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OMSB Ophthalmology (OEOPTH) study materials
OMSB Ophthalmology (OEOPTH) study resources

OMSB Ophthalmology (OEOPTH) practice questions

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Question 1Ophthalmology (OMSB specialty training program content)

A 62-year-old man with poorly controlled type 2 diabetes presents with sudden painless loss of vision in the left eye. Fundoscopy shows a pale, swollen retina with a cherry-red spot at the macula. Which vascular structure is most likely occluded?

  1. Long posterior ciliary artery
  2. Central retinal artery Correct answer.
  3. Short posterior ciliary artery supplying the fovea
  4. Central retinal vein

Explanation

The clinical picture of a sudden painless visual loss with a pale, opaque retina and a cherry-red spot is the classic appearance of central retinal artery occlusion. The fovea retains its red colour because it is supplied by the choroidal circulation rather than the retinal artery, so it stands out against the ischaemic surrounding retina.

Question 2Ophthalmology (OMSB specialty training program content)

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

  1. A shallow anterior chamber with a closed angle on gonioscopy
  2. Cupping of the optic disc with thinning of the neuroretinal rim Correct answer.
  3. Cells and flare in the anterior chamber
  4. Neovascularisation of the iris

Explanation

Primary open-angle glaucoma is a chronic optic neuropathy characterised by progressive loss of retinal ganglion cells with corresponding optic disc cupping and neuroretinal rim thinning. The anterior chamber angle is open by definition, and the anterior segment is otherwise quiet.

Question 3Ophthalmology (OMSB specialty training program content)

A 24-year-old contact lens wearer presents with a painful red eye, a corneal epithelial defect and a grey-white infiltrate. Which organism is the most common cause of this presentation?

  1. Acanthamoeba
  2. Pseudomonas aeruginosa Correct answer.
  3. Herpes simplex virus
  4. Staphylococcus epidermidis

Explanation

Microbial keratitis in contact lens wearers is most frequently caused by Pseudomonas aeruginosa, which is favoured by the biofilm on lenses and cases and can progress rapidly to corneal melting. Prompt intensive topical anti-pseudomonal therapy is required.

Question 4Ophthalmology (OMSB specialty training program content)

A 70-year-old woman reports gradual painless loss of central vision with distortion of straight lines. Which investigation is most appropriate to confirm the diagnosis?

  1. Anterior segment optical coherence tomography
  2. Optical coherence tomography of the macula Correct answer.
  3. B-scan ultrasonography
  4. Corneal topography

Explanation

Gradual painless central visual loss with metamorphopsia suggests macular disease such as age-related macular degeneration or an epiretinal membrane. Optical coherence tomography of the macula is the key investigation, demonstrating subretinal fluid, drusen, or membrane traction with high resolution.

Question 5Ophthalmology (OMSB specialty training program content)

Which of the following is the most common cause of preventable blindness worldwide?

  1. Onchocerciasis
  2. Trachoma
  3. Vitamin A deficiency
  4. Cataract Correct answer.

Explanation

Cataract is the leading cause of reversible blindness globally and is treatable with surgery. Although trachoma and vitamin A deficiency remain important causes of preventable blindness in specific regions, cataract accounts for the largest share of blindness worldwide.

Question 6Ophthalmology (OMSB specialty training program content)

A 35-year-old woman presents with a unilateral dilated pupil that reacts poorly to light but constricts briskly to near gaze. Which diagnosis is most likely?

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

Explanation

A tonic pupil (Adie pupil) results from parasympathetic denervation, typically post-viral or idiopathic, and shows light-near dissociation with a sluggish response to light but strong constriction on near effort. It is often associated with reduced deep tendon reflexes in Holmes-Adie syndrome.

Question 7Ophthalmology (OMSB specialty training program content)

A 3-year-old child is noted to have a white pupillary reflex. Which diagnosis must be excluded first because of its life-threatening potential?

  1. Retinoblastoma Correct answer.
  2. Congenital cataract
  3. Coats disease
  4. Persistent hyperplastic primary vitreous

Explanation

Leukocoria in a young child requires urgent exclusion of retinoblastoma, an intraocular malignancy that can be fatal if untreated and may be bilateral in heritable cases. Any child with a white pupillary reflex should be referred urgently for fundoscopy and imaging.

