KMK ocular disease level 3

All of the following signs may occur due to a full thickness corneal laceration EXCEPT: A. elevated intraocular pressure B. hyphema C. shallow anterior chamber depth D. positive Seidel sign

A A full thickness corneal laceration is characterized by a positive Seidel sign, shallow anterior chamber, and decreased intraocular pressure due to loss of aqueous humor through the open globe wound. Additional signs may include hyphema and iris transillumination defects

The MOST common presenting symptom of post-operative endophthalmitis is: A. blurred vision B. eyelid swelling C. ocular redness D. eye pain

A According to the Endophthalmitis Vitrectomy Study, blurred vision is the most common presenting complaint of post-operative endophthalmitis, reported in 93% of cases. Ocular redness (81%), eye pain (75%), and eyelid swelling (33%) are less common presenting symptoms.

Which of the following systemic conditions MOST commonly presents as a mild anterior uveitis with a transient, mobile hypopyon and minimal conjunctival hyperemia? A. Behcet's disease B. Juvenile rheumatoid arthritis C. Sarcoidosis D. HLA-B27 spondyloarthropathies

A Behcet's disease is an idiopathic multisystem disease characterized by recurrent episodes of orogenital ulcers and vasculitis. One of the most common ocular complications is an acute, recurrent, non-granulomatous, unilateral or bilateral, anterior, posterior, or panuveitis that is frequently associated with transient mobile hypopyon. The other listed conditions are associated with uveitis but not with a hypopyon.

A patient presents with a peripheral corneal ulcer and associated anterior necrotizing scleritis. What is the MOST likely cause of this patient's peripheral ulcerative keratitis? A. Collagen vascular disease B. Mooren's ulcer C. Ocular rosacea D. Staphylococcus marginal keratitis

A Peripheral ulcerative keratitis, particularly in combination with scleritis, carries a high risk of an underlying, often undiagnosed, collagen vascular disease or systemic vasculitis. The latter is a life-threatening condition. Mooren's ulcer is believed to be an autoimmune reaction specific to the peripheral cornea and not associated with systemic disease. Staph marginal keratitis is associated with numerous, small, subepithelial infiltrates in the paralimbal region. Ocular rosacea presents similarly to Staph marginal keratitis, but is often associated with corneal neovascularization.

You note a patient's RGP contact lenses have a flat fit, as well as an area of corneal stromal thinning with fluorescein pooling. What is the MOST appropriate diagnosis? A. Dellen B. Corneal ulcer C. Phlyctenule D. Pinguecula

A A corneal dellen results from poorly fitting RGP contact lenses, ptyergia, glaucoma filtering blebs, and ocular surface tumors that cause an uneven distribution of the tear film; this leads to progressive corneal stromal thinning that pools with fluorescein

The MOST common infectious cause of post-operative endophthalmitis is: A. gram positive bacteria B. mycobacteria C. fungi D. gram negative bacteria

A According to the Endophthalmitis Vitrectomy Study, nearly 95% of culture-positive endophthalmitis cases isolate gram-positive bacteria. Gram-negative bacteria cause only 6% of cases, with fungal cases less represented. Mycobacteria are uncommon causes of endophthalmitis.

The GREATEST risk for development of a macular hole is: A. increasing age B. ocular trauma C. intraocular surgery D. posterior vitreous detachment E. history of macular hole in the fellow eye

A Age is the most significant risk factor for the development of a macular hole, which results from focal vitreal traction at the fovea. Minor risks include a history of a macular hole in the fellow eye, trauma, and intraocular surgery. Macular holes do not develop subsequent to a complete PVD, as vitreal traction no longer exists.

Corneal edema is commonly associated with all of the following EXCEPT: A. daily gas permeable contact lens wear B. herpetic keratitis C. Fuchs' corneal dystrophy D. acute angle closure glaucoma

A Although corneal edema may be associated with contact lens wear, daily gas permeable contact lens wear is associated with the least risk of corneal edema compared to extended wear or soft contact lenses. Fuchs' endothelial dystrophy results in corneal edema due to decreased endothelial cell density. Herpetic keratitis, especially stromal keratitis or endotheliitis, is associated with corneal edema. Acute angle closure glaucoma may result in corneal edema because increased IOP impairs the function of the endothelial pumps.

Which of the following cause development of anterior polar cataracts? A. hereditary B. trauma C. oral steroids D. radiation

A Anterior polar cataracts are considered congenital cataracts and are most often inherited in a dominant fashion. Oral steroids are associated with the development of posterior subcapsular cataracts. Although radiation and trauma may also lead to cataract development, they are usually not associated with anterior polar cataracts

Which of the following retinal dystrophies is inherited in an autosomal dominant fashion? A. best dystrophy B. Stargardt's dystrophy C. congenital achromatopisa D. gyrate atrophy

A Best disease is inherited in an autosomal dominant fashion. Gyrate atrophy, Stargardt dystrophy, and congenital achromatopsia are all inherited in an autosomal recessive fashion.

Focal occlusions of the choriocapillaris that result in necrosis and subsequent atrophy of the RPE are known as: A. Elsching's spots B. cotton wool spots C. Berlin's edema D. Siegrist streaks

A Elsching's spots appear as white or tan chorioretinal lesions with surrounding pigment that develop as a result of focal occlusions of the choriocapillaris secondary to hypertension. Siegrist streaks, which are similar to Elschnig's spots, are linear areas of chorioretinal degeneration that are secondary to occlusions of large choroidal arteries. Cotton wool spots are thickened, opaque areas of the retina that develop secondary to focal retinal ischemia. Berlin's edema is due to disruption of the photoreceptor outer segments in the macula due to trauma (i.e., commotio retinae within the macula).

Which of the following is the MOST common cause of genetic visual impairment in infants and children? A. Leber congenital amaurosis B. Sorsby dystrophy C. Retinitis pigmentosa D. Choroideremia

A Leber congenital amaurosis is the most common genetic cause of visual impairment in children, often resulting in blindness and nystagmus at or shortly after birth. Retinitis pigmentosa generally does not manifest in childhood. Sorsby dystrophy is a peripheral choroidal and outer retinal disease that typically manifests in adulthood. Choroideremia is a rare X-linked choroidal disease that often does not cause visual impairment until middle adulthood.

Leukocoria in children is associated with all of the following EXCEPT: A. retinitis pigmentosa B. congenital cataract C. Coat's disease D. ROP E. retinoblastoma

A Leukocoria is typically seen in cases of marked retinal exudates (e.g., Coats' disease), retinal detachment (e.g., ROP), intraocular tumors (e.g., retinoblastoma), or media opacities (e.g., cataracts). It is not associated with retinitis pigmentosa.

Which of the following is NOT an association of iris coloboma? A. megalocornea B. microcornea C. cataract D. micropthalmia

A Microcornea may occur with several other ocular and systemic conditions, including iris coloboma. Microphthalmia, another congenital developmental condition, has also been linked to iris coloboma. Cataracts are associated with iris and chorioretinal colobomas. Megalocornea is associated with iris stromal hypoplasia and iris transillumination defects, but not iris coloboma.

