.

Referring to an urgent (within 1 week) ophthalmology appointment would not be appropriate as this is a
medical emergency.

Referring for an emergency (same day) ophthalmology appointment would be more appropriate than
referring for an appointment within 1 week as it highlights the urgency of the situation, however, this
patient should be admitted under the general medical take for intravenous antibiotics and should not be
left without treatment for a period up to 24 hours. As such an outpatient appointment is not appropriate.

Discharging home with oral antibiotics may be appropriate if periorbital cellulitis was suspected. The
inability to open the eye, pain on eye movements and history of fever point towards orbital cellulitis as
opposed to periorbital cellulitis and so admission is required.

Topical antibiotics could be used in conjunctivitis but would not be appropriate in this case.

Please see Orbital Cellulitis

Q-37
A 65-year-old male who has a new diagnosis of giant cell arteritis has had a positive relative afferent
pupillary defect (RAPD) in his left eye on examination.

Which of the following describes the finding of RAPD in this man?

A. The right eye appears to dilate when light is shone on the right eye
B. The left eye appears to dilate when light is shone on the left eye
C. The left and right eye appears to dilate when light is shone on the left eye
D. The left and right eye appears to dilate when light is shone on the right eye
E. The left and right eye appears to constrict when light is shone on the left eye

ANSWER:
C. The left and right eye appears to dilate when light is shone on the left eye

EXPLANATION:
A relative afferent pupillary defect is when the affected and normal eye appears to dilate when light is
shone on the affected eye

A RAPD is caused by differences between the two eyes in the afferent pathway due to retinal or optic
nerve disease. This leads to reduced constriction, hence appears as dilation, of both pupils when light is
shone from the unaffected eye to the affected eye.

Please see Relative Afferent Pupillary Defect

Q-38
A 54-year-old woman presents with a persistent watery left eye for the past 4 days. On examination there
is erythema and swelling of the inner canthus of the left eye. What is the most likely diagnosis?
A. Blepharitis
B. Acute angle closure glaucoma
C. Meibomian cyst
D. Dacryocystitis
E. Pinguecula

ANSWER:
D. Dacryocystitis

EXPLANATION:

Please see Lacrimal Duct Problems

Q-39
A 70-year-old man is investigated for blurred vision. Fundoscopy reveals drusen, retinal epithelial and
macular neovascularisation. A diagnosis of age related macular degeneration is suspected. What is the
most appropriate next investigation?

A. Vitreous fluid sampling

B. MRI orbits
C. Ocular tonometry
D. Fluorescein angiography
E. Kinetic perimetry

ANSWER:
D. Fluorescein angiography

EXPLANATION:

Please see Age Related Macular Degeneration

Q-40
Which one of the following is least recognised as a cause of tunnel vision?

A. Papilloedema
B. Choroidoretinitis
C. Angioid retinal streaks
D. Glaucoma
E. Retinitis pigmentosa

ANSWER:
C. Angioid retinal streaks

EXPLANATION:

Please see Tunnel Vision

Q-41
A 71-year-old with a history of type 2 diabetes mellitus and hypertension presents due to the sensation of
light flashes in his right eye. These symptoms have been present for the past 2 days and seem to occur
more at the peripheral part of vision. There is no redness or pain in the affected eye. Corrected visual
acuity is measured as 6/9 in both eyes. What is the most likely diagnosis?

A. Change in shape of eye secondary to variations in blood sugar

B. Primary open angle glaucoma
C. Vitreous detachment
D. Normal phenomenon in diabetic retinopathy
E. Normal phenomenon in healthy eyes

ANSWER:
C. Vitreous detachment

EXPLANATION:
Flashes and floaters - vitreous/retinal detachment

Flashes and floaters are symptoms of vitreous detachment. The patient is at risk of retinal detachment and
should be referred urgently to an ophthalmologist

Please see Sudden Loss of Vision

Q-42
A 35-year-old man presents with visual problems. He has had very poor vision in the dark for a long time
but is now worried as he is developing 'tunnel vision'. He states his grandfather had a similar problem and
was registered blind in his 50's. What is the most likely diagnosis?