Question 8Ophthalmology (OMSB specialty training program content)

Which test is used to assess for a relative afferent pupillary defect?

  1. Swinging flashlight test Correct answer.
  2. Bagolini striated glasses test
  3. Cover-uncover test
  4. Worth four-dot test

Explanation

The swinging flashlight test detects a relative afferent pupillary defect by comparing the pupillary response when light is alternated between eyes. An affected eye shows paradoxical dilation when light swings towards it, indicating asymmetric optic nerve or extensive retinal dysfunction.

Question 9Ophthalmology (OMSB specialty training program content)

A 55-year-old man presents with a gradual drooping of the right upper lid that worsens through the day and improves with rest. Which diagnosis is most likely?

  1. Myasthenia gravis Correct answer.
  2. Horner syndrome
  3. Aponeurotic ptosis
  4. Oculomotor nerve palsy

Explanation

Fatigable ptosis that worsens with sustained activity and improves with rest is characteristic of myasthenia gravis, an autoimmune neuromuscular junction disorder. It may be isolated to the ocular muscles or accompanied by diplopia and systemic weakness.

Question 10Ophthalmology (OMSB specialty training program content)

A 68-year-old man with hypertension presents with sudden painless loss of vision in one eye. Fundoscopy shows a blood-and-thunder appearance with scattered retinal haemorrhages and disc oedema. Which complication should be monitored for over the following months?

  1. Central retinal artery occlusion
  2. Retinal detachment
  3. Neovascular glaucoma Correct answer.
  4. Optic neuritis

Explanation

Central retinal vein occlusion can lead to anterior segment neovascularisation and neovascular glaucoma, particularly with ischaemic CRVO. Patients require periodic monitoring of iris and angle neovascularisation so that panretinal photocoagulation can be applied if needed.

Question 11Ophthalmology (OMSB specialty training program content)

A 40-year-old woman presents with a painful red eye and decreased vision. Slit-lamp examination shows fine keratic precipitates and cells in the anterior chamber. Which is the most appropriate initial management?

  1. Topical antihistamines
  2. Observation without treatment
  3. Topical antibiotics alone
  4. Topical corticosteroids with cycloplegia Correct answer.

Explanation

Anterior uveitis is treated with topical corticosteroids to suppress inflammation and a cycloplegic agent to relieve ciliary spasm and prevent posterior synechiae. Antibiotics are not indicated in the absence of infection.

Question 12Ophthalmology (OMSB specialty training program content)

A 60-year-old patient with a history of angle-closure glaucoma presents with acute severe eye pain, headache, nausea and blurred vision. The cornea is hazy and the pupil is mid-dilated and fixed. Which is the most appropriate immediate management?

  1. Topical antibiotics and review in one week
  2. Topical and systemic pressure-lowering agents with definitive laser peripheral iridotomy Correct answer.
  3. Immediate surgical trabeculectomy
  4. Topical steroids alone

Explanation

Acute angle-closure glaucoma is an emergency requiring rapid lowering of intraocular pressure with topical beta-blockers, alpha-agonists, carbonic anhydrase inhibitors and systemic hyperosmotic agents, followed by definitive laser peripheral iridotomy. Delay risks irreversible optic nerve damage.

Question 13Ophthalmology (OMSB specialty training program content)

A 45-year-old man presents with a gradual painless proptosis of the right eye, lid retraction and restriction of upgaze. Which diagnosis is most likely?

  1. Orbital cellulitis
  2. Cavernous sinus thrombosis
  3. Orbital lymphoma
  4. Thyroid eye disease Correct answer.

Explanation

Gradual painless proptosis with lid retraction and restrictive myopathy, particularly involving the inferior rectus, is typical of thyroid eye disease. It is associated with Graves disease and can be sight-threatening through optic nerve compression.

Question 14Ophthalmology (OMSB specialty training program content)

A 6-year-old child is found to have reduced visual acuity in one eye with normal ocular examination and a normal red reflex. Which condition should be considered and treated promptly to prevent permanent visual loss?

  1. Retinoblastoma
  2. Optic nerve hypoplasia
  3. Congenital glaucoma
  4. Amblyopia Correct answer.

Explanation

Amblyopia is reduced vision in an otherwise structurally normal eye due to abnormal visual experience during the critical period, such as strabismus or anisometropia. Early detection and treatment with occlusion or refractive correction can restore vision.