Neovascular glaucoma is MOST likely to occur within what time period following a central retinal vein occlusion? A. 12 weeks B. 9 weeks C. 15 weeks D. 3 weeks E. 6 weeks

A Neovascular glaucoma most commonly occurs within 12 weeks of onset of a central retinal vein occlusion (CRVO), and is sometimes referred to as "90-day glaucoma." However, it is important to remember that neovascular glaucoma may develop as soon as 2 weeks or as late as 6 months after onset of an acute CRVO; thus, patients should be followed closely with gonioscopy for the first 6 months.

A formerly emmetropic, presbyopic patient reporting a recently improved ability to read is MOST likely to display which of the following types of cataracts? A. nuclear B. cortical C. posterior subcapsular D. lamellar

A Nuclear sclerotic cataracts cause a refractive change in the crystalline lens, most often resulting in a myopic shift in the refractive error. This refractive change in a presbyopic patient enhances reading ability and is often termed "second sight."

Clinical findings in ocular ischemic syndrome may include all of the following EXCEPT: A. dilated retinal arteries B. retinal hemorrhage C. cherry red spot at the fovea D. iris neovascularization E. anterior uveitis

A Ocular ischemic syndrome is due to a chronic reduction in blood supply to the ocular tissues, typically arising from carotid artery occlusion. Ocular ischemia results in narrowing of the retinal arteries, non-tortuous dilation of retinal veins, retinal hemorrhage, ocular neovascularization, and anterior uveitis, among other findings. A cherry red spot at the fovea is often a result of acute neovascular glaucoma and resulting central retinal artery occlusion.

Which of the following conditions is associated with spontaneous corneal perforation? A. Keratoglobus B. Keratoconus C. Pellucid marginal degeneration D. Map dot dystrophy

A Patients with keratoglobus can often experience spontaneous corneal perforation with only minor trauma secondary to severe diffuse corneal thinning. Patients with this condition are often advised to sleep with their eyes protected (e.g., Fox shields). Patients with keratoconus or pellucid marginal degeneration rarely experience spontaneous corneal perforation. Map dot dystrophy is associated with recurrent epithelial corneal erosions, not corneal perforation

Which of the following statements is TRUE regarding phthiriasis palpebrarum? A. The eyelids are a secondary location for infestation; the presence of eyelid lice suggests involvement of the pubic region. B. The lice tend to burrow into the lash follicles. C. Lice breed within the meibomian glands, and as the glands secrete meibum, the nits are deposited on the eyelid margin. D. Elderly individuals are at greatest risk of having phthiriasis palpebrarum.

A Phthiriasis palpebrarum is an infestation of the eyelashes by lice. They tend to live among the lashes by anchoring themselves with their claws. The species is adapted to reside in the pubic region; therefore, infestation of the eyelashes implies systemic involvement. Demodex is the parasite that lives and breeds within the eyelash follicles and sometimes the meibomian glands themselves. Elderly individuals are most at risk for Demodex infestation, while children living under poor sanitary conditions are most at risk for phthiriasis.

All of the following are associated with plateau iris syndrome EXCEPT: A. improved iris configuration with laser peripheral iridotomy B. anterior rotation of the ciliary processes C. absence of the ciliary sulcus on ultrasound biomicroscopy D. double hump sign on indentation gonioscopy

A Plateau iris syndrome is due to enlarged, rotated, or anteriorly positioned ciliary processes that bolster the peripheral iris into a plateau configuration. These abnormal ciliary processes result in the absence of the ciliary sulcus as seen with ultrasound biomicroscopy. A double hump sign will also be noted with indentation gonioscopy. The iris configuration in plateau iris syndrome does not change in response to laser peripheral iridotomy.

You note moderate lash debris, moderate lid telangiectasia, and tear saponification in your patient who complains of burning, gritty, dry eyes. You correctly diagnose blepharitis. Why may blepharitis lead to the development of tear saponification? A. Staphylococcal species secrete lipases that digest tear film lipids, producing gaseous byproducts. B. Altered meibum composition promotes increased oxygen diffusion into the tears. C. Inflammatory mediators promote transport of lipids to the deeper layers of the tear film, leaving the aqueous exposed. D. The soaps from therapeutic lid scrubs are deposited onto the ocular surface.

A Remember that tear saponification refers to "frothy" or "soapy" tears that may appear along the eyelid margins. Tear saponification results from the release of gaseous byproducts into the tear film due to breakdown of tear lipids by Staphylococcal bacterial enzymes. There is no evidence to support the remaining statements.

Which of the following conditions is NOT associated with retinal vasculitis? A. Stargardt disease B. multiple sclerosis C. Bechet's disease D. Sarcoidosis

A Retinal vasculitis may be caused by systemic vasculitides (e.g., sarcoidosis and Behcet's disease) and intraocular inflammation (e.g., uveitis), as well as multiple sclerosis. Retinal vasculitis may also be idiopathic in nature. Stargardt disease is a hereditary retinal disorder resulting in abnormal lipofuscin accumulation and is not known to result in retinal vasculitis.

Ocular signs of retinitis pigmentosa include all of the following EXCEPT: A. retinal drusen B. RPE hyperplasia C. retinal vascular attenuation D. macular edema E. optic disc pallor

A Retinitis pigmentosa (RP) is associated with optic disc pallor secondary to orthograde degeneration, RPE hyperplasia, vascular attenuation, and cystoid macular edema. It has also been associated with optic disc drusen and posterior subcapsular cataracts. RP is not known to result in retinal drusen.

Which of the following malignant eyelid conditions is LEAST likely to be caused by exposure to ultraviolet light? A. Sebaceous cell carcinoma B. Merkel cell carcinoma C. Squamous cell carcinoma D. Malignant melanoma E. Basal cell carcinoma

A Sebaceous cell carcinoma is a tumor of the meibomian glands; it is the third most common eyelid malignancy and is associated with a high risk of metastasis. It often appears similar to benign lid conditions including blepharoconjunctivitis, blepharitis, and chalazia. Although the exact etiology is unknown, sebaceous cell carcinoma is not associated with UV exposure.

A 45-year-old female presents with 2+ superior bulbar conjunctival injection that stains with lissamine green and fluorescein, small superior bulbar conjunctival papillae, and superior superficial punctate keratitis OU. What is the MOST likely diagnosis? A. Superior limbic keratoconjunctivitis B. Giant papillary conjunctivitis C. Vernal keratoconjunctivitis D. Allergic conjunctivitis

A Superior limbic keratoconjunctivitis most commonly affects females ages 40-60 and is associated with thyroid disease and contact lens wear. Clinical findings include injection of the superior bulbar conjunctiva adjacent to the limbus, superior bulbar conjunctival papillae, superior superficial punctate keratitis (SPK), and superior corneal infiltrates.

You order a lacrimal gland biopsy for your 56-year-old patient with a suspected malignant tumor of the lacrimal gland. Which portion of the lacrimal gland should be biopsied? A. Orbital B. Palpebral C. Orbital and palpebral D. The location of the biopsy is unimportant

A The orbital portion of the lacrimal gland contains the origin of the ducts of the glandular units that make up the lacrimal gland; it is larger and more superior compared to the smaller inferior palpebral portion of the lacrimal gland. The ducts traverse through the orbital portion and extend into the palpebral portion. The glandular tissue is the tissue of interest for a suspected tumor of the lacrimal gland; thus, the orbital portion should be biopsied.

