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Question 1Ophthalmology (content domains not enumerated in source)

A patient with a known diagnosis of keratoconus undergoes refraction. Which finding on retinoscopy is most characteristic of this condition?

  1. A pinpoint reflex that fills the pupil at a working distance of 67 cm
  2. A uniform with-the-rule astigmatic reflex
  3. Scissoring of the retinoscopic reflex Correct answer.
  4. A bright crescent that moves opposite to the mirror in all meridians

Explanation

Keratoconus produces irregular corneal astigmatism, which appears on retinoscopy as a scissoring or split reflex that cannot be neutralized with a single cylindrical lens. The irregularity reflects the conical protrusion and the asymmetric corneal curvature. A regular astigmatic reflex would instead suggest a simple cylindrical error.

Question 2Ophthalmology (content domains not enumerated in source)

Which corneal finding is most consistent with advanced keratoconus on slit-lamp examination?

  1. A central corneal thickness greater than 600 micrometres
  2. Fleischer ring at the cone apex Correct answer.
  3. Vogt striae that persist after digital pressure
  4. A posterior corneal surface parallel to the anterior surface

Explanation

Fleischer ring is an iron deposition ring at the base of the cone and is a classic slit-lamp sign of keratoconus. Vogt striae are also seen but typically disappear with pressure, and corneal thickness is reduced rather than increased. The posterior surface becomes non-parallel as the cone protrudes.

Question 3Ophthalmology (content domains not enumerated in source)

A 62-year-old presents with sudden painless loss of vision in one eye. Fundoscopy shows a pale retina with a cherry-red spot at the macula. Which vessel is most likely occluded?

  1. Branch retinal vein
  2. Central retinal vein
  3. Central retinal artery Correct answer.
  4. Posterior ciliary artery

Explanation

Central retinal artery occlusion produces sudden painless visual loss with a pale, oedematous retina and a cherry-red spot where the choroidal circulation shows through the thin fovea. Venous occlusion instead produces a blood-and-thunder appearance with flame haemorrhages. The posterior ciliary arteries supply the choroid and outer retina.

Question 4Ophthalmology (content domains not enumerated in source)

Which finding on optical coherence tomography is most characteristic of active neovascular age-related macular degeneration?

  1. Subretinal fluid with an underlying pigment epithelial detachment Correct answer.
  2. Uniform thinning of the ganglion cell layer
  3. A lamellar macular hole with intact outer retina
  4. A continuous ellipsoid zone with normal foveal contour

Explanation

Active neovascular AMD shows subretinal or intraretinal fluid, often with a pigment epithelial detachment, reflecting choroidal neovascular membrane activity. An intact ellipsoid zone and normal contour indicate a dry, non-exudative macula. Ganglion cell thinning is non-specific and does not indicate neovascular activity.

Question 5Ophthalmology (content domains not enumerated in source)

A patient reports a sudden curtain descending over the visual field with flashes and floaters. Which diagnosis should be prioritized?

  1. Retinal detachment Correct answer.
  2. Optic neuritis
  3. Vitreous haemorrhage alone
  4. Acute angle-closure glaucoma

Explanation

A descending field defect with photopsia and floaters is the classic presentation of rhegmatogenous retinal detachment, requiring urgent assessment. Optic neuritis causes painful visual loss with colour desaturation, and angle closure causes a painful red eye. Vitreous haemorrhage causes floaters and reduced acuity without a curtain-like field defect.

Question 6Ophthalmology (content domains not enumerated in source)

Which test is the reference standard for detecting glaucomatous visual field loss in clinical practice?

  1. Contrast sensitivity testing
  2. Colour vision testing
  3. Amsler grid testing
  4. Standard automated perimetry Correct answer.

Explanation

Standard automated perimetry quantifies the visual field and detects the characteristic arcuate and nasal step defects of glaucoma. Contrast and colour vision tests are not field tests, and the Amsler grid screens the central ten degrees only. Perimetry remains the functional reference standard for monitoring progression.

