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ICO Clinical Ophthalmology (Advanced) study materials
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ICO Clinical Ophthalmology (Advanced) practice questions

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Question 1Clinical Ophthalmology (Advanced)

A 24-year-old presents with sudden painless loss of vision in one eye. Fundoscopy shows a pale, oedematous retina with a cherry-red spot at the macula. Which vascular event is the most likely cause?

  1. Central retinal vein occlusion
  2. Branch retinal vein occlusion
  3. Vitreous haemorrhage
  4. Central retinal artery occlusion Correct answer.

Explanation

Central retinal artery occlusion produces acute painless visual loss with diffuse retinal whitening from ischaemia and a cherry-red spot where the thin fovea reveals underlying choroidal perfusion. Venous occlusions instead show flame haemorrhages, cotton-wool spots and disc oedema in a blood-and-thunder pattern.

Question 2Clinical Ophthalmology (Advanced)

Which finding on slit-lamp examination is most characteristic of primary open-angle glaucoma?

  1. A shallow anterior chamber with a closed angle
  2. Neovascularisation of the iris
  3. Bilateral anterior uveitis with keratic precipitates
  4. Increased cup-to-disc ratio with neuroretinal rim thinning Correct answer.

Explanation

Primary open-angle glaucoma is defined by progressive optic neuropathy with characteristic cupping and neuroretinal rim loss, usually with an open angle and raised intraocular pressure. The anterior chamber depth is normal and the angle remains open on gonioscopy.

Question 3Clinical Ophthalmology (Advanced)

A patient reports a sudden curtain-like shadow across the superior visual field with new floaters. Which diagnosis must be excluded urgently?

  1. Rhegmatogenous retinal detachment Correct answer.
  2. Migraine with aura
  3. Vitreous syneresis
  4. Posterior vitreous detachment alone

Explanation

A superior field defect with photopsia and floaters suggests a rhegmatogenous retinal detachment, where a retinal tear allows fluid to accumulate subretinally and the detached inferior retina produces a superior field loss. This requires urgent fundus examination and surgical repair.

Question 4Clinical Ophthalmology (Advanced)

Which organism is the most common cause of acute bacterial conjunctivitis in adults?

  1. Staphylococcus aureus Correct answer.
  2. Chlamydia trachomatis
  3. Pseudomonas aeruginosa
  4. Neisseria gonorrhoeae

Explanation

Staphylococcus aureus is among the most frequent bacterial causes of acute purulent conjunctivitis in adults, alongside Streptococcus pneumoniae and Haemophilus influenzae. Gonococcal and chlamydial conjunctivitis are less common and have distinct hyperacute or chronic presentations.

Question 5Clinical Ophthalmology (Advanced)

Which clinical feature best distinguishes bacterial from viral keratitis in a contact lens wearer?

  1. Diffuse punctate epithelial erosions
  2. A fluorescein-staining epithelial defect with a dense stromal infiltrate Correct answer.
  3. Watery discharge with preauricular lymphadenopathy
  4. Bilateral involvement

Explanation

Bacterial keratitis typically shows a focal epithelial defect with an underlying dense stromal infiltrate and overlying suppuration. Viral keratitis more often produces dendritic or punctate epithelial lesions with less dense stromal involvement.

Question 6Clinical Ophthalmology (Advanced)

A 68-year-old with hypertension presents with sudden painless visual loss and disc swelling with a sector field defect. Which mechanism is most likely?

  1. Anterior ischaemic optic neuropathy Correct answer.
  2. Compressive optic neuropathy
  3. Optic neuritis
  4. Papilloedema from raised intracranial pressure

Explanation

Non-arteritic anterior ischaemic optic neuropathy results from short posterior ciliary artery insufficiency, causing sudden painless altitudinal visual loss with sectoral disc swelling, often in older hypertensive patients. Optic neuritis is typically painful and affects younger patients.

Question 7Clinical Ophthalmology (Advanced)

Which finding on optical coherence tomography is most consistent with active choroidal neovascularisation in neovascular age-related macular degeneration?