Question 15Ophthalmology (OMSB specialty training program content)

A 70-year-old woman with a history of giant cell arteritis presents with sudden visual loss in one eye. Which is the most appropriate immediate treatment to protect the fellow eye?

  1. High-dose systemic corticosteroids Correct answer.
  2. Oral antibiotics
  3. Topical beta-blockers
  4. Intravitreal anti-VEGF injection

Explanation

Giant cell arteritis can cause anterior ischaemic optic neuropathy and sudden visual loss, and the fellow eye is at high risk. High-dose systemic corticosteroids should be started immediately to prevent contralateral involvement.

Question 16Ophthalmology (OMSB specialty training program content)

A 30-year-old man presents with a painful red eye and a dendritic corneal ulcer staining with fluorescein. Which treatment is most appropriate?

  1. Topical aciclovir Correct answer.
  2. Topical antifungal agents
  3. Topical antibiotics
  4. Topical corticosteroids alone

Explanation

A dendritic ulcer is characteristic of herpes simplex keratitis, which is treated with topical antiviral agents such as aciclovir. Topical corticosteroids are contraindicated in active epithelial disease because they can worsen the infection.

Question 17Ophthalmology (OMSB specialty training program content)

Which refractive error is corrected with a concave (minus) lens?

  1. Hyperopia
  2. Myopia Correct answer.
  3. Astigmatism
  4. Presbyopia

Explanation

Myopia is corrected with a concave, diverging lens that moves the focal point back onto the retina. Hyperopia requires a convex converging lens, while astigmatism requires a cylindrical component.

Question 18Ophthalmology (OMSB specialty training program content)

A 50-year-old man presents with a sudden onset of floaters and flashes of light followed by a curtain-like loss of peripheral vision. Which diagnosis is most likely?

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

Explanation

Photopsia and floaters followed by a curtain-like visual field defect suggest a rhegmatogenous retinal detachment, in which a retinal tear allows fluid to accumulate under the retina. Urgent surgical repair is required to prevent permanent visual loss.

Question 19Ophthalmology (OMSB specialty training program content)

A 65-year-old woman with long-standing diabetes presents with a sudden painless loss of vision. Fundoscopy is limited by a dense vitreous haemorrhage. Which is the most appropriate next step?

  1. Fluorescein angiography
  2. B-scan ultrasonography Correct answer.
  3. Anterior segment OCT
  4. Optical coherence tomography

Explanation

When the fundus cannot be visualised because of dense vitreous haemorrhage, B-scan ultrasonography is used to assess for retinal detachment, vitreous traction or underlying masses. It guides the decision for vitrectomy.

Question 20Ophthalmology (OMSB specialty training program content)

A 45-year-old woman presents with a slowly growing, painless, yellowish nodule on the bulbar conjunctiva near the limbus. Which diagnosis is most likely?

  1. Pterygium
  2. Squamous cell carcinoma of the conjunctiva
  3. Conjunctival melanoma
  4. Pinguecula Correct answer.

Explanation

A pinguecula is a benign, yellowish conjunctival degeneration near the limbus that does not invade the cornea. A pterygium, by contrast, is a fibrovascular growth that crosses onto the cornea.

Question 21Ophthalmology (OMSB specialty training program content)

A 28-year-old man presents with a painful red eye, photophobia and a history of recurrent oral ulcers. Slit-lamp examination shows hypopyon and cells in the anterior chamber. Which systemic condition is most likely?

  1. Sarcoidosis
  2. Behçet disease Correct answer.
  3. Ankylosing spondylitis
  4. Systemic lupus erythematosus

Explanation

Recurrent oral ulcers with hypopyon uveitis are characteristic of Behçet disease, an inflammatory vasculitis that can cause severe sight-threatening ocular inflammation. Prompt immunosuppressive treatment is required.

Question 22Ophthalmology (OMSB specialty training program content)

A 55-year-old woman presents with a gradual painless loss of vision and a cherry-red spot at the macula with a normal-calibre retinal vasculature. Which diagnosis is most likely?

  1. Retinitis pigmentosa
  2. Tay-Sachs disease
  3. Central serous chorioretinopathy
  4. Central retinal artery occlusion Correct answer.

