Thursday, January 31, 2013

Thyroid Eye Disease

There are many different names you might find for the autoimmune eye condition that is often seen with thyroid disease, including:
  • Thyroid Eye Disease, sometimes abbreviated as TED
  • Graves' Opthamolopathy
  • Thyroid-associated orbitopathy (TAO)
  • Grave's orbitopathy
One general sign of a thyroid problem is steady and unexpected weight loss, which is actually caused by a sudden increase in metabolism. A person may go months without realizing there is a problem with the thyroid because many of the patients suffering from an overactive thyroid will not feel unwell. Untreated, an overactive thyroid can go on to cause other problems, one of them being eye disease. This is just one example of why it is so important to treat any problems with the thyroid as soon as they are discovered.
Thyroid Eye Disease is an autoimmune eye condition that, while separate from thyroid disease, is often seen in conjunction with Graves' Disease. The condition, however, is seen in people with no other evidence of thyroid dysfunction, and occasionally in patients who have Hashimoto's Disease. Most thyroid patients, however, will not develop thyroid eye disease, and if so, only mildly so.

Most people with thyroid eye disease have or had or will subsequently develop an overactive thyroid gland. In 20% the thyroid eye disease develops in people who do not have an overactive thyroid at the time (may subsequently develop this years later). In 40% thyroid eye disease occurs whilst the thyroid is overactive and in 40% can occur years after the overactive thyroid has been treated successfully.
Overactivity of the thyroid gland is usually caused by an "autoimmune condition" This means that cells which normally protect the body from infection develop a "fault" and begin to recognise the thyroid gland as foreign material and attack it. This stimulates the thyroid gland to produce extra thyroid hormones. The attacking process may spill over to the cells behind the eye causing them to swell. It is not yet known why cells develop the fault that causes them to attack the thyroid gland or why only some patients with overactivity of the thyroid develop thyroid eye disease. Thyroid eye disease does appear to be more common in smokers.

Signs and Symptoms of Thyroid Eye Disease

Signs and symptoms include:
  • Pain in the eyes, pain when looking up, down or sideways
  • Dryness, itching, dry eyes, difficulty wearing contact lenses
  • Inflammation and swelling of the eye, and its surrounding tissues
  • Swelling in the orbital tissues which causes the eye to be pushed forward -- referred to as exophthalmos -- which can make Thyroid Eye Disease sufferers appear to have a wide-eyed or bulging stare.
  • Bloodshot appearance to eyes
  • Double vision (doctors call it diplopia)
  • Impaired vision

  • The normal procedure for checking for eye disease is to do a complete eye test. The eye test will include procedures designed to assess the optic nerve, the cornea and the eyelid. Special attention is given to the movement of the eye and the position the eye rests in. It is a good idea to have the blood checked to see what level the thyroid hormones are at. Some doctors will order a CT scan or an ultrasound to get a better look at the swelling of the eye and the surrounding tissue.
-Irritation and Redness of the eyes
Artificial tears (hypromellose drops) are often helpful for this problem. These drops are harmless and can be applied as often as required.
-Puffiness around the eyes
This is more difficult to treat. Using extra pillows at night may help or sometimes a water tablet (diuretic) may be prescribed for you. The swelling usually improves as the eyes begin to settle down.
-Staring eyes
This may settle with time however if the problem is very severe the appearance can be improved by surgery to the eyelids.
-Deteriorating vision
If this occurs quite rapidly specialist treatment with powerful (immunosuppressive) drugs may be needed to damp down the inflammation around the eyes. Alternatively surgery called orbital decompression or radiotherapy treatment may be considered.
-Eyelid Retraction Repair
In thyroid eye disease, or Graves' disease, the eyelids can open too widely. Once the disease has remained stable for six months, corrective eyelid surgery can be performed to lower the eyelids back to their normal position. This is done both to improve appearance and to improve the health of the eyes, (the abnormally open eyelids cannot blink properly and leaving the eye inadequately lubricated and protected). This is performed as an outpatient, often with the CO2 laser in order to minimize bruising and speed healing.
-Orbital Decompression
Some patients with Graves' disease require orbital decompression, either to protect the vision, improve comfort, or improve their appearance by letting the eyes go back into the orbit. Dr. Schiller is pleased to be able to offer state-of-the-art minimal incision orbital decompression with the incisions placed inside the eyelids. Recovery is remarkably fast with minimal bruising and a small or no external scar.
-Double Vision Correction
Double vision is often the most disturbing result of thyroid eye disease, and surgical correction provides remarkable relief for these unhappy patients. Dr. Schiller performs adjustable muscle surgery under local anesthesia with intravenous sedation, which guarantees the patient's comfort and safety, while allowing the eyes to be adjusted to achieve clear single vision after only one procedure in almost all cases.

