Ophthalmology Exam - Section B: Complete Answers

Q.4 - Fill in the Blanks

1. Haab striae are seen in - Infantile (congenital) glaucoma (horizontal breaks/tears in Descemet's membrane caused by raised IOP stretching the cornea in buphthalmos)
2. Munson sign is seen in - Keratoconus (also keratoglobus) - it is the bulging of the lower eyelid when the patient looks downward, caused by the conical protrusion of the cornea
3. Arlt's line is seen in - Trachoma (a horizontal scar on the superior tarsal conjunctiva in cicatricial/late-stage trachoma)
4. Cherry red spot is seen in - Central Retinal Artery Occlusion (CRAO) - the fovea retains its red color from the choroidal supply while the surrounding ischemic retina turns white/opaque (also seen in storage disorders like Tay-Sachs, Niemann-Pick)
5. Gunn's Sign is seen in - Hypertensive retinopathy (arteriovenous (A-V) nipping/nicking where the thickened arterial wall compresses the underlying vein at crossings)

Q.5 - MCQs

1. Marcus Gunn Pupil is NOT seen in? - Answer: (c) Papilloedema

• Optic neuritis (a)
• Traumatic optic neuropathy (b)
• Optic nerve compression (d)

2. Which is NOT associated with Glaucoma? - Answer: (b) Reversible damage

• Raised IOP (a) - a major risk factor
• Visual field defects (c) - characteristic arcuate scotomas, nasal step, etc.
• Optic disc cupping (d) - increased cup-to-disc ratio

3. Which is NOT seen in High Myopia? - Answer: (c) Shallow anterior chamber

• Foster Fuchs spots (a) - pigmented macular lesions from choroidal neovascularization
• Risk of retinal detachment (b) - due to vitreous degeneration and peripheral retinal lattice degeneration
• Concave (diverging) lens used for correction (d)

4. Which is NOT found in Anterior Uveitis? - Answer: (c) Steroids are contraindicated

• Keratic precipitates (a) - inflammatory cells depositing on corneal endothelium
• Aqueous flare (b) - protein leakage making the aqueous beam visible on slit lamp
• Recurrent episodes (d) - classically it is a relapsing-remitting condition

5. Kayser-Fleischer Ring is found in... - Answer: (b) Chalcosis

• Keratoconus (a) - has Fleischer ring (iron deposits at cone base), NOT Kayser-Fleischer
• Chalcosis (b) - copper deposition causes a Kayser-Fleischer-like ring in the cornea
• Argyrosis (c) - silver deposition causes a grey/slate-colored discoloration, NOT KF ring
• Buphthalmos (d) - enlarged eye from infantile glaucoma, no KF ring

Note: If Wilson's disease were an option, it would be the classic answer. But among these four options, chalcosis (copper foreign body) is correct because the KF ring is specifically a copper deposition phenomenon.

Q.6 - Clinical Case: 65-year-old with Bilateral, Gradual, Painless, Progressive Dimness of Vision (3 years), Greyish-white opacity in pupillary area

Part 1: Differential Diagnoses (5 marks)

1. Senile Cataract (most likely) - Nuclear/posterior subcapsular cataract is the most common cause; greyish-white opacity in pupillary area, bilateral, progressive, does not improve with glasses
2. Posterior Capsular Opacification (PCO) - in patients with prior cataract surgery
3. Corneal Opacity/Leucoma - corneal scarring from old keratitis, dystrophies
4. Vitreous Opacity - vitreous degeneration or hemorrhage (less likely to be greyish-white in pupillary area)
5. Lens-induced conditions - e.g., hypermature cataract (Morgagnian)

Primary diagnosis: Senile Cataract - the classic triad is present: age >60, bilateral gradual painless visual loss, not correctable with spectacles, visible opacity in pupillary area.

Part 2: Management (15 marks)

• History: Duration, rate of progression, previous ocular surgery, systemic diseases (DM, HTN), medications (steroids), family history
• Visual Acuity (Snellen chart) - both distance and near; with and without correction
• Slit-lamp examination - type of cataract (nuclear, cortical, posterior subcapsular), grading (LOCS system)
• Pupillary reflexes - rule out RAPD (suggests posterior segment disease)
• Fundus examination - assess posterior segment through the opacity; if not possible, use:
  • B-scan ultrasonography - rule out vitreous hemorrhage, retinal detachment, posterior staphyloma
  • ERG (Electroretinogram) - assess retinal function if fundus not visible
• IOP measurement - rule out glaucoma
• Biometry (A-scan) - axial length + keratometry for IOL power calculation (pre-surgical)
• Corneal endothelial count - specular microscopy (pre-surgical)
• Systemic work-up - Blood glucose (DM), BP, CBC, ECG (pre-anesthesia fitness)

• Visual acuity <6/18 in the better eye (affecting daily activities)
• Patient's subjective complaint of significant visual disability
• Complications: lens-induced glaucoma, uveitis

1. Phacoemulsification (Phaco) with foldable IOL implantation - gold standard
   • Small incision (2.2-2.8 mm), self-sealing
   • Ultrasonic fragmentation of nucleus
   • Implant foldable IOL (acrylic) in the capsular bag
   • Faster recovery, minimal astigmatism
2. MSICS (Manual Small Incision Cataract Surgery) - if hard nucleus or resource-limited setting
   • Effective, cost-efficient alternative used widely in developing countries
3. ECCE (Extra-capsular Cataract Extraction) - older technique, reserved for very hard cataracts

• Monofocal IOL (standard)
• Multifocal/EDOF IOL (reduces spectacle dependence)
• Toric IOL (if significant astigmatism present)

• Topical antibiotic + steroid eye drops (e.g., moxifloxacin + prednisolone)
• NSAIDs drops (prevent cystoid macular edema)
• Eye shield at night for first week
• Review at day 1, week 1, month 1
• Spectacle prescription at 4-6 weeks post-op
• Watch for complications: endophthalmitis, PCO, cystoid macular edema, corneal decompensation

• Nd:YAG laser posterior capsulotomy - quick outpatient procedure to restore vision