Explanation

A cherry-red spot with a pale, opaque retina is the hallmark of central retinal artery occlusion. The fovea remains red because it is supplied by the choroid, while the surrounding retina becomes ischaemic and opaque.

Question 23Ophthalmology (OMSB specialty training program content)

A 60-year-old man presents with a slowly progressive, painless loss of peripheral vision in both eyes. Gonioscopy shows an open angle and the optic discs show marked cupping. Which is the most appropriate initial treatment?

  1. Topical prostaglandin analogue Correct answer.
  2. Topical antibiotics
  3. Laser peripheral iridotomy
  4. Systemic corticosteroids

Explanation

Primary open-angle glaucoma is initially managed with a topical prostaglandin analogue, which lowers intraocular pressure by increasing uveoscleral outflow. Laser peripheral iridotomy is used for angle closure, not open-angle glaucoma.

Question 24Ophthalmology (OMSB specialty training program content)

A 70-year-old man presents with a sudden onset of diplopia and a complete ptosis of the left eye. Examination shows a fixed, dilated left pupil and the eye is deviated down and out. Which is the most likely diagnosis?

  1. Myasthenia gravis
  2. Left trochlear nerve palsy
  3. Left oculomotor nerve palsy Correct answer.
  4. Left abducens nerve palsy

Explanation

A complete third nerve palsy produces ptosis, a fixed dilated pupil and a down-and-out eye due to unopposed lateral rectus and superior oblique action. The pupillary involvement suggests a compressive lesion, which requires urgent neuroimaging.

Question 25Ophthalmology (OMSB specialty training program content)

A 35-year-old woman presents with a gradual painless proptosis of one eye and a palpable mass in the lacrimal gland region. Imaging shows a well-circumscribed mass. Which diagnosis is most likely?

  1. Cavernous sinus thrombosis
  2. Pleomorphic adenoma of the lacrimal gland Correct answer.
  3. Orbital cellulitis
  4. Thyroid eye disease

Explanation

A well-circumscribed, painless lacrimal gland mass in a middle-aged adult is most consistent with a pleomorphic adenoma, a benign mixed tumour. Complete excision is required because of the risk of malignant transformation and recurrence.

Question 26Ophthalmology (OMSB specialty training program content)

A 24-year-old man is hit in the right eye with a squash ball. He has a 2 mm hyphema, a deep anterior chamber, and intraocular pressure of 16 mmHg. Which of the following is the most important immediate management step?

  1. Prescribe topical corticosteroid, cycloplegic, and advise limited activity with head elevation and follow-up within 24 hours Correct answer.
  2. Start topical prostaglandin analogue to lower intraocular pressure
  3. Perform immediate surgical anterior chamber washout
  4. Prescribe aspirin for pain control

Explanation

Most traumatic hyphema patients can be managed conservatively with topical steroid to reduce inflammation, a cycloplegic for comfort and to prevent rebleed, and restriction of activity with head elevation. Surgical washout is reserved for persistent clot, high pressure, or corneal staining. Aspirin is contraindicated because it increases rebleeding risk.

Question 27Ophthalmology (OMSB specialty training program content)

A 58-year-old woman with type 2 diabetes has a best-corrected visual acuity of 20/40 in the right eye and clinically significant macular edema on optical coherence tomography. Which treatment is first-line for center-involving diabetic macular edema?

  1. Observation with tight glycemic control alone
  2. Focal grid laser photocoagulation alone
  3. Intravitreal anti-VEGF injection Correct answer.
  4. Pars plana vitrectomy with internal limiting membrane peel

Explanation

Intravitreal anti-VEGF therapy is the first-line treatment for center-involving diabetic macular edema and typically produces better visual outcomes than laser. Focal laser remains useful for non-center-involving edema. Vitrectomy is reserved for cases with vitreomacular traction or non-clearing hemorrhage.

Question 28Ophthalmology (OMSB specialty training program content)

A 32-year-old woman with no prior eye disease presents with a 3-day history of a painful red left eye and photophobia. Slit-lamp examination shows circumlimbal injection, fine keratic precipitates, and 2+ cells in the anterior chamber. Which of the following is the most appropriate initial treatment?

  1. Topical antihistamine and cool compresses
  2. Oral acyclovir 400 mg five times daily
  3. Topical antibiotic every hour
  4. Topical corticosteroid with cycloplegic Correct answer.