Will the eyes return to normal?
If the eyes are mildly affected they may return to nearly normal. This can take between 12 and 24 months. If your eyes have been more severely affected it is less likely that the changes will go away. In this situation expert treatment is required and carefully planned surgery can be very effective in improving the appearance of the eyes. This may require squint and lid surgery to improve the cosmetic appearance of the eyes. However neither is 100% effective but certainly help greatly to improve the situation.



·         Fixing the thyroid problem may prevent eye disease. Thyroid problems are corrected through anti-thyroid medication and surgery. There are several ways of treating eye disease, including medication for the thyroid hormone levels. Other options may include adjusting the eyelids in a way that allows them to close proper, use of rewetting drops or surgery to adjust the eye muscles. Steroids also may be prescribed to reduce the swelling.

Monday, November 19, 2012

Algorithmic approach in ophthalmology

Click to the picture to see it in its normal size

Tuesday, September 4, 2012

Clinical cases of ophthalmological problems associated with neurological diseases

Q1- 7 years old boy- present with head ache and repeated vomiting after FFH
CT-scan show no features of brain edema, and treated conservatively
In the second day, the patient had visual loss
Ophthamological examination show:
No features of internal and external ophthalmoplegia
Normal reacting pupil
Normal fundus
*What is the possible cause of visual loss and why?
Most propably due ho cortical blindness due to absence of internal and external ophthalmoplegia

*What is the prognosis?
Good prognosis
It is transient visual loss for few days

*What is the treatment?
Treated conservatively

Q2-50 years old female with head ache and visual disturbance for 20 days duration on gradual progression and of subacute onset, head ache was diffuse, non throbbing, persisted all over the time
The patient is poor controlled diabetic on oral hypoglycemic agents
On examination
-General condition
No jaundice, no anemia, no lymph node enlargement, good hydration
-cranial n.
No relevant find
No parietal lobe signs
No cerebellal signs
No meningeal signs

*What investigations you need?
2-lumber puncture

The investigations show that the patient had elevated I.C.P
Then, emergency lumber peritoneal shunt done
Patient get better regarding head ache and vision
3 months later, symptoms recurrent and after few weeks visual deteriorations occur
On evaluation abdominal catheter was disloged, reimplantation done, the patient also get better but still there is some residual visual disturbance

*What is the investigations we need:
1- lumber puncture
2- abdominal X-ray

The last investigations show normal CSF pressure and normal catheter position
Then , the patient reffered to ophthalmologist for ophthalmological evaluation

*What is the possible ophthalmological causes in this case?
1- atrophic changes
2- diabetic retinopathy

*What is the treatment?
Good blood sugar control

**special thanks to Dr. Saif Anmar (neurosurgeon, M.B.CH.B. ,F.I.C.M.S.) for his great helpness in collect this cases and presented it in this nice picture, from Ibn sina hospital

Thursday, July 12, 2012

Multiple choice questions

Q1- Which one of the following cranial nerves does not directly innervate the eye ball or it’s
A-Optic nerve.     
B- Trochlear nerve.
C Facial nerve
D. Vestibulocochlear nerve

Q2- The following factors are responsible for cornea! clarity, except:    
A- Corneal avascularity
B- Endothelia! cell ion pumps.
C-Stromal hydration with 90% water content
D- Pre corneal tear film

Q3-Related to the aqueous humor the following statements are true except:
A-It is secreted from the non pigmented ciliary epithelium.         
B-It nourishes the iris
C- It: passes from the posterior chamber to the anterior chamber through the pupil.
D- It drains through the trabecular meshwork in the angle of the anterior chamber.