Question 7Ophthalmology (content domains not enumerated in source)

Which organism is the most common cause of bacterial keratitis associated with contact lens wear?

  1. Streptococcus pneumoniae
  2. Pseudomonas aeruginosa Correct answer.
  3. Neisseria gonorrhoeae
  4. Corynebacterium diphtheriae

Explanation

Pseudomonas aeruginosa is the leading cause of contact lens-associated bacterial keratitis and can progress rapidly to corneal melting. Pneumococcus is more associated with trauma or ocular surface disease. Gonococcus and diphtheria are rare causes of keratitis in this context.

Question 8Ophthalmology (content domains not enumerated in source)

A patient with type 2 diabetes has a normal dilated fundus examination. Which additional finding best indicates that diabetic retinopathy screening is still required at regular intervals?

  1. Normal visual acuity
  2. Absence of microalbuminuria
  3. Presence of any diabetes duration and poor glycaemic control Correct answer.
  4. Age under 40 years

Explanation

Duration of diabetes and glycaemic control are the strongest predictors of retinopathy, so screening continues regardless of a single normal examination. Microalbuminuria and visual acuity are not exclusion criteria. Younger age does not remove the need for periodic retinal screening.

Question 9Ophthalmology (content domains not enumerated in source)

Which clinical feature distinguishes bacterial from viral conjunctivitis in a general practice setting?

  1. A history of seasonal recurrence
  2. Mucopurulent discharge with glued lashes on waking Correct answer.
  3. Watery discharge with preauricular lymphadenopathy
  4. Bilateral itching with a cobblestone appearance

Explanation

Bacterial conjunctivitis typically produces mucopurulent discharge that sticks the lids together on waking. Watery discharge with preauricular nodes and itching suggest viral or allergic causes. Seasonal recurrence and cobblestone papillae point to allergic conjunctivitis.

Question 10Ophthalmology (content domains not enumerated in source)

A patient with open-angle glaucoma is started on latanoprost. Which side effect should be specifically discussed?

  1. Corneal oedema and endothelial loss
  2. Increased iris pigmentation and eyelash lengthening Correct answer.
  3. Systemic bradycardia and bronchospasm
  4. Pupillary constriction and brow ache

Explanation

Prostaglandin analogues such as latanoprost commonly cause iris darkening and eyelash growth, which are often irreversible. Corneal oedema is not a typical effect. Miosis and brow ache reflect cholinergic agents, and bronchospasm with bradycardia reflects beta-blockers.

Question 11Ophthalmology (content domains not enumerated in source)

A patient has an intraocular pressure of 28 mmHg, a shallow anterior chamber, and a mid-dilated pupil after an anticholinergic medication. Which is the most appropriate immediate management?

  1. Topical pilocarpine, topical beta-blocker, and urgent ophthalmology referral Correct answer.
  2. Oral steroids and outpatient review in one week
  3. Topical atropine and observation
  4. Topical prostaglandin analogue alone

Explanation

This presentation suggests acute angle-closure glaucoma, which requires immediate lowering of intraocular pressure with agents such as pilocarpine and a beta-blocker plus urgent specialist review for definitive treatment. Atropine would worsen angle closure by dilating the pupil. Steroids and a prostaglandin analogue alone are inadequate for an acute attack.

Question 12Ophthalmology (content domains not enumerated in source)

A patient with a swollen optic disc is found to have bilateral disc elevation with normal visual acuity and no relative afferent pupillary defect. Which condition should be considered?

  1. Papilloedema from raised intracranial pressure Correct answer.
  2. Optic neuritis
  3. Anterior ischaemic optic neuropathy
  4. Central retinal vein occlusion

Explanation

Bilateral disc swelling with preserved acuity and no relative afferent pupillary defect suggests papilloedema from raised intracranial pressure. Ischaemic optic neuropathy and optic neuritis are usually unilateral with an afferent pupillary defect. Central retinal vein occlusion shows haemorrhages and venous engorgement.