Explanation

The findings describe acute anterior uveitis (iritis), for which topical corticosteroid reduces inflammation and a cycloplegic relieves pain and prevents posterior synechiae. Antibiotics and antihistamines have no role. Oral antivirals are used for herpetic keratouveitis with dendritic disease, not for isolated non-herpetic anterior uveitis.

Question 29Ophthalmology (OMSB specialty training program content)

A 62-year-old man presents with a 6-month history of gradually increasing proptosis of the right eye, periorbital swelling, and intermittent diplopia. CT shows diffuse enlargement of the extraocular muscles with tendon sparing. Which of the following is the most likely diagnosis?

  1. Cavernous sinus thrombosis
  2. Orbital cellulitis
  3. Orbital lymphoma
  4. Thyroid eye disease Correct answer.

Explanation

Thyroid eye disease classically causes bilateral (often asymmetric) enlargement of the extraocular muscles with tendon sparing and proptosis. Lymphoma more often involves the lacrimal gland or orbital fat with a discrete mass. Orbital cellulitis is acute and painful, and cavernous sinus thrombosis is acute with cranial nerve palsies.

Question 30Ophthalmology (OMSB specialty training program content)

A 42-year-old woman presents with a slowly enlarging, painless, translucent fleshy mass on the nasal bulbar conjunctiva that has crossed the limbus onto the cornea. Which of the following is the most likely diagnosis?

  1. Pterygium Correct answer.
  2. Squamous cell carcinoma of the conjunctiva
  3. Conjunctival lymphoma
  4. Pinguecula

Explanation

A pterygium is a fibrovascular wedge of conjunctiva that crosses the limbus onto the cornea, usually on the nasal side, and is associated with ultraviolet exposure. A pinguecula is a similar lesion that remains confined to the conjunctiva and does not cross the limbus. Conjunctival malignancy is typically raised, irregular, and may have feeder vessels.

Question 31Ophthalmology (OMSB specialty training program content)

A 70-year-old woman reports a 1-year history of gradual painless blurring of vision in both eyes. Slit-lamp examination shows a dense central corneal opacity with a grayish granular appearance and a clear peripheral rim. Which of the following is the most likely diagnosis?

  1. Keratoconus
  2. Corneal arcus
  3. Fuchs endothelial dystrophy
  4. Granular corneal dystrophy Correct answer.

Explanation

Granular corneal dystrophy presents with bilateral, symmetric, discrete grayish granular opacities in the central cornea that may coalesce over time, with a clear peripheral rim. Fuchs dystrophy primarily affects the endothelium with guttae and stromal edema. Keratoconus causes corneal thinning and ectasia, and arcus is a peripheral lipid ring.

Question 32Ophthalmology (OMSB specialty training program content)

A 6-year-old boy is brought in with a 2-week history of a painless red eye and a fleshy conjunctival mass in the right fornix. Examination reveals a salmon-pink subconjunctival infiltration with a rubbery consistency. Which of the following is the most appropriate next step?

  1. Observation with repeat examination in 6 months
  2. Topical corticosteroid alone
  3. Excisional or incisional biopsy for histopathology Correct answer.
  4. Topical antibiotic and observation

Explanation

Conjunctival lymphoma typically presents as a salmon-pink fleshy infiltration in the fornix and requires biopsy for histopathologic diagnosis and staging. Antibiotics and steroids do not treat lymphoma and delay diagnosis. Observation is inappropriate for a suspected malignancy.

Question 33Ophthalmology (OMSB specialty training program content)

A 55-year-old man is evaluated for a gradual painless loss of vision in both eyes. Fundoscopy shows optic disc pallor with a normal cup-to-disc ratio, and visual field testing shows a central scotoma. Which of the following is the most likely diagnosis?

  1. Ischemic optic neuropathy
  2. Hereditary optic neuropathy Correct answer.
  3. Optic neuritis
  4. Primary open-angle glaucoma

Explanation

Hereditary optic neuropathies such as Leber hereditary optic neuropathy or dominant optic atrophy present with bilateral, symmetric, painless optic disc pallor with a central or cecocentral scotoma and normal cupping. Glaucoma causes cupping and arcuate field defects. Optic neuritis is usually painful and unilateral, and ischemic optic neuropathy is usually sudden and altitudinal.