Q4-Related to ptosis:
A -.Neurogenic ptosis is due to facial nerve palsy.
B- Ptosis is defined as drooping of the upper lid to cover the upper one sixth of the cornea.
C- Simple congenital ptosis is due to aponeurotic defect.
D- Bell's phenomenon should always be tested for before commencing into surgery

Q5-Related to the trichiasis 'the following statements are true except
A- trichiasis (congenital trichiasis) usually affect one lid only
B- Trachoma is.the commonest cause of acquired trichiasis,
C- Cicatricial conditions like burn may be a cause.
D- Ulcerative blepharitis may be a cause.
       .                               .
Q6-Treatment of blepharitis includes all of the following except:   
A- Proper-removal of crust.
B- Systemjc steroids
C- Topical antibiotics.
D- Systemic tetracycline

Q7- Regarding ltd tumors all of the following statements are true except;         
A- Neurofibromatosis is a benign tumor,
B- Xcifttlielasma may be associated with hypercholesterolemia.              
C-Nevus never undergoes malignant changes
D- Hemangioma may be associated with Sturge-Weber syndrome

Q8- Differential diagnosis of chronic conjunctivitis includes all of the following, except:
A- Toxic conjunctivitis.
B- chronic nasalacrimal duct obstruction.
C-Gonococcal keratoconjunctlvitis.

Q9- Regarding conjunctiva! dermoid all of the following statements are true except:
A- Often associated with Goldenhar syndrome
B- Presents in late adulthood.
C- May cause: astigmatism which leads to meridional amblyopia,
D- Appears as a soft yellowish subconjactivl mass
Q10- Acute conjunctivitis includes all of the following except
B- Gonococcal keratoconjunctivitis.          
C- Staph. aureus conjunctivitis,     
D- Strept. pneumonias conjunctivitis
Q11- Regarding neonatal Chlamydia conjunctivitis the following statements are true except:
 A-.It is a common cause of neonatal conjunctivitis,.       .
B- It is a notifiable disease
C- It may be associated with systemic Chlamydia infection:
 D-The infection is transmitted by flise

Q12-Kratopathy in vernal keratoconjuctivitisUvitis includes all of the following 'except:
A-Punctate epithelial erosions      
 B- Shield ulceration.       
C- PlaaueJormation.       
D-Arlt s line
Ql3-Regarding arcus lipidus:
A-If severe, it'may affect vision.
B-lt may indicate a coexisting hypercholcsterolemia.
 C- It rnay need to be treated by .penetrating keratoplasty.
 D- It never occurs in a person under fifty years of age

Q14- Regarding the treatment of bacterial'keratitis all of the following statements are true except;
A- Antibiotics should be used from the start, even before the results of culture and sensitivity.
B-mydriatlcs (e.g. atropine drops) may be used to prevent synechia..
C-TopicaI steroid drops are used from the first day of diagnosis to reduce corned! scarring.
            D- Bandage contact lens can be used to aid healing of the ulcer after it has been sterilize

Ql5-The following are predisposing factors for keratitis except:
A- Contact lens wear.
B- Dry cornea.
C- Decreased corneal sensation,
D-Use of topical antibiotics

Q16-Complications of Keratitis include:
A-. Anterior uveitis
B- Cornea! Perforation
C- Endoplithalmitis. 
D- All of 'the above

Q17- Regarding scleritis and episcleritis all of the following statements are true except:
A- Episcleritis is more common than scleritis.
B-Episcleritis is more benign shan sclcritis
.C-Both episcleritis and scleritis affects vision
 D- Episcleritis is lessassociated with systemic diseases than scleritis

QI8- Regarding the treatment of herpetic keratitis the 'following statements are true except:
A-Primary hepetic infection may be self limiting
 B- Topical acyclovir may be used.
D-Debridement of the epithelial ulcer is useful D-Amoeboid (geographical) ulcer will fonn if topical steroid is not used

Q19- Regarding.fungal keratitis following statements are true except:
A- the patient may have a history of an ocular trauma with organic contamination.
B- Satellite lesion may occur.
C-Uveitis and hypopyon never occur
D-It may be treated with chlorhexidine
Q20- Regarding management of cornea! chemical burn the following statements, are true except:
A-Full ocular examination shoud be done berore treatment
B. Copious irrigation of the eye is essential.   
C. Blanching of the limbal vessels is a poor prognostic sign.
 D. Atropine eye drops may be used, but phenylphrine drops should be avoided.