Topical ophthalmic latanoprost administration is associated with which of the following posterior segment findings? A. Cystoid macular edema B. Bulls-eye maculopathy C. RPE hyperplasia D. Retinal detachment

A Use of topical ophthalmic prostaglandins may result in cystoid macular edema through pro-inflammatory pathways. Hydroxychloroquine and chloroquine are associated with bulls-eye maculopathy, pilocarpine is associated with retinal detachment, and phenothiazines are associated with RPE hyperplasia.

Which of the following retinal findings is LEAST likely to result in a loss of underlying signal intensity on ocular coherence tomography? A. Lipid exudates B. Pigmentation C. Serous fluid D. Hemorrhage

C Retinal hemorrhage, pigment, and lipid exudate all result in loss of the underlying signal intensity, which is seen as "shadowing" on OCT images; serous retinal fluid does not result in signal disruption.

Which infectious entity is MOST commonly implicated in the development of acute retinal necrosis syndrome (ARN)? A. Toxoplasma gondii B. Clostridium dificile C. Histoplasma capsulatum D. Varicella zoster

D Acute retinal necrosis is most commonly attributed to members of the herpes virus family, predominantly varicella zoster and herpes simplex. The remaining options are not known to cause acute retinal necrosis.

A deficiency in the enzyme ornithine ketoacid aminotransferase (OAT) is associated with which retinal condition? A. Refsum disease B. Stargardt disease C. Familial drusen D. Gyrate atrophy E. Oguchi disease

D Gyrate atrophy is an inherited retinal condition caused by OAT deficiency that results in progressive loss of vision, night blindness, and cataracts. Stargardt disease is associated with abnormal accumulation of retinal lipofuscin, usually from a mutation in the ABCA4 gene. Refsum disease results from abnormal phytanic acid metabolism and is associated with retinitis pigmentosa. Oguchi disease is an inherited disorder that causes congenital stationary night blindness. Familial drusen is characterized by retinal drusen in young patients and often results from a mutation in the EFEMP1 gene.

The MOST common clinical finding in toxic anterior segment syndrome following cataract extraction is: A. vitritis B. corneal edema C. suppurative conjunctivitis D. posterior synechiae

D Marked diffuse corneal edema with little to no posterior segment inflammation diagnosed within the first 12-48 hours following cataract extraction is highly characteristic of toxic anterior segment syndrome (TASS). Posterior synechiae and suppurative conjunctivitis are less common but possible findings associated with this condition.

Optic disc pallor may result from all of the following EXCEPT: A. optic nerve head edema B. retinal atrophy C. optic nerve sheath meningioma D. adult occipital lobe infarct

D Pallor of the optic nerve may be caused by advanced retinal atrophy via orthograde degeneration (e.g., retinitis pigmentosa), optic disc edema, and tumors of the optic nerve. Stroke events anterior to the lateral geniculate nucleus (LGN) in the visual pathway may result in optic nerve pallor, but trans-synaptic retrograde degeneration (e.g., occipital lobe CVA) does not result in clinically evident optic disc pallor unless the event occurs prenatally.

Which of the following statements regarding the pathophysiology of dry eye disease are CORRECT? SELECT 4 A. Chronic evaporative dry eye often leads to a secondary aqueous-deficient dry eye due to neurogenic desensitization of the lacrimal gland. B. Goblet cell loss is present in all forms of dry eye disease. C. Acinar atrophy of the meibomian glands is a compensatory action to help restore normal biochemical properties to the tear film. D. The nonspecific immune system is involved E. The specific immune system is involved. F. Inflammation is only associated with dry eye disease in Sjogren's syndrome.

A, B, D, E Inflammation is associated with all forms of dry eye disease, not just dry eye disease associated with Sjogren's syndrome. Acinar atrophy is a consequence of meibomian gland disease, not a compensatory measure to restore the normal physiological properties of the tear film. All other statements regarding the pathophysiology of dry eye disease are correct.

Which of the following medications is associated with idiopathic intracranial hypertension? SELECT 3 A. Oral contraceptives B. Topiramate C. Tetracyclines D. Isotretinoin E. Vitamin D F. Tamoxifen G. Amiodarone

A, C, D Oral contraceptives, tetracyclines, isotretinoin (Accutane), vitamin A, and naladixic acid (a quiniolone antibiotic) are associated with increased intracranial pressure. Topiramate is a treatment option for intracranial hypertension in patients who cannot tolerate acetazolamide. Vitamin D does not contribute to idiopathic intracranial hypertension. Tamoxifen is prescribed in women with breast cancer and may result in toxic maculopathy. Amiodarone is an anti-arrhythmia medication that may cause whorl keratopathy, anterior subcapsular crystalline lens deposits, and non-arteritic anterior ischemic optic neuropathy.

Which of the following clinical findings are MOST consistent with a direct carotid-cavernous fistula? SELECT 4 A. Ophthalmoplegia B. Contralateral afferent pupillary defect C. Unilateral increased intraocular pressure D. Pulsatile proptosis E. Marked episcleral injection and hemorrhagic chemosis F. Pulsatile enophthalmos G. Lid retraction

A, C, D, E Direct carotid-cavernous fistula is a direct connection between the internal carotid artery and the cavernous sinus, such that a high-pressure system becomes continuous with a low-pressure system. This results in an increase in venous pressure, including the episcleral system, and will lead to episcleral injection and hemorrhagic chemosis. Aqueous humor outflow will also be reduced, causing increased intraocular pressure. Pulsatile proptosis occurs due to increased pressure in the retrobulbar orbit. Ptosis, not lid retraction, is more common with this condition.

A 32-year-old African American patient presents with a small hyphema OS. She denies a history of ocular trauma. Which of the following are the MOST appropriate next steps for this patient? SELECT 4 A. Order hemoglobin electrophoresis B. Prescribe an oral NSAID C. Order a complete blood count (CBC) with differential D. Recommend the patient sleep with her head elevated by 30 degrees E. Prescribe oral aspirin F. Order prothrombin time/partial thromboplastin time (PT/PTT)

A, C, D, F African American patients who present with a hyphema without a history of blunt ocular trauma should be screened for sickle cell anemia and clotting diseases. A complete CBC with differential and PT/PTT aid in the diagnosis of clotting diseases. Hemoglobin electrophoresis (i.e., SICKLEDEX®) is indicated in cases of suspected sickle cell anemia. Patients should sleep with their head elevated by 30 degrees to allow the red blood cells to settle inferiorly. Patients should not take oral NSAIDs or aspirin, as they decrease the blood's ability to clot and may worsen the hyphema.

A 32-year-old female presents with red blood cells in the anterior chamber on slit lamp examination after being punched in the eye. Which of the following should NOT be performed on this patient? SELECT 2 A. Scleral depression B. Goldmann tonometry C. B-scan ultrasonography D. Gonioscopy E. Pupillary dilation

A, D The most appropriate diagnosis in this case is hyphema resulting from blunt trauma. Gonioscopy and scleral depression should not be performed at the initial visit in patients with hyphema, as the pressure applied during these procedures may worsen the condition.