Question 13Ophthalmology (content domains not enumerated in source)

Which finding on gonioscopy is most consistent with a diagnosis of primary open-angle glaucoma?

  1. An open angle with heavy trabecular pigmentation Correct answer.
  2. A flat iris approach with a narrow angle
  3. A closed angle with peripheral anterior synechiae
  4. A plateau iris configuration

Explanation

Primary open-angle glaucoma shows an open angle, often with trabecular pigmentation, while the optic nerve and field show glaucomatous damage. Closed angles and plateau iris describe angle-closure mechanisms. A flat iris approach with a narrow angle indicates risk of closure rather than open-angle disease.

Question 14Ophthalmology (content domains not enumerated in source)

A 70-year-old reports distortion of straight lines on an Amsler grid in one eye. Which is the most appropriate next step?

  1. Commencement of topical antibiotic drops
  2. Prescription of a new spectacle correction
  3. Reassurance and review in twelve months
  4. Dilated fundus examination with optical coherence tomography Correct answer.

Explanation

Metamorphopsia suggests macular disease such as wet age-related macular degeneration or epiretinal membrane, so dilated examination with OCT is required to identify treatable pathology. A new refraction would not address the underlying cause. Reassurance and antibiotics are inappropriate for suspected macular disease.

Question 15Ophthalmology (content domains not enumerated in source)

A patient with a history of herpes zoster ophthalmicus develops a dendritic corneal lesion. Which treatment is most appropriate?

  1. Observation without treatment
  2. Topical steroid alone
  3. Topical antibiotic alone
  4. Topical acyclovir with ophthalmology review Correct answer.

Explanation

Dendritic lesions from herpes simplex or zoster require antiviral therapy, and specialist review is needed because steroids alone can worsen herpetic disease. Antibiotics do not treat viral replication. Observation risks progression to stromal keratitis.

Question 16Ophthalmology (content domains not enumerated in source)

Which clinical feature most strongly suggests giant cell arteritis in an elderly patient with sudden visual loss?

  1. Bilateral watery discharge and itching
  2. Photophobia with a dendritic corneal lesion
  3. Jaw claudication and an elevated erythrocyte sedimentation rate Correct answer.
  4. Painless proptosis with a bruit

Explanation

Jaw claudication with a raised ESR strongly supports giant cell arteritis, which can cause arteritic anterior ischaemic optic neuropathy and irreversible blindness. Watery discharge and itching suggest allergy, dendritic lesions suggest herpes, and proptosis with a bruit suggests a vascular malformation.

Question 17Ophthalmology (content domains not enumerated in source)

A patient has a painful red eye with a hypopyon and a corneal infiltrate. Which is the most appropriate initial management?

  1. Topical steroid alone
  2. Topical antiviral therapy
  3. Corneal scraping for culture and intensive topical antibiotics Correct answer.
  4. Pressure patching and observation

Explanation

A hypopyon with a corneal infiltrate indicates microbial keratitis, requiring corneal scraping for culture and intensive broad-spectrum topical antibiotics. Steroids alone can worsen infection, patching may promote organism growth, and antivirals are ineffective against bacterial causes.

Question 18Ophthalmology (content domains not enumerated in source)

Which finding on a Humphrey visual field test is most typical of early glaucomatous damage?

  1. A nasal step defect Correct answer.
  2. A homonymous hemianopia
  3. A bitemporal hemianopia
  4. A central scotoma

Explanation

Early glaucomatous field loss typically begins with nasal steps and arcuate scotomas reflecting retinal nerve fibre bundle damage. Central scotomas suggest macular or optic nerve disease. Bitemporal and homonymous hemianopias indicate chiasmal and retrochiasmal lesions respectively.