Q21- Regarding posterior scleritis               
A-Dilopia may occur.                      
B-Retina is never affected.
C- Pain is not a symptom.
D- Vision is usually normal.
Q22- Intraocular pressure (IOP) in a patient anterior uveitis may be:   
A - Normal.        
B- Increased
C- Decrease
D- All of the above

Q23- Clinical features of anterior uveitis is include all of the following except:
A- Photophobia.
B-Painless red eye
C-Inflammatory cells in the aqueous humor.
D-Keratic precipitates.

24- Regarding congenital anomalies of uveal tract all of the following statements are true except:
A-Coloboma is a tissue deficiency that is most common at the superotemporal aspect.
B-Corectopia means that the pupil is ectopic.
C-Polycoria means the presence of multiple pupils
D- Persistent pupillary membrane may present as leukocoria

Q25- In a uveitis patient the following situations necessitate investigations
A- Chronic or recurrent uveitis.
B- Bilateral uveitis,
C- Uveitis associated with systemic findings.
D-All of the above

Q26- The following drugs can be used for treating anterior uveitis  except:
A-Timolol 0.5% eye drops.
B- Atropine eye drops.
C-Pilocarpine eye drops
D-Topical steroid drops.

Q27- Choroiditis may be complicated by the following except;
A-Corneal edema
B-Exudative retinal detachement
C- Macularedema.
D- Retinitis.

Q28- Painful red eye may be any of the following except:
A- Angle closure glaucoma,
B- Acute iritis.
C- Cornea! ulcer,

Q29- All of the following statements about ocular discharge are true except;
A- Purulent in bacterial infections.
B- Mucopurulent in Chlamydial infection.
C- Mucoid in allergic conjunctivitis,
D- Watery in Gonococcal infection.
Q30-Visual Impairment and red eye occur in the following condition
B-Acute iritis
Q31- The most propable diagnosis in a 30 years old male patient known to have ankylosing spondylitis and recently complained of red eye, photophobia and visual impairment is:
A- Angle closure glaucoma.
B-Acute anterior uveitis
C- Subconjunctival hemorrhage.
D- Acute conjunctivitis.

Q32- Sectorial redness in the nasal aspect of the balbar conjunctive could be any of the following diagnoses except:
A- Inflamed pterygium
B-Acute iritis.
C- Nodular episcleritis,
D- Subconjunctival hemorrhage
Q33- Circumcorneal injection may be dueto all of the following except
A- Acute iritis.
B- Angle closure glaucoma,
D-Acute conjuctivitis

Q34-Red eye accompanied by adilated pupil could be seen in:
A-Acute iritis,
B-Angle closure glaucoma

Q35-Red eye accompanied by a small irregular pupil could be seen in:
A-Acute iritis
B-angle closture glaucoma.
C- Keratitis.
D-Acute conjunctivitis.

Q36- The cornea in a patient with conjunctivitis
A-Is normal
B-Stains with fluresceine.
C- Is cloudy
D-none of the above

Q37- The most significant cause of leukocoria in children is;
A- Congenital cataract,
C- Retinopathy of pre maturity,                  .
D- Retinal dysplasia.

Q38- The most common cause of leukocoria in
 A-Congenital cataract. .   
B- Retinoblastoma.         
C- Retinopathy of prematurity.
D-Retinal dysplasia.

Q39- Possible causes for chronic painless visual loss in an elderly patient include all of the following except:
A- Cataract
B-Primary open angle glaucoma
C-Chronic anterior uveitis.       
D- Diabetic maculopathy.

Q40- Possible causes for sudden visual loss include all of the following except:
A ^Retinal detachment.
B- Vitreous hemorrhage
C- Central retinal artery occlusion
D-Secodary open angle glaucoma.

Q41- During accommodation process:
A- Ciliary muscles relax. .    '
B- Zonules become tense.     
C- Crystalline lens jncreases its convexity.
D- Antero-posterior diameter of crystalline lens decreases.

Q42- A patient with cataract may present with the following complaints except:
A- Gradually increasing painless loss of vision. 
C- Change in refractive state.