Which of the following accurately describes the relationship between demodicidosis and rosacea? A. Patients with demodicidosis are protected from subsequently developing ocular rosacea. B. Patients with ocular rosacea tend have a higher prevalence of demodicidosis than age-matched normal patients. C. Demodicidosis is the inciting event that initiates rosaceal disease. D. Patients with ocular rosacea are protected from subsequently acquiring demodicidosis.

B Although the association is not fully understood, rosacea patients have a higher than average prevalence of non-ocular and/or ocular Demodex infestation. There is no evidence that Demodex actually causes rosacea.

Atopic dermatitis is MOST frequently associated with which of the following types of cataract? A. Cortical B. Anterior subcapsular C. Cerulean D. Nuclear

B An acquired, bilateral, anterior subcapsular plaque (i.e., shield cataract) is most commonly associated with atopic dermatitis. Posterior subcapsular cataracts are less frequently reported in conjunction with this condition. Cerulean cataracts are rare congenital cataracts that are not associated with atopic dermatitis.

HLA-A29 serotyping is PRIMARILY used in the diagnosis of which posterior segment disease? A. Gyrate atrophy B. Birdshot chorioretinopathy C. Ocular histoplasmosis D. Central serous chorioretinopathy E. Morning glory syndrome

B HLA-A29 serotyping is useful in the diagnosis of birdshot chorioretinopathy, one of the so-called white dot syndromes that are associated with vitritis, optic disc edema, macular edema, and nyctalopia. Approximately 90-97% of patients with birdshot chorioretinopathy are HLA-A29 positive, the highest association of any HLA subtype with disease.

Anterior displacement of the mucocutaneous junction on the eyelid has been associated with meibomian gland dysfunction. What is the functional consequence of this event? A. The conjunctiva grows over the meibomian duct orifices, blocking meibum secretion. B. Meibum is secreted onto the non-lipid-wettable, mucosal surface of the conjunctiva, preventing even distribution across the tear film. C. Goblet cells invade the meibomian glands, disrupting normal meibum composition. D. There is no consequence of this clinical finding.

B If the mucocutaneous junction of the eyelid is displaced anteriorly, the meibomian glands will secrete meibum on to the conjunctiva. Remember that the mucosal surface of the conjunctiva is hydrophilic and therefore has low wettability for lipid secretions. This will result in an uneven distribution of the tear film across the cornea. There is no scientific evidence that supports the remaining statements.

Which of the following is NOT a complication of juvenile retinoschisis? A. RPE atrophy B. choroidal folds C. vitreous hemorrhage D. retinal detachment

B Juvenile retinoschisis (x-linked retinoschisis) is characterized by a splitting of the outer plexiform layer within the macula. It is associated with the development of retinal detachments, vitreous hemorrhage, and RPE atrophy. Choroidal folds are not associated with juvenile retinoschisis.

Which of the following BEST describes the composition of a nodule that occurs in nodular scleritis? A. Calcium deposits B. Serous fluid C. Air bubbles D. Blood

B Nodules associated with scleritis and episcleritis are composed of serous fluid that accumulates secondary to inflammation of the sclera and/or episclera. They are often firm, immobile, and very tender to the touch. Nodules may occur with each recurrence of scleritis and/or episcleritis.

Which of the following is NOT a characteristic of nutritional optic neuropathy? A. Vitamin deficiencies B. Unilateral visual field loss C. Central or centrocecal visual field defect D. Temporal optic nerve pallor

B Nutritional optic neuropathy develops in patients with severe vitamin and nutrient deficiencies, most commonly vitamin B12 deficiency. It is characterized by bilateral temporal optic nerve pallor and bilateral central or centrocecal visual field defects. Patients with suspected nutritional optic neuropathy should have B12 and intrinsic factor blood levels measured to aid in the diagnosis (recall that intrinsic factor is necessary for vitamin B12 absorption).

Which of the following statements regarding penetrating ocular injuries is CORRECT? A. Penetrating ocular injuries are associated with a negative Seidel sign. B. Intraocular pressure should only be measured if there is no ruptured globe C. Penetrating ocular injuries more commonly occur in the elderly. D. The incidence of penetrating ocular injuries is greater in females.

B Penetrating ocular injuries are more common in young to middle aged males. Patients will present with a positive Seidel sign. Intraocular pressure should only be measured after a ruptured globe has been ruled out; it will be decreased in a penetrating ocular injury.

Which of the following ocular findings is MOST consistent with phenothiazine toxicity? A. Cotton wool spots B. RPE hyperplasia C. Optic disc pallor D. Macular edema E. Macular star

B Phenothiazine use (e.g., thioridazine, chlorpromazine) is associated with RPE hyperplasia in doses greater than 800 mg/day or with chronic use. Macular edema, optic disc pallor, cotton wool spots, and macular stars are not commonly associated with use of these medications.

A 62-year-old female with a history of keratoconjunctivitis sicca presents with multiple gray-white elevated nodules in the mid-peripheral cornea OD. What is the MOST likely diagnosis? A. Recurrent corneal erosion B. Salzmann's nodular degeneration C. Phlyctenular keratoconjunctivitis D. Terrien's marginal degeneration

B Salzmann's nodular degeneration is an uncommon unilateral condition characterized by single or multiple blue-gray or white-gray, elevated corneal stromal nodules that are typically adjacent to a corneal scar. It most commonly occurs in patients with a history of keratoconjunctivitis sicca, vernal keratoconjunctivitis, phlyctenulosis, trachoma, and interstitial keratopathy.

The MOST significant ocular complication of Stickler's syndrome is: A. night blindness B. retinal detachment C. angle closure glaucoma D. central retinal artery occlusion

B Stickler's syndrome is associated with abnormal vitreous development and high myopia, resulting in an elevated incidence of retinal detachment. It is not associated with angle closure glaucoma, central retinal artery occlusion, or night blindness.

What is the MOST common site for metastasis of an iris melanoma? A. lung B. liver C. kidney D. brain

B The liver is the most common site of metastasis of a uveal melanoma, which includes melanoma of the iris, ciliary body, or choroid. Uveal melanoma is associated with high mortality rates of less than 6 months if liver metastases develop.

Crystalline retinopathy may result from use of which of the following substances? SELECT 3 A. rifampin B. tamoxifen C. tetracycline D. canthaxanthin E. talc F. niacin

B, D, E Crystalline retinopathy is associated with use of tamoxifen, canthaxanthin, and talc (often from IV drug abuse). Tetracycline, rifampin, and niacin are not known to cause this condition.

Which of the following statements regarding Argyll Robertson pupil secondary to syphilis is TRUE? A. It is characterized by larger than normal pupil size in the affected eye. B. Patients will have a negative FTA-ABS. C. It only occurs in tertiary syphilis. D. The affected pupil will not constrict in response to a near object.