Question 19Ophthalmology (content domains not enumerated in source)

A patient with high myopia reports sudden floaters and a temporal visual field defect. Which examination finding would most support a retinal tear?

  1. A flap with surrounding subretinal fluid on indirect ophthalmoscopy Correct answer.
  2. A cherry-red spot at the macula
  3. A posterior vitreous detachment without retinal breaks
  4. Bilateral disc drusen

Explanation

A retinal flap with subretinal fluid confirms a rhegmatogenous tear and explains the temporal field defect. A cherry-red spot indicates arterial occlusion, disc drusen are unrelated, and an uncomplicated posterior vitreous detachment alone does not account for a field defect.

Question 20Ophthalmology (content domains not enumerated in source)

A patient is diagnosed with dry age-related macular degeneration. Which management is most appropriate?

  1. Panretinal photocoagulation
  2. Topical prostaglandin analogue
  3. Intravitreal anti-VEGF injections
  4. Monitoring with home Amsler grid and smoking cessation advice Correct answer.

Explanation

Dry AMD has no proven curative treatment, so monitoring for conversion to neovascular disease with an Amsler grid plus risk-factor modification such as smoking cessation is appropriate. Anti-VEGF is reserved for neovascular disease, photocoagulation for proliferative retinopathy, and prostaglandins for glaucoma.

Question 21Ophthalmology (content domains not enumerated in source)

Which feature on B-scan ultrasonography would suggest a choroidal melanoma rather than a haemangioma?

  1. A flat lesion with acoustic shadowing behind it
  2. A lesion with a hyperechoic anterior surface and uniform high internal echoes
  3. A diffuse lesion with high internal reflectivity
  4. A dome-shaped lesion with low internal reflectivity Correct answer.

Explanation

Choroidal melanoma typically appears dome-shaped with low internal reflectivity and acoustic hollowness, whereas haemangioma shows high internal reflectivity. Uniform high internal echoes and acoustic shadowing are not characteristic of melanoma. These acoustic features help distinguish solid tumours.

Question 22Ophthalmology (content domains not enumerated in source)

A 35-year-old presents with a unilateral dilated pupil, ptosis, and anhidrosis on the same side. Which additional test is most useful to localize the lesion?

  1. Topical pilocarpine to constrict the pupil
  2. Topical atropine to dilate the pupil
  3. Topical fluorescein to assess the corneal surface
  4. Topical hydroxyamphetamine to differentiate preganglionic from postganglionic lesions Correct answer.

Explanation

The presentation suggests Horner syndrome, and hydroxyamphetamine testing helps distinguish a postganglionic from a preganglionic lesion because it releases stored noradrenaline. Pilocarpine and atropine do not localize the lesion. Fluorescein assesses the corneal epithelium and is irrelevant here.

Question 23Ophthalmology (content domains not enumerated in source)

A patient with a suspected pituitary adenoma has a bitemporal hemianopia. Which anatomical structure is most likely compressed?

  1. The optic tract
  2. The lateral geniculate nucleus
  3. The optic chiasm Correct answer.
  4. The optic radiation

Explanation

Bitemporal hemianopia results from compression of the decussating nasal fibres at the optic chiasm, typically by a pituitary lesion. Optic tract lesions cause incongruous homonymous defects, and lateral geniculate or optic radiation lesions cause homonymous hemianopias.

Question 24Ophthalmology (content domains not enumerated in source)

A patient with proliferative diabetic retinopathy has a vitreous haemorrhage. Which management is most appropriate once the view clears?

  1. Intravitreal antibiotic injection
  2. Panretinal photocoagulation Correct answer.
  3. Topical prostaglandin analogue
  4. Oral acetazolamide alone

Explanation

Proliferative diabetic retinopathy is treated with panretinal photocoagulation to ablate ischaemic retina and reduce neovascular drive. Prostaglandins and acetazolamide address intraocular pressure, and antibiotics treat infection, none of which treat proliferative retinopathy. Vitrectomy is reserved for persistent haemorrhage or tractional detachment.