Question 34Ophthalmology (OMSB specialty training program content)

A 48-year-old woman with a history of migraine presents with a 3-day history of a dilated right pupil that is unreactive to light but constricts with near effort. The right eyelid is slightly ptotic and the eye is otherwise normal. Which of the following is the most likely diagnosis?

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

Explanation

An Adie tonic pupil is characterized by a dilated pupil with light-near dissociation, sluggish constriction to near, and denervation supersensitivity to dilute pilocarpine. Third nerve palsy would cause ptosis and ophthalmoplegia. Horner syndrome causes miosis, not mydriasis. Pharmacologic mydriasis typically does not constrict to near.

Question 35Ophthalmology (OMSB specialty training program content)

A 30-year-old man presents with a painful red left eye, decreased vision, and a hypopyon. Slit-lamp examination shows a corneal infiltrate with an overlying epithelial defect. Which of the following is the most appropriate initial management?

  1. Topical antiviral therapy and patching
  2. Topical corticosteroid every hour
  3. Corneal scraping for culture and frequent topical fortified antibiotics Correct answer.
  4. Observation with lubricants

Explanation

A hypopyon with a corneal infiltrate and epithelial defect suggests bacterial keratitis, which requires corneal scraping for culture and prompt frequent topical fortified antibiotics. Topical steroids alone can worsen infection. Antivirals are used for dendritic herpetic disease, and observation is inappropriate for a sight-threatening ulcer.

Question 36Ophthalmology (OMSB specialty training program content)

A 62-year-old woman is found to have an intraocular pressure of 34 mmHg in the right eye with a closed angle on gonioscopy, corneal edema, and a mid-dilated pupil. Which of the following is the most appropriate initial medication to lower the pressure rapidly?

  1. Intravenous acetazolamide Correct answer.
  2. Topical phenylephrine 2.5%
  3. Topical atropine 1%
  4. Topical pilocarpine 2%

Explanation

In acute angle-closure glaucoma, systemic aqueous suppression with intravenous acetazolamide rapidly lowers intraocular pressure. Pilocarpine is less effective while the iris sphincter is ischemic and is typically used after pressure starts to fall. Atropine and phenylephrine are contraindicated because they dilate the pupil and worsen angle closure.

Question 37Ophthalmology (OMSB specialty training program content)

A 70-year-old man with hypertension reports sudden painless loss of the upper half of the visual field in the right eye. Fundoscopy shows a swollen, pale optic disc with a splinter hemorrhage at the disc margin. Which of the following is the most likely diagnosis?

  1. Central retinal artery occlusion
  2. Non-arteritic anterior ischemic optic neuropathy Correct answer.
  3. Optic neuritis
  4. Papilledema

Explanation

Non-arteritic anterior ischemic optic neuropathy classically presents with sudden painless altitudinal visual field loss and a swollen pale optic disc, often with a splinter hemorrhage. Central retinal artery occlusion causes diffuse retinal whitening with a cherry-red spot. Papilledema is bilateral, and optic neuritis is usually painful and unilateral with a relative afferent pupillary defect.

Question 38Ophthalmology (OMSB specialty training program content)

A 4-year-old boy is noted by his parents to have intermittent inward turning of the right eye, worse when he is tired. Cover testing confirms an esotropia that is more pronounced at near than at distance. Which of the following is the most likely diagnosis?

  1. Congenital fibrosis of the extraocular muscles
  2. Accommodative esotropia Correct answer.
  3. Intermittent exotropia
  4. Duane retraction syndrome

Explanation

Accommodative esotropia typically presents in a hyperopic child around 2 to 4 years of age with intermittent esotropia that is greater at near fixation and improves with corrective lenses. Intermittent exotropia causes outward deviation. Duane syndrome shows limited abduction with globe retraction on adduction.

Question 39Ophthalmology (OMSB specialty training program content)

A 35-year-old woman presents with a 2-day history of a painful red right eye and a watery discharge. Slit-lamp examination shows a dendritic corneal ulcer that stains with fluorescein. Which of the following is the most appropriate treatment?