C Argyll Robertson pupils occur in patients with neurosyphilis (tertiary syphilis), which is characterized by a spirochete infection within the cerebrospinal fluid. Patients will have a positive FTA-ABS test even if there is no current active infection because they developed antibodies in response to the initial treponemal infection. An Argyll Robertson pupil is a miotic pupil that does not constrict to light but does constrict in response to a near object (light-near dissociation)

In typical degenerative retinoschisis, splitting of the retinal layers occurs MOST commonly in the: A. inner nuclear layer B. retinal pigment epithelium C. outer plexiform layer D. retinal nerve fiber layer

C Degenerative (senile) retinoschisis is divided into typical and reticular forms. In typical retinoschisis, splitting of the retinal layers occurs in the outer plexiform layer. In reticular retinoschisis, splitting of the retinal layers occurs in the retinal nerve fiber layer. Reticular retinoschisis is more commonly associated with retinal detachments.

Delicate, gray-white, dandruff-like deposits on the anterior capsule of the crystalline lens and zonules is associated with an increased risk of which of the following? A. Vitreous prolapse B. Choroidal rupture C. Open angle glaucoma D. Retinal detachment

C Flaky deposits on the anterior crystalline lens capsule are associated with pseudoexfoliation syndrome; the most significant complication of this disorder is the development of open angle glaucoma. Pseudoexfoliation syndrome is not associated with retinal detachment, choroidal rupture, or vitreous prolapse

Peripheral anterior synechiae and posterior synechiae are RARELY found in uveitis associated with which of the following conditions? A. Sarcoidosis B. Juvenile rheumatoid arthritis C. Fuchs' heterochromic iridocyclitis D. HLA-B27 spondyloarthropathy

C Fuchs' heterochromic iridocyclitis is most commonly a unilateral iridocyclitis that presents with minimal pain and redness. It is rarely associated with the development of peripheral anterior or posterior synechiae, although patients may have angle neovascularization. Remember that chronic inflammation in this condition leads to progressive iris atrophy and heterochromia. The affected eye is typically darker (more blue) in patients with blue eyes, and lighter (less brown) in patients with brown eyes.

Which of the following conditions is NOT associated with the premature development of cataracts? A. Diabetes mellitus B. Myotonic dystrophy C. Systemic hypertension D. Hepatolenticular degeneration E. Atopic dermatitis

C Hepatolenticular degeneration (i.e., Wilson's disease) is associated with "sunflower cataracts" due to copper deposition within the crystalline lens. Myotonic dystrophy is associated with "Christmas tree" cataracts. Atopic dermatitis and diabetes mellitus are additional systemic conditions associated with the early development of cataracts. Systemic hypertension is not associated with the early development of cataracts.

Microspherophakia is PRIMARILY associated with an increased risk of which of the following types of glaucoma? A. primary open angle B. pigmentary C. primary angle closure D. neovascular

C Microspherophakia is a congenital condition characterized by a small spherical crystalline lens shape and an increased risk of development of pupillary block (primary angle closure) glaucoma. Neovascular glaucoma, pigmentary glaucoma, and primary open angle glaucoma are not associated with microspherophakia

A 31-year-old patient presents with multiple molluscum contagiosum lesions bilaterally on his eyelids. What is the MOST appropriate test you should order to further evaluate this patient? A. Lyme titer B. FTA-ABS and RPR C. ELISA D. CBC with differential

C Molluscum contagiosum lesions are caused by the DNA poxvirus. It is a self-limiting condition that typically resolves 2-3 months after onset. It most commonly occurs in children or in adults as a single or few lesions. Adults who present with multiple lesions should be evaluated for an underlying immunosuppressive condition, including HIV. ELISA is the most appropriate test to order in cases of suspected HIV. FTA-ABS and RPR test for syphilis, CBC with differential is a nonspecific test, and Lyme titer tests for Lyme disease; neither Lyme nor syphilis is an immunosuppressive condition.

A 7-year-old patient presents with a chronic follicular conjunctivitis associated with molluscum contagiosum. Which of the following statements is TRUE? A. Molluscum contagiosum is caused by indirect contact with another infected person. B. Patients may present with a severe purulent discharge. C. An underlying HIV infection should be considered when multiple nodules are present. D. Molluscum contagiosum is caused by an RNA pox virus

C Molluscum contagiosum, a chronic infectious condition caused by the DNA pox virus, typically results in a solitary, waxy, domed lesion of the eyelid. If multiple nodules are noted, especially in adults, patients should be tested for an underlying immunosuppressive disease (e.g., HIV).

Which of the following statements regarding Mooren's ulcer is INCORRECT? A. The pathophysiology is primarily mediated through an autoimmune process. B. It is associated with an increased risk of corneal perforation. C. The most frequent pathogen is methicillin-resistant Staphylococcal aureus. D. It begins as a peripheral ulcer that first expands circumferentially then centrally

C Mooren's ulcer is a diagnosis of exclusion and is associated with a negative culture. All other statements are correct.

Which of the following test results is NOT associated with myasthenia gravis? A. Improved eyelid ptosis with the ice pack test B. Improved eyelid ptosis after injection of edrophonium C. Improved eyelid ptosis after sustained up gaze D. Cogan's lid twitch after sustained up gaze

C Myasthenia gravis results from autoantibodies directed against acetylcholine receptors within the neuromuscular junction. Decreased activity of acetylcholine results in increased muscle fatigue and weakness with prolonged voluntary muscle activity. Eyelid ptosis and diplopia are often the first symptoms to present in patients with myasthenia gravis. Cogan's lid twitch, which is a slow lowering of the eyelid after sustained up gaze with twitching, is associated with MG. Improved eyelid ptosis after the ice pack test or after injection of edrophonium (acetylcholinesterase inhibitor) are also associated with MG. Eyelid ptosis will get worse after sustained up gaze due to muscle fatigue.

Which of the following is associated with Purtscher's retinopathy? A. Sinus reconstruction surgery B. Premature birth C. Traumatic chest compression D. Metastatic breast carcinoma

C Purtscher's retinopathy is characterized by bilateral and symmetrical peripapillary cotton wool spots and diffuse retinal hemorrhages. It is associated with chest compression or severe head or long bone trauma, acute pancreatitis, systemic lupus erythematosus, or chronic renal failure. It results from arteriole occlusion from small intravascular particles. Vision loss is usually severe, and there is no known treatment.

A serous retinal detachment is associated with all of the following EXCEPT: A. optic pit B. posterior scleritis C. proliferative vitreoretinopathy D. intraocular neoplasm

C Serous retinal detachments may result from ocular tumors, inflammation such as posterior scleritis, and optic pits, among other causes. Proliferative vitreoretinopathy (PVR) results in fibrotic membrane formation and is the primary risk for tractional retinal detachment.

Which of the following statements regarding posterior polymorphous dystrophy is CORRECT based on modern studies? SELECT 2 A. It is characterized by corneal thinning. B. It is a benign non-progressive disease. C. Corneal transplantation is a potential treatment. D. It is associated with an increased risk of glaucoma

C, D Although older texts suggest posterior polymorphous dystrophy (PPD) is benign and non-progressive, recent research strongly suggests PPD is associated with corneal steepening (not thinning) that may lead to keratoconus-like corneal disease and the need for a penetrating keratoplasty. PPD is also associated with secondary angle closure glaucoma due to the formation of peripheral anterior synechiae by epithelial-like endothelial cells that extend into the iris and angle architecture.