Question 25Ophthalmology (content domains not enumerated in source)

A patient on long-term topical steroid therapy for anterior uveitis develops a raised intraocular pressure with an open angle. Which mechanism best explains this finding?

  1. Increased episcleral venous pressure from a fistula
  2. Reduced trabecular outflow from steroid-induced changes Correct answer.
  3. Ciliary body shutdown with reduced aqueous production
  4. Pupillary block from iris-lens apposition

Explanation

Steroid-induced ocular hypertension results from increased resistance to aqueous outflow at the trabecular meshwork, with an open angle on gonioscopy. Pupillary block causes angle closure, ciliary body shutdown reduces rather than raises pressure, and episcleral venous pressure elevation relates to vascular fistulae.

Question 26Ophthalmology (content domains not enumerated in source)

Which corneal layer is primarily responsible for the mechanical strength of the cornea?

  1. Descemet membrane
  2. Endothelium
  3. Epithelium
  4. Stroma Correct answer.

Explanation

The stroma makes up about 90% of corneal thickness and consists of highly organised collagen lamellae that provide tensile strength and transparency. The epithelium and endothelium are cellular barriers with little structural strength, and Descemet membrane is a thin basement membrane.

Question 27Ophthalmology (content domains not enumerated in source)

A patient reports a sudden painless loss of vision in one eye with a normal fundus examination. Which additional finding most suggests retrobulbar optic neuritis?

  1. Shallow anterior chamber on slit lamp
  2. Pain on eye movement with reduced colour vision Correct answer.
  3. Marked conjunctival injection
  4. Increased intraocular pressure

Explanation

Retrobulbar optic neuritis classically causes pain on eye movement, reduced contrast and colour sensitivity, and an afferent pupillary defect despite a normal-looking disc. The other findings point to anterior segment or pressure-related pathology rather than optic nerve inflammation.

Question 28Ophthalmology (content domains not enumerated in source)

Which parameter on optical coherence tomography is most useful for monitoring progression of glaucomatous damage?

  1. Retinal nerve fibre layer thickness Correct answer.
  2. Corneal thickness
  3. Central macular thickness
  4. Choroidal thickness

Explanation

Peripapillary retinal nerve fibre layer thickness measured by OCT correlates with ganglion cell loss and is used to track structural progression in glaucoma. Macular, choroidal and corneal thickness measurements do not directly index optic nerve damage.

Question 29Ophthalmology (content domains not enumerated in source)

Which organism most commonly causes corneal ulceration after agricultural trauma with vegetative material?

  1. Staphylococcus epidermidis
  2. Fusarium species Correct answer.
  3. Adenovirus
  4. Neisseria gonorrhoeae

Explanation

Filamentous fungi such as Fusarium are classic causes of keratitis following trauma with plant or soil material. Gonococcus causes hyperacute purulent conjunctivitis, and S. epidermidis and adenovirus do not fit the vegetative trauma history.

Question 30Ophthalmology (content domains not enumerated in source)

A patient with acute anterior uveitis is treated with topical prednisolone and a cycloplegic. What is the main purpose of the cycloplegic agent?

  1. To reduce corneal epithelial turnover
  2. To lower intraocular pressure directly
  3. To eradicate the underlying infectious trigger
  4. To relieve ciliary spasm and prevent posterior synechiae Correct answer.

Explanation

Cycloplegics relax the ciliary body, reducing pain from spasm, and immobilise the pupil to limit synechia formation. They do not treat infection, directly lower pressure, or act on corneal epithelium.

Question 31Ophthalmology (content domains not enumerated in source)

A 6-year-old has reduced vision in one eye with a normal fundus and a two-line interocular acuity difference. Which management is most appropriate?