  1. Topical antibiotic drops
  2. Topical corticosteroid drops
  3. Topical trifluridine or oral acyclovir Correct answer.
  4. Topical antifungal drops

Explanation

A dendritic ulcer is characteristic of herpes simplex epithelial keratitis and is treated with topical antiviral agents such as trifluridine or ganciclovir, or oral acyclovir. Topical corticosteroids are contraindicated in epithelial herpetic disease because they can worsen the infection. Antibiotics and antifungals do not treat viral keratitis.

Question 40Ophthalmology (OMSB specialty training program content)

A 68-year-old man with chronic open-angle glaucoma has been using topical latanoprost for 3 years. He reports increased pigmentation of the iris and eyelashes and darkening of the periocular skin. Which of the following is the most likely cause?

  1. Alpha-agonist therapy
  2. Prostaglandin analogue therapy Correct answer.
  3. Carbonic anhydrase inhibitor therapy
  4. Beta-blocker therapy

Explanation

Prostaglandin analogues such as latanoprost are associated with iris and eyelash hyperpigmentation, eyelash lengthening, and periocular skin darkening. These effects are typically irreversible for the iris and are important to discuss with patients. Beta-blockers, alpha-agonists, and carbonic anhydrase inhibitors do not cause these changes.

Question 41Ophthalmology (OMSB specialty training program content)

A 25-year-old woman presents with a 1-week history of a painful red left eye, photophobia, and a foreign-body sensation. Slit-lamp examination shows a hypopyon, a hyphema, and a small pigmented lesion at the pupillary margin. Which of the following is the most important next step?

  1. Reassurance and lubricants
  2. Topical corticosteroid and observation
  3. Topical antibiotic and patching
  4. B-scan ultrasound of the globe Correct answer.

Explanation

A pigmented lesion at the iris root with hyphema and hypopyon in a young patient suggests an intraocular foreign body or retained intraocular foreign body, and B-scan ultrasound helps localize it. Plain radiography may miss small or radiolucent foreign bodies. Topical steroids or antibiotics alone do not address a retained foreign body.

Question 42Ophthalmology (OMSB specialty training program content)

A 50-year-old man presents with a 3-month history of a gradually enlarging, painless swelling of the right upper eyelid. Examination shows a firm, nontender nodule with loss of eyelashes and madarosis. Which of the following is the most likely diagnosis?

  1. Blepharitis
  2. Basal cell carcinoma Correct answer.
  3. Chalazion
  4. Hordeolum

Explanation

A firm, painless eyelid nodule with loss of eyelashes (madarosis) and ulceration is suspicious for basal cell carcinoma, the most common eyelid malignancy. Chalazion is a tender or nontender lid nodule from a blocked meibomian gland but does not cause lash loss. Hordeolum is acute and painful, and blepharitis is diffuse inflammation.

Question 43Ophthalmology (OMSB specialty training program content)

A 45-year-old woman presents with a 6-month history of dry eye symptoms, dry mouth, and bilateral parotid enlargement. Schirmer test is 2 mm in 5 minutes in both eyes. Which of the following is the most likely diagnosis?

  1. Chronic dacryocystitis
  2. Sjögren syndrome Correct answer.
  3. Sarcoidosis
  4. Blepharitis

Explanation

Sjögren syndrome is an autoimmune exocrinopathy causing dry eyes (keratoconjunctivitis sicca) and dry mouth, often with parotid enlargement. A Schirmer test of 5 mm or less in 5 minutes supports severe aqueous deficiency. Sarcoidosis can cause dry eye but typically has other systemic findings such as hilar adenopathy.

Question 44Ophthalmology (OMSB specialty training program content)

A 60-year-old woman with a history of treated breast carcinoma presents with a 4-month history of a painless, enlarging mass in the superotemporal orbit and a palpable lacrimal gland. Which of the following is the most appropriate next step?

  1. Oral antibiotics
  2. Observation with repeat imaging in 6 months
  3. Incisional or excisional biopsy of the lacrimal gland mass Correct answer.
  4. Topical corticosteroid drops

Explanation

A lacrimal gland mass in an older patient with a history of malignancy is suspicious for metastasis or a primary lacrimal gland tumor, and biopsy is required for diagnosis. Observation is inappropriate for a growing mass. Topical steroids and antibiotics do not treat a neoplastic lesion.