Q43- Evaluation of retinal function in a patient with dense cataract includes:
A- Light pupillary reaction test.
B- Four quadrants light projection test,
C-Color-discrimination test
D- All of the above

Q44- The most suitable surgical method for congenital cataract is:
A- Intracapsular cataract extraction (ICCE).
B- Extracapsular cataract extraction (ECCE).
C- Phacomulsification.

Q45- The most recent and preferred surgical method for adult cataract Surgery is:
A- Intracapsular cataract extraction (ICCE).  
B-Extracapsular cataract extraction (ECCE).
C- Phacomusificat'ion.
D- Lfenscctomy.

46- Among the following complications of cataract surgery, the most serious is:
B- Astigmatism
C- Surgical hyphema,
D- Cystoid macular edema,

Q47- Causes of proptosis include all of the following except;
A - Orbital cellulitis
B- Thyrotoxicosis.         
C-Congenital glaucoma.
D- Retro bulbar hemorrhage
Q48-Reiters Syndrome includes the following:
B- Urethritis
C-Anterior uveitis.             
 D-All of the above

Q49-Behcet disease includes the following:
A- Recurrent non granulamatous uveitis.
B- Recurrent oral a phrhous ulceration.
C- Genital.ulcerntion.              
D-All of the above.

Q50- Congenital obstruction of the nasolacrimal duct (Congenital dacryocystitis) may be treated with all of the following except:               
A- Topical antibiotics.
B- Frequent massage of the inner canthal region.
C- Probing after six months of age. 
D- Urgent surgery^ immediately after birth.

Q51- Ophthalmic uses of laser include;
A- Retina! detachment surgery,
B- Glaucoma surgery.
C- Refractive surgery.
D- All of the above.

Q52-Causes of orbital cellulitis include:
A- Retained intraorbital foreign body.
B- Extension of infection from a nearby sinus infection, 
C- Following infected orbital surgery
D- All of the above.

Q53- Clinical features of orbital cellulites Include all of the following except;
A- Mild proptosis,
B- Limitation of ocular movements.
C- Swelling and congestion of the lids and conjunctive,
D- Seasonal itching of the eye.

Q54-Complicationsof orbital cellulitis include all of the following except:
A- Cavernous sinus thrombosis.
B- Pan ophthalmitis
D-Angle closure glaucoma.

Q55-In a patient with orbital cellulitis, the following is an early sign of cavernous sinus thrombosis:
A-Increasing fever and rigor.
B- Frozen (Immobile) eye
C- Dilated pupil.
D-Loss of corneal reflex due to corneal insensitivity

Q56- The following statements about retina.are true except
A- Retina is divided into two main layers; outer neurosensory layer and inner retinal pigment epithelium
B-Macula lutae lies in the posterior pole of the retina temporal to the optic disc.  
C- Optic disc is devoid of photoreceptors
D- Fovea contains cones only (no rods).
Q57-One of the following statements about retina is true:
A- Optic disc is the most light- sensitive area in the retina.             
B- Fovea centralis contains rods only.                                              
C-Retinal vein pulsation is normal while retinal arterial pulsation is abnormal.
D- Outer retinal layers are supplied by the central retinal artery,

Q58- The following statements about retinitis are true except:
A- Retinitis  is usually secondary to choroiditis (Chorioreiinitis).
B- Toxocara infection may present itself as a retinal granuloma.
C- Toxoplasma chorioretinitis is usually congenital and may be associated with anterior uveitis
D-Congenital rubella syndrome is due to infection of pregnant lady during her last trimester

Q59- The following statements central retinal vein are true except:
A- Glaucoma may be either a cause or a complication of the disease.
B- DM, hypertension and polycythemia are systemic risk factors that should be looked for.
C-The development of cotton wool spots is a good prognostic sign that occurs more in the non ischemic
D-It presents as a sudden painless loss of vision.

Q60- The following statements about central retinal vein occlusion are true except:
A - Laser retinal photocoagulation is used in treatment.
B- Development of retinal neovascularization is a poor prognostic sign and indicates retinal ischemia,
C-Jt may be complicated by retinal detachment.
D- About ninety percent 90% of patients will lose their vision.

Q61- The following statements about central retinal artery occlusion are true except:
A- It may present as a sudden painless loss of vision.                
B- If associated with pain, high ESR in an elderly patient, then giant cell arteritis should be considered. C-Light pupillary reaction is brisk.       .                                
D- Vision is severely reduced.