  1. Topical atropine in the amblyopic eye
  2. Observation until age 12
  3. Occlusion therapy of the better eye with refractive correction Correct answer.
  4. Immediate cataract surgery

Explanation

Amblyopia is treated by correcting refractive error and penalising the dominant eye, usually with patching. Surgery is reserved for structural causes such as cataract, and observation risks permanent visual loss during the sensitive period. Atropine is placed in the better eye, not the amblyopic eye.

Question 32Ophthalmology (content domains not enumerated in source)

Which feature on fundoscopy most suggests a retinal detachment rather than a retinal tear alone?

  1. A single horseshoe tear with attached surrounding retina
  2. Lattice degeneration without subretinal fluid
  3. A pigmented choroidal naevus
  4. Corrugated, elevated retina with loss of underlying choroidal detail Correct answer.

Explanation

Detached retina appears elevated, corrugated and out of focus, with the underlying choroid obscured by subretinal fluid. A tear with attached retina, lattice degeneration and a choroidal naevus do not by themselves indicate detachment.

Question 33Ophthalmology (content domains not enumerated in source)

A patient with known atrial fibrillation presents with sudden painless monocular visual loss and a cherry-red spot at the macula. Which diagnosis is most likely?

  1. Central retinal vein occlusion
  2. Vitreous haemorrhage
  3. Anterior ischaemic optic neuropathy
  4. Central retinal artery occlusion Correct answer.

Explanation

Central retinal artery occlusion produces sudden painless loss with a pale, oedematous retina and a cherry-red spot where the choroidal circulation shows through the fovea. Embolic risk from atrial fibrillation fits this presentation.

Question 34Ophthalmology (content domains not enumerated in source)

Which test is most appropriate to confirm a diagnosis of dry eye disease in a patient with chronic irritation and punctate staining?

  1. Gonioscopy
  2. B-scan ultrasonography
  3. Tear break-up time with ocular surface staining Correct answer.
  4. Goldmann applanation tonometry

Explanation

Tear film instability measured by break-up time, combined with ocular surface staining, supports the diagnosis of dry eye. Tonometry, gonioscopy and B-scan assess pressure, angle anatomy and posterior segment respectively.

Question 35Ophthalmology (content domains not enumerated in source)

A patient with a long-standing esotropia has reduced binocular vision. Which finding on cover testing would confirm a constant manifest deviation?

  1. Equal visual acuity in both eyes
  2. Refixation movement when the uncovered eye takes up fixation Correct answer.
  3. No movement on alternate cover testing
  4. Normal stereopsis on testing

Explanation

A manifest strabismus produces a refixation movement when the occluder is removed and the deviated eye resumes fixation. Absence of movement, equal acuity and normal stereopsis argue against a constant manifest deviation.

Question 36Ophthalmology (content domains not enumerated in source)

Which clinical sign most reliably distinguishes a hordeolum from a chalazion?

  1. Acute tenderness and pointing at the lid margin Correct answer.
  2. A firm, painless nodule within the tarsus
  3. Chronic low-grade lid margin erythema
  4. Punctate corneal staining

Explanation

A hordeolum is an acute infection of lid glands and presents with tenderness and a pointing lesion at the margin. A chalazion is a chronic, painless lipogranuloma within the tarsus.

Question 37Ophthalmology (content domains not enumerated in source)

A 55-year-old reports transient visual obscurations and pulsatile tinnitus, and fundoscopy shows bilateral disc swelling. Which underlying mechanism best explains these symptoms?

  1. Vitreous traction at the macula
  2. Raised intracranial pressure transmitted along the optic nerve sheath Correct answer.
  3. Retinal ischaemia from carotid stenosis
  4. Inflammation of the optic nerve head

Explanation

Papilloedema from raised intracranial pressure causes transient obscurations and pulsatile tinnitus through transmission of pressure along the subarachnoid space surrounding the optic nerve. Carotid stenosis, optic neuritis and vitreomacular traction do not produce bilateral disc swelling with these symptoms.