An oil-drop cataract PRIMARILY affects which layer of the crystalline lens? A.Posterior capsule B. Anterior capsule C. Nucleus D. Cortex

C. Oil-drop cataracts are most often associated with abnormalities in the nucleus of the crystalline lens, although other crystalline lens disorders, such as lenticonus, have infrequently been described as giving an "oil-drop" appearance. These uncommon cataracts may occur in a variety of systemic disorders, but are classically associated with galactosemia.

A ruddy brown, petaloid opacification of the crystalline lens is MOST suggestive of which of the following systemic conditions? A. Weill-Marchesani syndrome B. Goldenhar syndrome C. Alport syndrome D. Wilson's disease

D A brownish petaloid cataract (sunflower cataract) is characteristic of Wilson's disease (i.e., hepatolenticular degeneration), which is characterized by abnormal deposition of copper within tissues including the cornea and crystalline lens. Alport, Goldenhar, and Weill-Marchesani syndromes are not associated with this type of cataract.

An elderly patient with severe vision loss displays an opaque, orange-yellow spherule inferiorly located within a milky white crystalline lens on slit lamp examination. Which of the following is the MOST likely cause of this patient's cataract? A. Galactosemia B. Fabry disease C. Congenital D. Age-related

D A hypermature, senile, cortical "morgagnian" cataract is a result of cortical liquefaction and inferior settling of the yellow-orange lens nucleus within the milky cortex. Galactosemia classically results in an "oil-drop" cataract that often appears relatively clear and is best distinguished on retroillumination. Fabry disease often results in posterior capsular opacification and dense deposits of granular material in a spoke-like pattern (Fabry cataract). Congenital cataracts appear in a variety of forms, but are typically not associated with cortical liquefaction and nucleus drop.

You correctly diagnose your patient with episcleritis. Which of the following tests would be LEAST likely to aid in the diagnosis of an associated systemic condition? A. Erythrocyte sedimentation rate B. Sacroiliac x-ray C. FTA-ABS and VDRL D. Chest x-ray E. Antinuclear antibody

D Antinuclear antibody (ANA) would help in the diagnosis of rheumatoid arthritis, systemic lupus erythematosus (SLE), and potentially Crohn's disease. Erythrocyte sedimentation rate (ESR) may also aid in the diagnosis of SLE. FTA-ABS and VDRL are blood tests for syphilis. Sacroiliac x-rays are indicated for patients with suspected ankylosing spondylitis. A chest x-ray would aid in the diagnosis of tuberculosis, which is only rarely associated with episcleritis (it is more often associated with scleritis).

The MOST common site of the retinal break in a rhegmatogenous retinal detachment is: A. inferior nasal B. superior nasal C. inferior temporal D. superior temporal

D Approximately 60% of retinal breaks in eyes with a retinal detachment (RD) are located in the superior temporal quadrant, followed by 15% in the superior nasal, 15% in the inferior temporal, and 10% in the inferior nasal quadrants. The superior temporal quadrant should therefore be examined very carefully in eyes with RD in which retinal breaks are not immediately discovered.

Which of the following conditions is MOST likely to result in permanent loss of vision? A. VKC B. perennial allergic conjunctivitis C. seasonal allergic conjunctivitis D. AKC

D Atopic keratoconjunctivitis may cause corneal epithelial erosions, corneal neovascularization and opacification, conjunctival scarring, and symblepharon formation, resulting in permanent decreased vision.

Avulsion of the vitreous base is considered pathognomonic for: A. Stickler syndrome B. exudative retinal detachment C. familial exudative vitreoretinopathy D. blunt force trauma

D Avulsion of the vitreous base almost exclusively occurs following blunt force trauma to the globe. Exudative retinal detachment, Stickler syndrome, and familial exudative vitreoretinopathy are not associated with avulsion of the vitreous base.

Which form of optical correction is MOST likely to reduce aniseikonia following unilateral cataract extraction? A. flat top bifocal spectacles B. single vision spectacles C. progressive multifocal spectacles D. contact lenses

D Contact lenses are the best method for reducing aniseikonia secondary to unilateral cataract surgery because of optical centration and decreased vertex distance compared to spectacles. Recall that symptomatic aniseikonia most commonly occurs with greater than 3.00 D refractive anisometropia.

Crystalline deposits in the corneal stroma may be associated with all of the following conditions EXCEPT: A. Schnyder crystalline dystrophy B. cystinosis C. tyrosinemia D. fleck corneal dystrophy

D Schnyder crystalline dystrophy, tyrosinemia, and cystinosis all result in corneal stromal crystals. Additional conditions with a similar presentation include Bietti crystalline dystrophy, gold deposits, and gout. Fleck corneal dystrophy presents as white stromal flecks, not crystalline deposits.

Which of the following topical ophthalmic pharmacologic agents would aid in the differential diagnosis of scleritis compared to episcleritis? A. Tropicamide 0.5% B. Tropicamide 1% C. Paremyd D. Phenylephrine 2.5%

D. Topical ophthalmic tropicamide of any concentration does not constrict blood vessels and is therefore of little use in differentiating episcleritis from scleritis. Paremyd contains tropicamide and hydroxyamphetamine hydrobromide, an indirect acting sympathomimetic agent that will likely only produce subclinical vasoconstriction. Topical phenylephrine 2.5% will cause vasoconstriction of only the conjunctival and superficial episcleral vessels, and is thus useful in differentiating between episcleritis (the vessels blanch) and scleritis (the eye remains red).

Central retinal artery occlusion associated with giant cell arteritis is considered an ocular emergency because the causative disorder may MOST likely result in: A. aortic aneurysm B. acute glaucoma C. extraocular muscle misalignment D. cerebrovascular accident E. bilateral severe vision loss

E Central retinal artery occlusion (CRAO) is associated with giant cell arteritis, which presents the only true emergency as it may result in bilateral severe vision loss in up to 95% of cases if left untreated, usually within the first four months. Other potential causes of CRAO are not generally considered to be emergent but often merit diagnostic workup.

Spontaneous corneal epithelial erosions may occur in which of the following conditions? SELECT 2 A. Epithelial basement membrane dystrophy B. Keratoconus C. Following trauma D. Fuchs' endothelial dystrophy

A, B By definition, corneal erosion following trauma is not spontaneous. However, corneal epithelial erosions may develop secondary to keratoconus, epithelial basement membrane dystrophy, or TGFB1 corneal stromal dystrophies (e.g., granular, lattice, or Avellino). They are not associated with Fuchs' endothelial dystrophy

Although nodules may develop in any quadrant in nodular scleritis, what are the MOST common locations? SELECT 2 A. Near the limbus B. Interpalpebral sclera C. In the conjunctival fornices D. Temporal peripheral quadrant E. Nasal peripheral quadrant

A, B Nodules in scleritis are most commonly found in the interpalpebral zone near the limbus. Recall that nodules are localized areas of serous fluid that appear yellow or deep red, depending on the degree of underlying vascular congestion. Nodular scleritis may present with one or multiple nodules that may or may not recur with additional episodes of inflammation.