Q62- The fallowing statements about central retinal artery  are true except:
A- The patient may be treated as out patient and docs not need hospital admission.
B- Thorough assessment of the cardiovascular system is needed.
C- Retina shows attenuated blood vessels and cotton wool spots.                  
D- .Reducing IOP by i- v. acetazolamide & paracentisis may help to improve perfusion pressure.

Q63- The following statements about age related macular degeneration  are true except
A-central vision is preserved while peripheral (navigational) vision is severely reduced.  
B- Visual impairment is more marked during day time than night time.
C- Wet AMD is characterized by hemorrhage exudate and sub retinal neovascular membrane.
D- It is usually bilateral asymmetrical,                       

Q64- The following statements about retinal detachment are true except;
A-retinal detachment means separation of the retina from the choroid,
B-In rhegmatogenous retinal detachment there is a retinal, break,
C- -Advanced diabetic eye disease and penetrating ocular injury are common causes of fractional RD.
D.- Infra 'ocular inflammation may lead to exudative retinal detachment by damaging RPE barrier,

Q65- The following statement about the management of retinal detachment is true:
A- Tractional R.D. is best treated with pars plana vitrectomy.
B- Cryotherapy and laser therapy are used to reattach the retina.
C- Exudative R.D. Is treatedby treating the cause,
D-AII of the above.

Q66- The following statements about the retinitis pigmentosa are true except;
A- Retinitis pigmentosa affects rods photoreceptors that are present mainly in the retinal periphery.
B- Night blindness is the typical presentation.         
C- Pigmentary retinopathy is characteristic.              
D-Visual field is typically normal.
Q67- Possible ocular findings in retinitis pigmentosa include all of the following except:
A- Posterior subcapsular cataract
B- Cystoid macular oedema.    
D-Retinal detachment

Q68- About retinoblastoma, the following statements are true except:
A- It is the most common primary malignant infra ocular tumour in children.
B- The usual age of presentation is around eighteen months,
C- Most cases are familial with autosomal dominant inheritance.
D- If the condition is bilateral, then all family members must be examined.

Q69- Clinical features of retinoblastoma include the following:       
A- Leukocoria.           
B- Squint.                                             
C- Uveitis.
D- All of the above.

Q70- Ocular complications of diabetes mellitus include the following:
A- Cataract.
B- Glaucoma
C- Diplopia due to Abducent nerve palsy
D- All of the above.

Q71- The following factors favours good prognosis regarding  diabetic retinopathy except
A- Strict metabolic control,
B- Correction of associated hypertension, renal failure and hypercholesterolemia.
C- Smoking and anemia.
D- Short duration of D.M.
Q72- The following statements about stages diabetic retinopathy are true except:
A- Back grount stage is characterized by new vessels formation.
B- Diabetic maculopathy is the most common cause of visual impairment in diabolic patients.
C- In the proliferative stage, new vessels at the disc are more dangerous than new vessels elsewhere.
D- End stage usually needs to be treated with pars plana viterectomy.

Q73- In diabetic retinopathy, Laser photocoagulation is indicated in the following situations except:
A-Presence of microaneurysms scattered all over the retina.
B- Retinal edema within 500 microns from the center of the fovea,
C- Hard exudate within 500 microns from the center of the fovea.
D- New vessels at the disc margin.

Q.74- Dysthyroid ophthalmopathy include all of the following except:
A-Lid lag and lid retraction. 
B-Axial proptosis that may be sever enough to prevent lids closure.
C-Vertical diplopia due to cranial nerve palsy.    
D- Corneal involvement in the form of superior limbic KC.

Q75- Ocular features of anemia include the following:
A- Pale conjunctiva
B- Retinal hemorrhages.             
C- Dilated retinal veins.
 D- All of the above

Q76- Causes of vitreous hemorrhage include:
A- Ocular trauma.
B- Proleferative retinoopathy (e.g. diabetic retinopathy).
C- Blood dyscrasias.
D- A II of the above.