A. Leber's congenital amaurosis

B. Vitelliform macular dystrophy
C. Central serous retinopathy
D. Primary open angle glaucoma
E. Retinitis pigmentosa

ANSWER:
E. Retinitis pigmentosa

EXPLANATION:
Retinitis pigmentosa - night blindness + tunnel vision

Please see Retinitis Pigmentosa

Q-43
A 24-year-old man presents to the emergency department complaining of left eye pain. He has not been
able to wear his contact lenses for the past 24 hours due to the pain. He describes the pain as severe and
wonders whether he has 'got something stuck in his eye'. On examination there is diffuse hyperaemia of
the left eye. The left cornea appears hazy and pupillary reaction is normal. Visual acuity is reduced on the
left side and a degree of photophobia is noted. A hypopyon is also seen. What is the most likely diagnosis?
A. Acute angle closure glaucoma
B. Viral conjunctivitis
C. Keratitis
D. Episcleritis
E. Anterior uveitis

ANSWER:
C. Keratitis

EXPLANATION:
Whilst a hypopyon can of course be seen in anterior uveitis the combination of a normal pupillary reaction
and contact lens use make a diagnosis of keratitis more likely.

Please see Keratitis

Q-44
Which one of the following statements regarding macular degeneration is true?

A. Drusen are characteristic of wet macular degeneration

B. Photodynamic therapy is useful in dry macular degeneration
C. Asian ethnicity is a risk factor
D. Male sex is a risk factor
E. Wet macular degeneration carries the worst prognosis

ANSWER:
E. Wet macular degeneration carries the worst prognosis

EXPLANATION:

Please see Age-Related Macular Degeneration

Q-45
A 63-year-old man presents to his GP complaining of pain in his right eye. On examination the sclera is red
and the pupil is dilated with a hazy cornea. What is the most likely diagnosis?

A. Scleritis
B. Conjunctivitis
C. Acute angle closure glaucoma
D. Anterior uveitis
E. Subconjunctival haemorrhage

ANSWER:
C. Acute angle closure glaucoma

EXPLANATION:
Red eye - glaucoma or uveitis?
 glaucoma: severe pain, haloes, 'semi-dilated' pupil
 uveitis: small, fixed oval pupil, ciliary flush
Please see Red Eye

Q-46
Which one of the following is associated with heterochromia in congenital disease?

A. Holmes-Adie pupil
B. Third nerve palsy
C. Sixth nerve palsy
D. Argyll-Robertson pupil
E. Horner's syndrome

ANSWER:
E. Horner's syndrome

EXPLANATION:

Please see Horner's Syndrome

Q-47
Each one of the following predisposes to cataract formation, except:

A. Down's syndrome
B. Hypercalcaemia
C. Diabetes mellitus
D. Long-term steroid use
E. Uveitis

ANSWER:
B. Hypercalcaemia

EXPLANATION:
Hypocalcaemia is a cause of cataracts

Please see Cataracts

Q-48
A 40-year-old man presents with bilateral dry, gritty eyes. A diagnosis of blepharitis is considered. Which
one of the following is least likely to be associated with blepharitis?

A. Meibomian gland dysfunction

B. Seborrhoeic dermatitis
C. Staphylococcal infection
D. Acne rosacea
E. Viral upper respiratory tract infection

ANSWER:
E. Viral upper respiratory tract infection
EXPLANATION:

Please see Blepharitis

Q-49
A 65-year-old man with a known history of Paget's disease is noted to have irregular dark red lines
radiating from the optic nerve. What is the likely diagnosis?

A. Retinitis pigmentosa
B. Optic neuritis
C. Angioid retinal streaks
D. Choroidoretinitis
E. Malignant hypertension

ANSWER:
C. Angioid retinal streaks

EXPLANATION:
This is a typical description of angioid retinal streaks which are associated with Paget's disease

Please see Angioid Retinal Steaks

Q-50
A 24-year-old man who has a family history of retinitis pigmentosa is reviewed in the ophthalmology
clinic. He reports worsening vision over the past few months. During fundoscopy, which of the following
findings with most support a diagnosis of retinitis pigmentosa?