Which of the following conditions are associated with peripheral corneal epithelial hypertrophy and phlyctenular ocular disease? SELECT 3 A. Tuberculosis B. Ocular rosacea C. Staphylococcus aureus D. Moraxella catarrhalis E. Terrien's marginal degeneration

A, B, C Moraxella catarrhalis is the only ocular infection not associated with phlyctenular ocular surface disease. Remember that phlyctenules are lymphocytic nodules on the cornea or conjunctiva that are a result of a type IV hypersensitivity reaction to certain pathogens, including staphylococcus aureus (commonly from chronic blepharitis), tuberculin protein, and ocular rosacea. Terrien's marginal degeneration is unrelated to phlyctenular ocular surface disease.

You note a slate-grey lesion within the choroid OD in your 59-year-old patient. Which of the following findings should increase suspicion of choroidal melanoma? SELECT 3 A. Subretinal fluid B. Location adjacent to the optic nerve C. Overlying orange pigment D. Approximately 0.5 mm elevation E. Overlying hard drusen F. Diameter of 3 mm

A, B, C Several studies have established characteristics that significantly increase the likelihood of a choroidal melanoma compared to a choroidal nevus. These characteristics include elevation greater than 2 mm, orange pigment (lipofuscin), lack of overlying hard drusen, absence of a surrounding halo (area of hypopigmentation around the lesion), less than 3 mm proximity to the optic nerve, subretinal fluid, ultrasonographic hollowness, and patient symptoms (e.g., flashes of light, blurred vision).

Which of the following procedures utilizes photoablation? SELECT 4 A. LASEK B. e-LASIK C. LASIK D. Photorefractive keratectomy E. conductive keratoplasty

A, B, C, D Photoablation refers to laser-tissue interaction. LASIK, e-LASIK, LASEK, and photorefractive keratectomy utilize photoablation to remove corneal tissue. Conductive keratoplasty uses radiofrequency energy.

Which of the following statements are CORRECT regarding retinal ganglion cell death in primary open angle glaucoma? SELECT 4 A. Retinal ganglion cell death is partly due to mechanical compression by intraocular pressure that disrupts axoplasmic flow. B. Retinal ganglion cell death occurs primarily via apoptosis. C. The retinal ganglion cell bodies are the initial site of insult in glaucoma. D. The retinal ganglion cell axons are the initial site of insult in glaucoma. E. Retinal ganglion cell death occurs primarily via necrosis. F. Retinal ganglion cell death is partly due to microvascular ischemia of the optic nerve head. G. Retinal ganglion cell death is partly due to excess glutamate released from the vitreous in response to poorly regulated intraocular pressure.

A, B, D, F Glutamate excitotoxicity has been implicated in retinal ganglion cell death, but its source is not the vitreous, nor is it known to be associated with poorly regulated intraocular pressure. Retinal ganglion cell axons are the initial site of insult in glaucoma, not the cell bodies. Retinal ganglion cell death occurs through apoptosis rather than necrosis.

B-scan ultrasonography is indicated for which of the following? SELECT 3 A. Evaluation of optic nerve head drusen B. Differentiation between choroidal nevus and choroidal melanoma C. Calculation of an IOL power D. Determination of glare impact prior to cataract surgery E. Determination of an intact retina posterior to a vitreous hemorrhage

A, B, E B-scan ultrasonography may be used to detect posterior segment abnormalities when the view of the fundus is obscured by cataracts, vitreous hemorrhage, or other opacities. A B-scan may also be used to diagnose the presence of buried optic nerve head drusen (will appear hyperreflective at low gains), as well as to differentiate a choroidal nevus from a choroidal melanoma. A-scan ultrasonography is used in the calculation of IOL powers. The brightness acuity tester (BAT) is used to determine the impact of glare prior to cataract surgery.

Which of the following is MOST commonly noted in a patient with anterior uveitis? SELECT 3 A. Cells in the anterior chamber due to a breakdown of the blood-aqueous barrier. B. Circumlimbal injection due to involvement of the anterior ciliary arteries. C. Cells in the anterior chamber due to a breakdown of the blood-retinal barrier. D. Inflammation of the iris due to involvement of the short posterior ciliary artery E. Inflammation of the ciliary body due to involvement of the major arterial circle of the iris

A, B, E Cells enter the anterior chamber due to a breakdown of the blood aqueous barrier. Remember that the major arterial circle of the iris (MACI), which is formed by anastomoses of the long posterior and anterior ciliary arteries, is located within the ciliary body. Inflammation of the ciliary body will result in vasodilation of the anterior ciliary arteries that supply the MACI and the corneal limbus, leading to circumlimbal injection. The short posterior ciliary arteries do not supply ocular structures of the anterior segment and are not involved in anterior uveitis.

Complications of pathologic myopia include which of the following? SELECT 3 A. posterior staphyloma B. retinal detachment C. PDS D. anterior subcapsular cataract E. choroidal neovascularization F. choroidal folds G. acute angle closure

A, B, E Pathologic myopia, often defined as spherical equivalent greater than -6.00 DS and axial length greater than 26.5 mm, is characterized by scleral and retinal thinning and the development of a posterior staphyloma, lacquer cracks, choroidal neovascularization, and rhegmatogenous retinal detachment. Acute angle closure, pigment dispersion syndrome, choroidal folds, and anterior subcapsular cataract are not complications associated with pathologic myopia.

Which of the following are associated with iridocorneal endothelial syndromes? SELECT 4 A. Corectopia B. Peripheral anterior synechiae C. Nuclear cataract D. Plateau iris E. Abnormal corneal membrane F. Iris holes G. Posterior synechiae

A, B, E F Iridocorneal endothelial (ICE) syndromes are associated with corectopia (displaced pupil), iris holes (polycoria), iris nodules, and iris heterochromia. The corneal endothelium in ICE syndromes acts similar to epithelial tissue and can grow to the iris and trabecular meshwork, forming a membrane. Continuous traction of the corneal membrane on the iris can worsen corectopia and polycoria and eventually cause the development of peripheral anterior synechiae.

Which of the following are potential causes of scleritis? SELECT 4 A. Surgical trauma B. Systemic vasculitis C. Uveitis D. Episcleritis E. Idiopathic F. Bisphosphonate medications

A, B, E, F Episcleritis and scleritis are separate entities; one does not cause the other. Uveitis is also unrelated to scleritis, although a patient with an underlying systemic condition (e.g., rheumatoid arthritis) may present with scleritis and uveitis at the same time or throughout the patient's life. Systemic vasculitides (e.g., rheumatoid arthritis, Wegener's granulomatosis) are commonly associated with scleritis. Trauma secondary to ocular surgeries (e.g., cataract, glaucoma, strabismus, retina) has been linked to the development of scleritis. Bisphosphonate medications have also been linked to scleritis.