  1. Preretinal fibrosis with macular pucker
  2. A normal foveal contour with intact outer retinal bands
  3. Subretinal fluid with an irregular pigment epithelial detachment Correct answer.
  4. Diffuse retinal thinning with no subretinal material

Explanation

Active neovascular AMD shows subretinal or intraretinal fluid, subretinal hyperreflective material and irregular pigment epithelial detachments corresponding to the choroidal neovascular membrane. These features guide anti-VEGF treatment decisions.

Question 8Clinical Ophthalmology (Advanced)

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

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

Explanation

Standard automated perimetry, typically using a Humphrey field analyser with 24-2 or 10-2 patterns, quantifies differential light sensitivity and identifies characteristic glaucomatous defects. It is the mainstay for monitoring progression.

Question 9Clinical Ophthalmology (Advanced)

A child presents with a white pupillary reflex and strabismus. Which diagnosis must be prioritised?

  1. Retinoblastoma Correct answer.
  2. Allergic conjunctivitis
  3. Congenital glaucoma
  4. Simple refractive error

Explanation

Leukocoria with strabismus in a child is a red flag for retinoblastoma, which requires urgent paediatric oncology and ophthalmic assessment. Delay in diagnosis can allow tumour growth and metastatic spread.

Question 10Clinical Ophthalmology (Advanced)

Which feature is most typical of thyroid eye disease on clinical examination?

  1. Lid retraction with restrictive strabismus Correct answer.
  2. Conjunctival chemosis with corneal dendrites
  3. Blepharoptosis with miosis
  4. Sectoral iris atrophy

Explanation

Thyroid eye disease produces lid retraction, proptosis, restrictive myopathy and diplopia from enlarged extraocular muscles. Lid retraction is the most common and characteristic sign.

Question 11Clinical Ophthalmology (Advanced)

A patient develops acute angle-closure glaucoma with a fixed mid-dilated pupil and corneal oedema. Which initial medical measure is most appropriate?

  1. Observation with repeat tonometry in 48 hours
  2. Topical steroid alone
  3. Topical prostaglandin analogue alone
  4. Intravenous acetazolamide plus topical beta-blocker and pilocarpine Correct answer.

Explanation

Acute angle closure requires urgent lowering of intraocular pressure with systemic aqueous suppression, typically intravenous acetazolamide, combined with topical beta-blockers and pilocarpine to constrict the pupil once the iris sphincter is not ischaemic. Definitive laser peripheral iridotomy follows.

Question 12Clinical Ophthalmology (Advanced)

Which type of cataract is most strongly associated with prolonged corticosteroid use?

  1. Anterior polar cataract
  2. Traumatic rosette cataract
  3. Posterior subcapsular cataract Correct answer.
  4. Nuclear sclerotic cataract

Explanation

Systemic or topical corticosteroids characteristically cause posterior subcapsular opacities, often with early visual symptoms from glare and near vision difficulty. Nuclear sclerosis is more associated with ageing and ultraviolet exposure.

Question 13Clinical Ophthalmology (Advanced)

Which organism most commonly causes endogenous endophthalmitis in patients with prolonged hospitalisation and indwelling lines?

  1. Streptococcus pneumoniae
  2. Staphylococcus epidermidis
  3. Pseudomonas aeruginosa
  4. Candida albicans Correct answer.

Explanation

Candida species are the leading cause of endogenous fungal endophthalmitis, especially in hospitalised patients with central lines, broad-spectrum antibiotics or immunosuppression. It typically presents with fluffy vitreous lesions.

Question 14Clinical Ophthalmology (Advanced)

A patient with HLA-B27 presents with recurrent unilateral anterior uveitis. Which associated systemic feature is most likely?

  1. Sarcoidosis
  2. Systemic lupus erythematosus
  3. Ankylosing spondylitis Correct answer.
  4. Rheumatoid arthritis

Explanation

HLA-B27-associated anterior uveitis is strongly linked to seronegative spondyloarthropathies, especially ankylosing spondylitis. It tends to be recurrent, unilateral and fibrinous.

Question 15Clinical Ophthalmology (Advanced)

Which finding indicates optic atrophy on fundoscopy?