A. Pigmented scrambled egg appearance concentrated around the macula

B. Central irregular pigmentation with bull's eye maculopathy
C. Black bone spicule-shaped pigmentation in the peripheral retina
D. Drusen with haemorrhagic atrophic changes concentrated at the periphery of the retina
E. Pigmented choroidal neovascularisation throughout the retina

ANSWER:
C. Black bone spicule-shaped pigmentation in the peripheral retina

EXPLANATION:
Please see Retinitis Pigmentosa
Q-51
A 74-year-old man presents to ophthalmology clinic after seeing his optician. They have noticed raised
intra-ocular pressure and decreased peripheral vision. His past medical history includes asthma and type 2
diabetes mellitus. What is the most appropriate treatment given the likely diagnosis?

A. Latanoprost
B. Pilocarpine
C. Timolol
D. Dorzolamide
E. Brimonidine
ANSWER:
A. Latanoprost

EXPLANATION:
A prostaglandin analogue should be used first-line in patients with a history of asthma.

Please see Primary Open-Angle Glaucoma: Management

Q-52
Which one of the following is associated with the Holmes-Adie pupil?

A. Decreased ankle reflexes

B. Pupillary constriction
C. Ptosis in 10-20% of cases
D. An increased of developing multiple sclerosis
E. Neurosyphilis

ANSWER:
A. Decreased ankle reflexes

EXPLANATION:
Holmes ADIe = DIlated pupil, females, absent leg reflexes

Please see Holmes-Adie Pupil

Q-53
A 78-year-old gentleman presents to the emergency department complaining of a severe headache. His
only medical condition is hypertension, for which he take Ramipril 10 mg and Amlodipine 10 mg. As part
of the full work up fundoscopy is performed, with the following results bilaterally: Scattered cotton wool
spots, tortuous vessels throughout, and AV nipping.

What stage of hypertensive retinopathy according the Keith-Wagener classification does this patient
have?

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
E. No retinopathy present

ANSWER:
C. Stage 3

EXPLANATION:
Fundoscopy reveals end organ damage in hypertension

This describes stage 3 hypertensive retinopathy, as there are features of stages 1 to 3 described.
Hypertensive and diabetic retinopathy are both common finals questions.

Please see Hypertensive Retinopathy

Q-54
A 71-year-old man presents with a burning sensation around his right eye. On examination an
erythematous blistering rash can be seen in the right trigeminal distribution. What is the most likely
diagnosis?

A. Ramsay Hunt syndrome

B. Cluster headache
C. Fungal keratitis
D. Herpes zoster ophthalmicus
E. Trigeminal neuralgia

ANSWER:
D. Herpes zoster ophthalmicus

EXPLANATION:

Please see Herpes Zoster Ophthalmicus

Q-55
Which one of the following causes of Horner's syndrome is due to a central lesion?

A. Cavernous sinus thrombosis

B. Internal carotid aneurysm
C. Syringomyelia
D. Pancoast's tumour
E. Cervical rib

ANSWER:
C. Syringomyelia

EXPLANATION:
Horner's syndrome - anhydrosis determines site of lesion:
 head, arm, trunk = central lesion: stroke, syringomyelia
 just face = pre-ganglionic lesion: Pancoast's, cervical rib
 absent = post-ganglionic lesion: carotid artery

Please see Horner's Syndrome

Q-56
During routine follow-up at renal clinic a man is noted to have corpuscular pigmentation of the left retina.
Which one of the following conditions is associated with retinitis pigmentosa?
A. Autosomal dominant polycystic kidney disease
B. Tuberous sclerosis
C. Von Hippel-Lindau syndrome
D. Alport's syndrome
E. Medullary sponge kidney

ANSWER:
D. Alport's syndrome

EXPLANATION:

Please see Retinitis Pigmentosa

Q-57
A 64-year-old woman presents with bilateral sore eyelids. She also complains of her eyes being dry all the
time. On examination her eyelid margins are erythematous at the margins but are not swollen. Of the
given options, what is the most appropriate initial management?

A. Topical chloramphenicol + mechanical removal of lid debris

B. Hot compresses + topical steroids
C. Topical chloramphenicol + topical steroids
D. Hot compresses + mechanical removal of lid debris
E. Topical chloramphenicol + hot compresses

ANSWER:
D. Hot compresses + mechanical removal of lid debris

EXPLANATION:
1st line of treatment for blepharitis is hot compresses

Artificial tears may also be given for symptom relief of blepharitis

Please see Blepharitis

Q-58
An 80-year-old male presents to the Neurology clinic with double vision and unsteadiness whilst walking.
He has a past medical history of hypertension, hypercholesterolaemia and type 2 diabetes.