Question 45Ophthalmology (OMSB specialty training program content)

A 28-year-old man is diagnosed with a retinal detachment involving the macula. Which of the following findings on fundoscopy is most consistent with a rhegmatogenous retinal detachment?

  1. A traction band from proliferative diabetic retinopathy
  2. A serous detachment over a choroidal melanoma
  3. A dome-shaped choroidal mass with orange pigment
  4. A horseshoe retinal tear with subretinal fluid Correct answer.

Explanation

Rhegmatogenous retinal detachment is caused by a full-thickness retinal break allowing vitreous fluid to enter the subretinal space, producing a horseshoe tear with adjacent subretinal fluid. Choroidal masses cause exudative detachments, and traction bands cause tractional detachments.

Question 46Ophthalmology (OMSB specialty training program content)

A 3-year-old girl is brought in with a 2-week history of a white pupillary reflex in the left eye. Examination shows a white mass in the retina and strabismus. Which of the following is the most important diagnosis to exclude first?

  1. Retinoblastoma Correct answer.
  2. Persistent fetal vasculature
  3. Congenital cataract
  4. Coats disease

Explanation

Leukocoria in a young child requires urgent exclusion of retinoblastoma, a life-threatening intraocular malignancy. Other causes of leukocoria include congenital cataract, Coats disease, and persistent fetal vasculature, but retinoblastoma must be ruled out first because of its potential for metastasis and mortality.

Question 47Ophthalmology (OMSB specialty training program content)

A 65-year-old man presents with a 1-year history of gradual painless loss of vision in the right eye. Examination shows a dense cataract with a brownish nucleus. Which of the following is the most appropriate management?

  1. Topical corticosteroid drops
  2. Phacoemulsification with intraocular lens implantation Correct answer.
  3. YAG laser capsulotomy
  4. Observation with annual follow-up

Explanation

A visually significant cataract with a brownish (brunescent) nucleus is treated with phacoemulsification and intraocular lens implantation. Observation is appropriate only for mild, non-visually significant cataracts. YAG laser capsulotomy treats posterior capsule opacification after cataract surgery, not the cataract itself.

Question 48Ophthalmology (OMSB specialty training program content)

A 40-year-old woman presents with a 2-day history of a painful red right eye and decreased vision. Slit-lamp examination shows a corneal ulcer with a feathery edge, a ring infiltrate, and hypopyon. She wears contact lenses and admits to swimming with them. Which of the following is the most likely organism?

  1. Herpes simplex virus
  2. Staphylococcus aureus
  3. Pseudomonas aeruginosa
  4. Acanthamoeba Correct answer.

Explanation

Acanthamoeba keratitis is associated with contact lens wear and exposure to contaminated water, and it can present with a ring infiltrate, severe pain out of proportion to findings, and a feathery ulcer edge. Pseudomonas keratitis is also associated with contact lenses but typically presents with a rapidly progressive, suppurative ulcer. Herpes simplex causes dendritic ulcers.

Question 49Ophthalmology (OMSB specialty training program content)

A 55-year-old man with type 2 diabetes has a vitreous hemorrhage that has not cleared after 3 months. Ultrasound shows a tractional retinal detachment involving the macula. Which of the following is the most appropriate management?

  1. Observation for another 6 months
  2. Panretinal photocoagulation alone
  3. Pars plana vitrectomy Correct answer.
  4. Intravitreal anti-VEGF injection alone

Explanation

Non-clearing vitreous hemorrhage with tractional retinal detachment involving the macula is an indication for pars plana vitrectomy. Anti-VEGF and panretinal photocoagulation treat proliferative diabetic retinopathy but do not address a tractional detachment. Prolonged observation risks irreversible macular damage.

Question 50Ophthalmology (OMSB specialty training program content)

A 30-year-old woman presents with a 1-week history of a painless, gradually enlarging swelling in the medial canthus area that has been present for months. Pressure over the swelling produces purulent discharge from the punctum. Which of the following is the most likely diagnosis?

  1. Acute dacryocystitis
  2. Dacryocystocele
  3. Canaliculitis
  4. Chronic dacryocystitis Correct answer.

Explanation

Chronic dacryocystitis presents with a painless swelling over the lacrimal sac and regurgitation of purulent material from the punctum on pressure. Acute dacryocystitis is painful and erythematous. Canaliculitis presents with a pouting punctum and sulfur granules.