  1. Pallor of the optic disc with reduced neuroretinal rim Correct answer.
  2. Hyperaemic disc with blurred margins
  3. Cotton-wool spots adjacent to the disc
  4. Splinter haemorrhages at the disc margin

Explanation

Optic atrophy is characterised by pallor of the optic disc with loss of the normal pink neuroretinal tissue, reflecting axonal loss. Disc swelling and haemorrhages indicate active oedema or vascular events rather than established atrophy.

Question 16Clinical Ophthalmology (Advanced)

Which test best confirms a diagnosis of myasthenia gravis in a patient with variable ptosis and diplopia?

  1. Visual evoked potentials
  2. Gonioscopy
  3. Electroretinography
  4. Acetylcholine receptor antibody testing Correct answer.

Explanation

Acetylcholine receptor antibodies are highly specific for myasthenia gravis and support the diagnosis in patients with fatigable ptosis and diplopia. Single-fibre electromyography and ice-pack testing are useful adjuncts.

Question 17Clinical Ophthalmology (Advanced)

Which structure is most at risk during a trabeculectomy when the surgeon enters the anterior chamber too peripherally?

  1. Iris root Correct answer.
  2. Lens
  3. Ciliary body
  4. Corneal endothelium

Explanation

A peripheral entry during trabeculectomy risks engaging the iris root, which can cause bleeding and iris prolapse. Careful dissection at the limbus and peripheral iridectomy reduce this risk.

Question 18Clinical Ophthalmology (Advanced)

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

  1. A flat lesion with no internal echoes
  2. A diffuse lesion with high internal reflectivity
  3. A mobile lesion with posterior acoustic shadowing
  4. A dome-shaped mass with low internal reflectivity and acoustic hollowness Correct answer.

Explanation

Choroidal melanoma typically shows a dome or mushroom shape with low to medium internal reflectivity and acoustic hollowness on B-scan. Choroidal haemangioma tends to have high internal reflectivity.

Question 19Clinical Ophthalmology (Advanced)

A patient with diabetes develops sudden painless visual loss with extensive retinal haemorrhages and neovascularisation. Which treatment is first-line for the neovascularisation?

  1. Observation with repeat review in six months
  2. Topical beta-blocker
  3. Systemic corticosteroids
  4. Panretinal photocoagulation Correct answer.

Explanation

Proliferative diabetic retinopathy with neovascularisation is treated with panretinal photocoagulation to reduce retinal ischaemic drive and induce regression of new vessels. Intravitreal anti-VEGF is an alternative or adjunct in selected cases.

Question 20Clinical Ophthalmology (Advanced)

Which corneal dystrophy is characterised by bilateral central granular deposits that spare the limbus and are associated with the TGFBI gene?

  1. Granular corneal dystrophy Correct answer.
  2. Posterior polymorphous dystrophy
  3. Fuchs endothelial dystrophy
  4. Lattice corneal dystrophy type II

Explanation

Granular corneal dystrophy is caused by TGFBI mutations and produces discrete granular opacities in the central cornea with clear intervals and limbal sparing. Lattice dystrophy also involves TGFBI but shows branching lines.

Question 21Clinical Ophthalmology (Advanced)

Which sign on gonioscopy indicates previous acute angle closure?

  1. Trabecular pigmentation only
  2. Sampaolesi line
  3. A deep ciliary body band
  4. Peripheral anterior synechiae Correct answer.

Explanation

Peripheral anterior synechiae form when the iris adheres to the trabecular meshwork after an acute angle-closure episode, causing permanent angle damage. Their presence indicates prior appositional closure.

Question 22Clinical Ophthalmology (Advanced)

Which feature best differentiates bacterial from fungal corneal ulcer on clinical examination?

  1. A sharply demarcated epithelial defect
  2. Conjunctival injection
  3. A hypopyon
  4. Feathery margins with satellite lesions Correct answer.

Explanation

Fungal keratitis often shows feathery infiltrate margins, satellite lesions and endothelial plaques, whereas bacterial ulcers tend to have more defined borders. Microbiological confirmation is still required.