Which of the following is NOT an association of an acute, unilateral, non-granulomatous uveitis? SELECT 3 A. Tuberculosis B. Behcet's disease C. Fuchs' heterochromic iridocyclitis D. Juvenile rheumatoid arthritis E. Ankylosing spondylitis F. Reactive arthritis

A, C, D Fuchs' heterochromic iridocyclitis and juvenile rheumatoid arthritis are both associated with chronic non-granulomatous uveitis, most often unilateral in Fuchs' and bilateral in JRA. Tuberculosis is associated with chronic, bilateral, granulomatous uveitis that may be anterior, posterior, or panuveitis. The remaining options may all be associated with acute, unilateral, non-granulomatous uveitis.

You note corneal haze OD in a 2-week-old infant due to a forceps injury at birth. Which of the following is the patient at risk for developing later in life? SELECT 3 A. Amblyopia B. Corneal stromal thinning C. Irregular corneal astigmatism D. Bullous keratopathy E. Increased hyperopia

A, C, D Infants with a history of a forceps injury at birth most commonly present with damage to Decemet's membrane, which results in acute corneal edema (seen as stromal haze) without stromal thinning. Patients are at a higher risk of development of irregular corneal astigmatism with resulting amblyopia, as well as bullous keratopathy

Which of the following statements regarding demodicidosis are CORRECT? SELECT 3 A. Pathological changes due to Demodex are likely secondary to obstruction of meibomian gland orifices, induced hyperkeratinization, and microabrasions from the claws of the parasite. B. Toxins secreted from Demodex species in the lash follicles or meibomian glands typically leads to a pustular rash near the eyelid margin and intense pruritus. C. The presence of any form of lash debris is pathognomonic for demodicidosis. D. Essentially all individuals who are 70 years old or greater are believed to harbor Demodex E. Detection of Demodex can be made by eyelash rotation to provoke emergence of parasites from the lash follicle, or by epilating suspect lashes and observing them with light microscopy. F. The most sensitive way to detect Demodex infestation is to examine for nits among the eyelashes.

A, D, E Demodex is associated with cylindrical lash debri. Demodex has not been linked to a pustular rash of the eyelid margins. As it is a cause of blepharitis, some patients will report mild to moderate pruritus. Nits among the eyelashes are a sign of phthiriasis palpebrarum, not Demodex. The remaining statements are correct.

Which of the following signs are specific to meibomian gland dysfunction? SELECT 3 A. reduction in the quality of expressed meibum B. corneal staining C. reduced findings on Schirmer's test with anesthesia D. reduction in the volume of expressed meibum E. reduced tear meniscus F. changes in lid morphology

A, D, F Reduced tear meniscus and reduced findings on Schirmer's test with anesthesia are associated with reduced aqueous tear secretion, not meibomian gland dysfunction. Corneal staining is a nonspecific response. All other signs are specific to meibomian gland dysfunction.

Vitritis may be caused by which of the following systemic conditions? SELECT 4 A. toxoplasmosis B. benign essential hypertension C. neurofibromatosis D. rheumatoid arthritis e. syphillis F. sarcoidosis G. tuberculosis

A, E, F, G Causes of vitritis (i.e., posterior uveitis) include toxoplasmosis, sarcoidosis, syphilis, and tuberculosis, among other infectious and inflammatory diseases. Vitritis is not associated with systemic hypertension, rheumatoid arthritis, or neurofibromatosis.

Kearns-Sayre syndrome is associated with which of the following findings? SELECT 4 A. Pigmentary retinopathy B. Cystalline lens subluxation C. Retinal detachment D. Whorl keratopathy E. Progressive external ophthalmoplegia F. Ataxia G. Cardiac conduction defect

A, E, F, G Kearns-Sayre syndrome is a severe mitochondrial disorder that affects striated muscle. It classically presents with salt-and-pepper fundus pigmentation, progressive external ophthalmoplegia, cardiac conduction abnormalities, ataxia, and diminished stature. Ophthalmic complications are among the most prominent findings and may also include congenital glaucoma, microcornea, cataract, and corneal decompensation.

Which of the following is MOST consistent with the pathogenesis of phacolytic glaucoma? A. Accumulation of protein-laden macrophages within the trabecular meshwork B. Anterior rotation of the ciliary body and subsequent peripheral angle closure C. Anterior displacement of the crystalline lens capsule, resulting in pupillary block D. Posterior capsular rupture with vitreous prolapse into the trabecular meshwork

A. Phacolytic glaucoma results from leakage of crystalline lens proteins from within the capsule, triggering a non-granulomatous immune response (phacolytic uveitis). Crystalline lens proteins and protein-laden macrophages subsequently accumulate within the trabecular meshwork, resulting in obstruction of aqueous humor outflow and elevated intraocular pressure.

Which of the following does NOT describe one of the four types of ectropion? A. A 64-year-old male presents with passive eversion of the right lower lid and a basal cell carcinoma measuring 16 mm by 12 mm on the right lower lid. B. A 43-year-old male with idiopathic palsy of the seventh cranial nerve presents with unilateral passive eversion of the left lower lid. C. A 52-year-old obese male with floppy eyelid syndrome and a history of sleep apnea and nightly CPAP use presents with taut upper lids and lower lids that evert with lateral pressure. D. A 74-year-old female presents with newly acquired contact dermatitis and newly acquired passive eversion of the lower lids. E. An 83-year-old female presents with moderate, symmetric, and passive eversion of the lower lids. You note significant laxity of all eyelids.

C The four types of ectropion are involutional, cicatricial, paralytic, and mechanical. Involutional ectropion occurs in elderly patients and is characterized by moderate, symmetric, and passive eversion of the lower eyelids. Cicatricial ectropion occurs secondary to lid scarring or inflammation, as in contact dermatitis. Paralytic ectropion is a result of a seventh nerve palsy. Mechanical ectropion develops when a mass acts as a weight on the eyelid, causing it to evert away from the globe. Floppy eyelid syndrome has no association with ectropion development.

Which of the following does NOT describe the pathophysiology of a known crystalline lens-induced glaucoma? A. A large intumescent cataract pushes the iris forward and induces angle closure, resulting in increased IOP and the development of glaucoma. B. Penetrating or surgical trauma releases crystalline lens particles that disrupt aqueous humor outflow and initiate an immune response that further decreases aqueous humor drainage. C. Granulomatous inflammation and uveitic glaucoma can occur as a result of sensitization to self proteins in the crystalline lens that have been liberated due to surgery or trauma. D. Soluble high molecular weight crystalline lens proteins leak from a grossly intact crystalline lens capsule and deposit in the trabecular meshwork, impeding aqueous humor outflow. E. Neurodegenerative crystalline lens proteins that were previously sequestered are actively secreted into the vitreous, promoting

E Phacomorphic glaucoma occurs when a large intumescent cataract pushes the iris anteriorly, resulting in angle closure glaucoma. Phacolytic glaucoma occurs when soluble crystalline lens proteins leak from a grossly intact anterior lens capsule and deposit in the trabecular meshwork, resulting in decreased outflow and increased IOP. Lens-particle glaucoma occurs when penetrating or surgical trauma releases crystalline lens particles into the anterior chamber and trabecular meshwork, resulting in a decrease in outflow and the development of an immune response that further decreases aqueous humor outflow. Phacoanaphylactic glaucoma is characterized by granulomatous inflammation due to sensitization to self proteins in the crystalline lens that have been liberated secondary to surgery or trauma.