On examination, you notice a right partial ptosis and miosis. The patient also has notable right facial loss
of pain and temperature sensation with left sided truncal sensory loss contralateral to the face.

In the clinic, apraclonidine eye drops are added to the affected eye, which causes a dilatation, whilst in
the opposite eye, a pupil constriction occurs. After the eye drops have been eliminated from the body, 1%
hydroxyamphetamine eye drops are then instilled. One hour after instillation, both pupils dilate.

What neurone order is likely affected in the sympathetic pathway?

A. First order
B. Second order
C. Third order
D. Fourth order
E. Fifth order

ANSWER:
A. First order

EXPLANATION:
The answer is the first order neurone.

Apraclonidine eye drops are initially used to confirm a Horner's pupil. Apraclonidine stimulates both alpha-
1 and alpha-2 receptors. When added to the affected eye, it causes pupil dilation by >2mm because of the
relative supersensitivity of this pupil to alpha-1 receptor activity. In a normal pupil, however, it causes
constriction due to the more potent activity at the alpha-2 receptor which triggers reuptake of
noradrenaline in the synaptic cleft.

Hydroxyamphetamine is then used to distinguish between first/second or third order neurones. In other
words, it will distinguish either a lesion in the brainstem, cervical cord, chest or neck and one affecting
above the superior cervical ganglion at the carotid bifurcation. In a normal pupil or a first/second order
Horner's, the pupil will dilate secondary to increased levels of noradrenaline released from the post-
synaptic neurones. In a third order neurone, this will not occur.

There is no fourth or fifth order neurone.

Please see Horner's Syndrome

Q-59
An 80-year-old woman presents with 'funny spots' affecting her vision. Over the past week she has
noticed a number of flashes and floaters in the visual field of the right eye. What is the most likely
diagnosis?

A. Retinal detachment
B. Posterior vitreous detachment
C. Optic neuritis
D. Depression
E. Vitreous haemorrhage

ANSWER:
B. Posterior vitreous detachment

EXPLANATION:
Posterior vitreous detachment is thought to occur in up to 50-75% of the population over 65 years and is
the most likely diagnosis here. Such patients are normally reviewed by an ophthalmologist to assess the
risk of progressing to retinal detachment.
Please see Sudden Loss of Vision
Q-60
A 71-year-old man who has recently been diagnosed with macular degeneration asks for advice regarding
antioxidant dietary supplements. Which one of the following may contraindicate the prescription of such
supplements?

A. Current smoker
B. Pernicious anaemia
C. Treated hypertension
D. History of depression
E. Previous episodes of tendonitis

ANSWER:
A. Current smoker

EXPLANATION:
Beta-carotene has been found to increase the risk of lung cancer and hence antioxidant dietary
supplements are not recommended for smokers.

Please see Age Related Macular Degeneration

Q-61
A 34-year-old woman presents complaining of headaches. Examination of her pupils using a light shone
alternately in each eye reveals that when the light is shone in the right eye both pupils constrict but when
the light source immediately moves to the left eye both eyes appear to dilate.

What is the most likely diagnosis?

A. Right optic neuritis

B. Left sided Horner's syndrome
C. Craniopharyngioma
D. Left optic neuritis
E. Right Holmes-Adie pupil

ANSWER:
D. Left optic neuritis

EXPLANATION:
This is the 'swinging light test' and reveals a relative afferent pupillary defect. As there is a defect in the
afferent nerve on the left side the pupils constrict less than normal, giving the impression of dilation.

Given her age, multiple sclerosis causing optic neuritis is the likely underlying diagnosis. Optic neuritis
typically causes a dull ache in the region of the eye which is aggravated by movement

Please see Relative Afferent Pupillary Defect

Q-62
A 67-year-old man who is known to have raised intraocular pressure is prescribed dorzolamide eye drops.
What is the mechanism of action of this drug?
A. Prostaglandin analogue
B. Alpha2-adrenoceptor agonist
C. Carbonic anhydrase inhibitor
D. Muscarinic receptor agonist
E. Beta-blocker

ANSWER:
C. Carbonic anhydrase inhibitor

EXPLANATION:
Dorzolamide - carbonic anhydrase inhibitor

Please see Primary Open-Angle Glaucoma: Management