Question 23Clinical Ophthalmology (Advanced)

A patient with a painful red eye has reduced corneal sensation and a dendritic epithelial lesion. Which treatment is indicated?

  1. Topical antibiotic alone
  2. Topical aciclovir Correct answer.
  3. Topical atropine alone
  4. Topical corticosteroid alone

Explanation

Herpes simplex epithelial keratitis is treated with topical or oral antiviral therapy such as aciclovir. Topical corticosteroids alone are contraindicated because they can worsen viral replication.

Question 24Clinical Ophthalmology (Advanced)

Which finding on fundoscopy is characteristic of a branch retinal vein occlusion?

  1. Bilateral optic disc swelling
  2. Sectoral flame haemorrhages along a vein Correct answer.
  3. Peripheral laser scars
  4. Diffuse retinal pallor with a cherry-red spot

Explanation

Branch retinal vein occlusion produces haemorrhages, oedema and cotton-wool spots limited to the drainage territory of the affected vein. The fellow retina remains normal.

Question 25Clinical Ophthalmology (Advanced)

Which refractive change is most expected after scleral buckling surgery for retinal detachment?

  1. No refractive change
  2. Induced myopia Correct answer.
  3. Increased astigmatism only
  4. Induced hyperopia

Explanation

Scleral buckling alters the axial length and can induce myopia, often requiring a postoperative refraction adjustment. Astigmatism may also occur but the typical shift is myopic.

Question 26Clinical Ophthalmology (Advanced)

A 24-year-old presents with a painful red eye, photophobia and a hypopyon. Slit-lamp examination shows fine keratic precipitates and no posterior synechiae. Which classification best describes this uveitis?

  1. Chronic granulomatous panuveitis
  2. Intermediate uveitis with snowbanking
  3. Acute non-granulomatous anterior uveitis Correct answer.
  4. Posterior uveitis with retinal vasculitis

Explanation

Fine keratic precipitates, acute onset and anterior segment inflammation without granulomatous features define acute non-granulomatous anterior uveitis, most often HLA-B27 associated. Granulomatous disease produces mutton-fat precipitates and iris nodules, while intermediate and posterior disease localise inflammation behind the lens.

Question 27Clinical Ophthalmology (Advanced)

Which clinical feature most reliably distinguishes posterior scleritis from a simple serous retinal detachment?

  1. A relative afferent pupillary defect
  2. Elevated intraocular pressure
  3. Choroidal folds on fundoscopy
  4. T-shaped fluid on B-scan with thickened posterior sclera Correct answer.

Explanation

Posterior scleritis classically produces a T-sign on B-scan ultrasonography, where fluid in Tenon's space meets the optic nerve, together with scleral thickening. Serous detachment alone shows subretinal fluid without scleral thickening or the T-sign, so imaging is the discriminating step.

Question 28Clinical Ophthalmology (Advanced)

A 55-year-old reports monocular diplopia that persists with a pinhole. Which mechanism best explains this symptom?

  1. Nuclear sclerosis with index myopia
  2. Complete third nerve palsy
  3. Intermittent exotropia
  4. Cortical cataract with irregular astigmatism Correct answer.

Explanation

Monocular diplopia that survives pinhole testing arises within the eye's optical media, typically from irregular astigmatism or a cortical cataract splitting the pupil. Binocular diplopia from misalignment disappears when one eye is occluded and is unaffected by a pinhole.

Question 29Clinical Ophthalmology (Advanced)

Which corneal finding is most characteristic of keratoconus on slit-lamp examination?

  1. Diffuse stromal oedema with Descemet folds
  2. Central epithelial microcysts
  3. Vogt striae that disappear on gentle pressure Correct answer.
  4. Bilateral inferior limbal pannus

Explanation

Vogt striae are fine vertical deep stromal stress lines in keratoconus that transiently disappear when the globe is pressed. This sign, together with Fleischer ring and apical thinning, supports the diagnosis.

Question 30Clinical Ophthalmology (Advanced)

A patient with known sickle cell disease develops a hyphema after blunt trauma. Which management consideration is most important?