Question 38Ophthalmology (content domains not enumerated in source)

Which finding on slit lamp examination most suggests posterior polymorphous corneal dystrophy rather than Fuchs endothelial dystrophy?

  1. Diffuse central guttae with stromal oedema
  2. Anterior stromal scarring after recurrent erosions
  3. Bilateral inferior corneal thinning
  4. Endothelial vesicles with a glassy, beaten-metal appearance Correct answer.

Explanation

Posterior polymorphous dystrophy shows endothelial changes with vesicles and a beaten-metal or glassy appearance, often with iridocorneal adhesions. Fuchs dystrophy is characterised by central guttae and progressive stromal oedema.

Question 39Ophthalmology (content domains not enumerated in source)

A patient on topical timolol for glaucoma develops wheeze and reduced exercise tolerance. Which mechanism best explains this?

  1. Prostaglandin-mediated conjunctival hyperaemia
  2. Systemic absorption causing beta-2 blockade in the airways Correct answer.
  3. Carbonic anhydrase inhibition in the ciliary body
  4. Local corneal toxicity from the preservative

Explanation

Topical timolol is absorbed systemically through the nasolacrimal mucosa and can block bronchial beta-2 receptors, precipitating bronchospasm. Punctal occlusion reduces this risk. Preservative toxicity, carbonic anhydrase inhibition and prostaglandin effects do not explain bronchospasm.

Question 40Ophthalmology (content domains not enumerated in source)

Which feature on visual field testing most suggests a non-organic or unreliable field rather than true glaucomatous loss?

  1. Cloverleaf pattern respecting the vertical midline Correct answer.
  2. Paracentral scotoma near fixation
  3. Arcuate defect respecting the horizontal midline
  4. Nasal step at the horizontal meridian

Explanation

A cloverleaf or tunnel pattern that does not respect the vertical midline and is inconsistent with the disc appearance suggests poor reliability or non-organic loss. Glaucomatous defects follow nerve fibre bundle anatomy and respect the horizontal midline.

Question 41Ophthalmology (content domains not enumerated in source)

Which ocular finding is most characteristic of moderate non-proliferative diabetic retinopathy?

  1. Dot and blot haemorrhages with hard exudates Correct answer.
  2. Neovascularisation at the disc
  3. Rubeosis iridis
  4. Tractional retinal detachment

Explanation

Moderate non-proliferative disease shows haemorrhages, microaneurysms and exudates without neovascularisation. Neovascularisation, tractional detachment and rubeosis indicate advanced proliferative disease.

Question 42Ophthalmology (content domains not enumerated in source)

A patient has a unilateral dilated pupil that reacts poorly to light but constricts briskly to near target. Which diagnosis is most likely?

  1. Pharmacological mydriasis
  2. Third nerve palsy
  3. Adie tonic pupil Correct answer.
  4. Horner syndrome

Explanation

A tonic pupil shows light-near dissociation with a sluggish or absent light reaction and a strong near response due to aberrant reinnervation. Third nerve palsy usually includes ptosis and motility deficit, Horner syndrome causes miosis, and pharmacological mydriasis blocks both light and near responses.

Question 43Ophthalmology (content domains not enumerated in source)

Which imaging finding is most suggestive of papilloedema rather than optic disc drusen?

  1. Lumpy, autofluorescent disc with a normal nerve sheath diameter
  2. Absent disc cupping with normal visual fields
  3. Bilateral buried hyperreflective deposits on OCT
  4. Smooth disc swelling with peripapillary haemorrhages and preserved spontaneous venous pulsation absent Correct answer.

Explanation

True papilloedema shows smooth swelling, obscuration of vessels, peripapillary haemorrhages and loss of spontaneous venous pulsation, with an enlarged optic nerve sheath on ultrasound. Drusen appear as lumpy autofluorescent deposits with normal sheath diameter.