  1. Correct metabolic acidosis aggressively with bicarbonate
  2. Avoid topical corticosteroids
  3. Monitor for central retinal artery occlusion from sickling Correct answer.
  4. Perform immediate anterior chamber washout in all cases

Explanation

Sickled erythrocytes increase blood viscosity and can obstruct the central retinal artery, so patients with sickle cell trait or disease need close monitoring of optic nerve and retinal perfusion. Management also avoids carbonic anhydrase inhibitors that may increase aqueous ascorbate and sickling risk.

Question 31Clinical Ophthalmology (Advanced)

Which finding on anterior segment optical coherence tomography most suggests a narrow angle likely to occlude?

  1. A small anterior chamber depth with a convex iris profile Correct answer.
  2. A deep anterior chamber with wide angle opening
  3. Increased trabecular meshwork pigmentation
  4. A prominent Schwalbe line

Explanation

Shallow anterior chamber depth with a convex or anteriorly bowed iris indicates a crowded angle predisposed to closure. Anterior segment OCT quantifies these parameters and helps identify eyes at risk before gonioscopy confirms apposition.

Question 32Clinical Ophthalmology (Advanced)

A 70-year-old with bilateral ptosis and fatigable chewing is suspected of myasthenia gravis. Which test provides the most specific confirmation?

  1. Serum acetylcholine receptor antibody assay Correct answer.
  2. Edrophonium challenge
  3. Ice pack test on the eyelid
  4. Repetitive nerve stimulation showing decrement

Explanation

Detection of acetylcholine receptor antibodies is highly specific for myasthenia gravis and confirms the diagnosis without relying on subjective clinical response. The ice pack and edrophonium tests are supportive bedside manoeuvres with lower specificity.

Question 33Clinical Ophthalmology (Advanced)

Which feature on MRI best supports a diagnosis of optic nerve sheath meningioma rather than optic nerve glioma?

  1. Tubular enlargement of the optic nerve with kinking
  2. Chiasmal enlargement with cystic change
  3. A 'tram-track' pattern of enhancement along the nerve sheath Correct answer.
  4. Bilateral optic nerve enhancement after gadolinium

Explanation

Optic nerve sheath meningioma typically shows tram-track enhancement outlining the nerve, sometimes with calcification and hyperostosis. Glioma tends to produce fusiform nerve enlargement with kinking or cystic components and occurs mainly in children.

Question 34Clinical Ophthalmology (Advanced)

A patient with long-standing poorly controlled diabetes has a pupil that dilates poorly and shows reduced amplitude of accommodation. Which mechanism best explains these findings?

  1. Retinal neovascularisation
  2. Cataract-induced myopia
  3. Diabetic papillopathy
  4. Autonomic neuropathy affecting the iris and ciliary body Correct answer.

Explanation

Autonomic neuropathy in diabetes impairs both sympathetic dilation and parasympathetic accommodation, producing a small poorly dilating pupil and reduced accommodative amplitude. These changes reflect systemic microvascular nerve damage rather than retinal or lens pathology.

Question 35Clinical Ophthalmology (Advanced)

Which finding on fundus examination is most consistent with a retinal dialysis?

  1. A horseshoe tear with a vitreous flap
  2. Lattice degeneration with round atrophic holes
  3. A peripheral retinal break at the ora serrata with subretinal fluid Correct answer.
  4. A macular hole with a cuff of subretinal fluid

Explanation

Retinal dialysis is a circumferential break at the ora serrata, often associated with blunt trauma and subretinal fluid tracking posteriorly. It differs from horseshoe tears, which result from vitreous traction.

Question 36Clinical Ophthalmology (Advanced)

A 60-year-old with chronic open-angle glaucoma has a visual field defect respecting the nasal horizontal meridian. Which structure's damage best explains this pattern?

  1. The optic chiasm
  2. The lateral geniculate nucleus
  3. The occipital cortex
  4. The retinal nerve fibre layer at the optic disc Correct answer.

Explanation

Glaucomatous field loss follows retinal nerve fibre bundle damage at the optic disc, producing arcuate defects that respect the horizontal meridian. Chiasmal and retrochiasmal lesions produce hemianopic patterns that respect the vertical meridian instead.