Question 44Ophthalmology (content domains not enumerated in source)

Which refractive change is most typical of nuclear sclerotic cataract?

  1. Sudden myopic shift with floaters
  2. Myopic shift with reduced contrast sensitivity Correct answer.
  3. Irregular astigmatism with monocular diplopia
  4. Hyperopic shift with improved near vision

Explanation

Nuclear sclerosis increases the refractive index of the lens, producing a myopic shift and reduced contrast sensitivity. Improved near vision without correction is the classic 'second sight' of early nuclear change, but the overall shift is myopic.

Question 45Ophthalmology (content domains not enumerated in source)

Which finding on gonioscopy most suggests a traumatic angle recession?

  1. Blood in Schlemm canal after pressure
  2. Dense peripheral anterior synechiae over 360 degrees
  3. A pigmented line anterior to Schwalbe line
  4. Widened ciliary body band with a tear in the angle recess Correct answer.

Explanation

Angle recession after blunt trauma appears as widening of the ciliary body band with a visible tear at the angle recess. Peripheral anterior synechiae, a Sampaolesi line and blood in Schlemm canal have other causes.

Question 46Ophthalmology (content domains not enumerated in source)

A patient with thyroid eye disease has diplopia in upgaze. Which muscle is most commonly restricted first?

  1. Inferior rectus Correct answer.
  2. Medial rectus
  3. Superior oblique
  4. Superior rectus

Explanation

The inferior rectus is the most frequently involved extraocular muscle in thyroid eye disease and restricts elevation, causing diplopia in upgaze. Superior rectus, medial rectus and superior oblique are involved less often or later.

Question 47Ophthalmology (content domains not enumerated in source)

Which feature most distinguishes posterior scleritis from optic neuritis on B-scan ultrasonography?

  1. Vitreous opacities
  2. T-sign from fluid in Tenon space Correct answer.
  3. Enlarged optic nerve sheath
  4. Retrobulbar fat artefact

Explanation

Posterior scleritis produces a T-sign, with fluid in Tenon space around the optic nerve, on B-scan. An enlarged nerve sheath suggests raised intracranial pressure, and vitreous opacities are non-specific.

Question 48Ophthalmology (content domains not enumerated in source)

Which treatment is first-line for a patient with mild allergic conjunctivitis and seasonal symptoms?

  1. Oral prednisolone taper
  2. Topical dexamethasone for two weeks
  3. Topical olopatadine with cold compresses Correct answer.
  4. Topical antibiotic drops

Explanation

Topical antihistamine-mast cell stabilisers such as olopatadine, combined with cold compresses and allergen avoidance, are first-line for mild seasonal allergic conjunctivitis. Steroids are reserved for severe disease, and antibiotics have no role.

Question 49Ophthalmology (content domains not enumerated in source)

A patient with a long-standing macular hole is being counselled. Which factor most strongly predicts successful anatomical closure after vitrectomy?

  1. Smaller basal hole diameter Correct answer.
  2. Older patient age
  3. Longer symptom duration
  4. Presence of epiretinal membrane

Explanation

Smaller macular hole diameter is the strongest predictor of anatomical closure after vitrectomy with internal limiting membrane peel and gas tamponade. Longer duration and larger size reduce success, and epiretinal membrane is a separate finding.

Question 50Ophthalmology (content domains not enumerated in source)

Which finding on examination most suggests a diagnosis of keratoconus rather than simple myopia?

  1. A steroid-induced posterior subcapsular cataract
  2. Scissoring of the retinoscopic reflex with inferior corneal steepening Correct answer.
  3. A clear cornea with normal pachymetry
  4. Bilateral symmetric myopia with normal topography

Explanation

Keratoconus produces irregular astigmatism with scissoring of the retinoscopic reflex and inferior corneal steepening on topography. Symmetric myopia, normal pachymetry and steroid cataract do not indicate ectasia.