Question 37Clinical Ophthalmology (Advanced)

Which organism is the most common cause of contact lens-related microbial keratitis?

  1. Candida albicans
  2. Pseudomonas aeruginosa Correct answer.
  3. Staphylococcus epidermidis
  4. Acanthamoeba species

Explanation

Pseudomonas aeruginosa is the leading cause of contact lens-related bacterial keratitis, particularly with extended wear and poor lens hygiene. It produces a rapidly progressive corneal infiltrate with mucopurulent discharge.

Question 38Clinical Ophthalmology (Advanced)

A patient with unilateral proptosis and a bruit over the orbit has dilated episcleral vessels. Which diagnosis is most likely?

  1. Orbital cellulitis
  2. Cavernous sinus thrombosis
  3. Carotid-cavernous fistula Correct answer.
  4. Thyroid eye disease

Explanation

A carotid-cavernous fistula produces pulsatile proptosis, an orbital bruit and arterialised episcleral vessels from abnormal communication between the carotid artery and cavernous sinus. These features are not typical of infection or thyroid eye disease.

Question 39Clinical Ophthalmology (Advanced)

Which feature on optical coherence tomography distinguishes epiretinal membrane from vitreomacular traction?

  1. Disruption of the outer retinal bands
  2. Subretinal fluid under the fovea
  3. A hyperreflective layer on the inner retinal surface with macular pucker Correct answer.
  4. Tractional elevation of the fovea with vitreous attachment

Explanation

An epiretinal membrane appears as a hyperreflective layer on the inner retinal surface that causes retinal wrinkling and pucker. Vitreomacular traction instead shows persistent vitreous attachment with focal tractional elevation of the retinal surface.

Question 40Clinical Ophthalmology (Advanced)

Which treatment is first-line for a symptomatic choroidal haemangioma causing serous macular detachment?

  1. Pars plana vitrectomy
  2. Intravitreal anti-VEGF monotherapy
  3. Photodynamic therapy with verteporfin Correct answer.
  4. Systemic corticosteroids

Explanation

Photodynamic therapy with verteporfin is the established first-line treatment for symptomatic circumscribed choroidal haemangioma with subretinal fluid. It induces vascular thrombosis and reduces exudation without the risks of systemic therapy.

Question 41Clinical Ophthalmology (Advanced)

A patient with a history of treated toxoplasma retinochoroiditis develops a new focus of retinitis adjacent to an old scar. Which finding most supports the diagnosis?

  1. A cherry-red spot at the macula
  2. Bilateral peripheral retinal necrosis
  3. A pigmented chorioretinal scar with adjacent white retinitis Correct answer.
  4. Diffuse vitritis with a 'headlight in the fog' appearance

Explanation

Recurrent toxoplasma retinochoroiditis classically presents as a new white focus of retinitis bordering an old pigmented scar, often with overlying vitritis. The 'headlight in the fog' appearance is more typical of dense vitritis in endophthalmitis.

Question 42Clinical Ophthalmology (Advanced)

Which sign on indirect ophthalmoscopy most suggests a retinal detachment caused by a retinal tear rather than exudative detachment?

  1. Shifting subretinal fluid with gravity
  2. A smooth dome-shaped elevation without a break
  3. A corrugated retinal break with a vitreous flap Correct answer.
  4. Subretinal lipid exudation

Explanation

A horseshoe-shaped retinal break with an attached vitreous flap indicates rhegmatogenous detachment from vitreoretinal traction. Exudative detachment instead shows shifting fluid and no break, often with underlying tumour or inflammation.

Question 43Clinical Ophthalmology (Advanced)

Which test is most appropriate to confirm a suspected diagnosis of primary open-angle glaucoma in a patient with suspicious discs but normal intraocular pressure?

  1. Single Goldmann tonometry reading
  2. Repeated diurnal intraocular pressure measurement with optic disc imaging and field testing Correct answer.
  3. Anterior chamber paracentesis
  4. Electroretinography

Explanation

Normal-tension glaucoma requires documentation of disc damage and field loss with repeated pressure measurements, including diurnal curves, to exclude intermittent elevation. Structural imaging and perimetry establish the diagnosis.

Question 44Clinical Ophthalmology (Advanced)

A patient with Marfan syndrome presents with a superotemporally subluxated crystalline lens. Which additional finding is most associated with this condition?

  1. Café-au-lait macules
  2. Renal angiomyolipoma
  3. Cerebellar haemangioblastoma
  4. Aortic root dilation Correct answer.

Explanation

Marfan syndrome results from fibrillin-1 mutations and is associated with aortic root dilation and lens subluxation, typically superotemporal. Cardiovascular surveillance is essential because aortic dissection is a major cause of mortality.

Question 45Clinical Ophthalmology (Advanced)

Which feature on gonioscopy indicates a previous episode of acute angle closure?

  1. Heavy trabecular pigmentation in a wide angle
  2. A deep angle with a prominent ciliary body band
  3. Broad peripheral anterior synechiae with iris atrophy Correct answer.
  4. Scattered pigment on Schwalbe line

Explanation

Broad peripheral anterior synechiae and iris atrophy reflect prior appositional closure and ischaemic damage to the iris. These findings help distinguish a previous acute attack from primary open-angle glaucoma.

Question 46Clinical Ophthalmology (Advanced)

A patient with a prosthetic hip develops acute endophthalmitis after cataract surgery. Which organism is most likely if the infection is endogenous?

  1. Staphylococcus epidermidis
  2. Pseudomonas aeruginosa
  3. Streptococcus pneumoniae
  4. Staphylococcus aureus Correct answer.

Explanation

Endogenous endophthalmitis in patients with indwelling devices or bacteraemia is often caused by Staphylococcus aureus, particularly in the setting of prosthetic material. Coagulase-negative staphylococci are more typical of postoperative exogenous infection.

Question 47Clinical Ophthalmology (Advanced)

Which finding on B-scan ultrasonography is most characteristic of a choroidal melanoma?

  1. A cystic lesion with a hyperechoic wall
  2. A homogeneous high-reflective lesion with no shadowing
  3. A diffuse thickening of the sclera
  4. A dome-shaped lesion with low internal reflectivity and acoustic hollowness Correct answer.

Explanation

Choroidal melanoma typically shows a dome or mushroom-shaped mass with low to medium internal reflectivity and acoustic hollowness from sound attenuation. These features help distinguish it from haemangioma, which is highly reflective.

Question 48Clinical Ophthalmology (Advanced)

A patient presents with a painful red eye and a ring-shaped corneal infiltrate after sleeping in contact lenses. Which management step is most appropriate initially?

  1. Prescribe topical corticosteroids alone
  2. Perform immediate penetrating keratoplasty
  3. Obtain corneal scrapings for culture and start broad-spectrum fortified antibiotics Correct answer.
  4. Apply a pressure patch and review in one week

Explanation

A ring infiltrate in a contact lens wearer suggests severe microbial keratitis, and corneal scrapings guide targeted therapy. Broad-spectrum fortified antibiotics are started empirically while cultures are pending, and steroids are not used alone.

Question 49Clinical Ophthalmology (Advanced)

Which refractive outcome is most expected immediately after successful scleral buckling surgery for a macula-on retinal detachment?

  1. A hyperopic shift
  2. No change in refraction
  3. A myopic shift Correct answer.
  4. An increase in astigmatism only

Explanation

Scleral buckling changes the axial length and lens position, typically producing a myopic shift of about one dioptre or more. This effect is important when counselling patients about postoperative vision.

Question 50Clinical Ophthalmology (Advanced)

Which clinical feature most strongly suggests giant cell arteritis in a patient with anterior ischaemic optic neuropathy?

  1. Altitudinal visual field loss
  2. A relative afferent pupillary defect
  3. Jaw claudication and an elevated erythrocyte sedimentation rate Correct answer.
  4. Sectoral disc swelling

Explanation

Giant cell arteritis should be suspected when ischaemic optic neuropathy is accompanied by systemic features such as jaw claudication, scalp tenderness and raised inflammatory markers. Urgent corticosteroids and temporal artery biopsy are indicated to protect the fellow eye.