Q77- Regarding vitreous hemorrhage all of the following statements are true except:
A - Subhyaloid hemorrhage is boat shaped and remains unclatted for long time.
B- It is presented with sudden onset of floaters.          
C- Treatment includes bed rest, eye padding and head elevation
D- Early viterectomy(within the first three months) is indicated if VA is less than 6/60.

Q78- Regarding vitreous disease all of the following statements are true except:
A- Asteroid hyalosis occur in elderly and does not need treatment.
B- Synehisis scintillans occur in eyes with old vitreous hemorrhage or uveitis, and is associated with poor vision
C- Muscae vollitantes usually needs to be treated with viterectomy
D- PHPV(Persistent hyperplastic primary vitreous) is usually unilateral.

Q79- Clinical features of optic nerve diseases include all of the following except:
A- Loss of vision,
B- Visual field defect.
C- Diminished light brightness sensitivity
D- Sudden onset of floaters

Q80- AII of the following statements about optic neuritis are true except:
A- Causes include inflammatory or demyelinated lesions.
B- Retrobullbar neuritis is characterized by a normal looking optic disc.
C-Clinical features may include visual impairment with increased body temperature.
D- Treatment should be started oral prednisolone for eleven days.

Q81- All of the following statements about papilledema are true except:
A- Vision is usually poor from the startِِ
B- All cases should be considered as having an intracranial mass unless proved otherwise,
C- Absent retinal venous pulsation is an early sign,
D- Chronic cases may be associated withretinal exudates in the form of macular star

Q82- Causes of optic disc swelling include all of the following except:
A- Open angle, glaucoma,
B- Central retinal vein occlusion.             
C- Malignant hypertension,
D- Ischem'ic optic neuropathy.

Q83-Near reflex involves the following:
A- Accommodation
B- Convergence.              
C- Miosis
D- All of the above.
Q84- Light- near dissociation means:  
A- Light reflex is present but near reflex is absent.
B- Both light reflex and near reflex are absent.
C- Both light reflex and near reflex are present.
D- None of the above.

Q85-Small irregular pupils in both eyes occur in the following condition:
A-Amaurotic pupil.
B-Argyll Robertson pupil.
C- Holmes-Adie pupil
D- Homer's syndrome,
Q86- Unilateral dilated pupil occur in the following condition:
A- Amaurotic pupil..  
B-Argyll Robertson pupil.
C- Holmes-Adie pupil.
D- Homer's syndrome.

Q87- Homer syndrome includes the following findings:
A- Mild ptosis.
 B- Miasis.
C- Heterochromia in congenital cases.
D- All of the above.

Q88- Causes of Homer syndrome include:
A- Pancoast tumour of the lung.
B- Carotid artery aneurysm.
C- Brain -stem demyelination.
D- All of the above.

Q89- One of the following statements about myasthenia gravis is true:
A- Ocular involvement is commonly found, but rarely a presenting symptom,
B- Cocaine 4% test is useful for diagnosis and localization,
C- Ptosis in myasthenia is most sever in the morning but improves with. the end of the day.
D-Long acting anticholine esterase drugs are used for the treatment.

Q90- the following signs are present in Qculomotor nerve palsy except:
A - Ptosis.                                 
B-Dilated pupil in medical cause like diabetic mellitus,
C- Divergent eye,                     
D- Weak accommodation.

Q9l- Involuntary rhythmic to and fro oscillatory movement of the eyes is called:
A- Strabismus.      
B- Nystagmus.                                             
C- Amblyopia.              
D- Diplopia.              

Q92- Ocular misalignment so that the image of an object does not fall on the both foveas simultaneously is,
A- Strabismus.      
B- Nystagmus.              
C- Amblyopia.   
D- Diplopia.
Q93-In pseudosquint:                                 
A- Corneal light reflection test is normal but cover test is abnormal.   
B- Wide interpupillary distance due to Hypertelorism will present as pseudoesotropia.
C- Retinal examination is not necessary.  
D- Prominent epicanthal fold is a common cause that may disappear or lessen with age.         

Q94- Convergent squint in a two years old child can be due to any of the following except:
A-Abducent palsy.               
B- Accomodative esotrapia.
C- Oculomotor palsy.                   
D- Essential esotropia.
                                    ...        •        . '
Q95- Comparing between accornmodative esotropia and essential esotropia, only one statement is-true:
A- Essential esotropia usually starts at the age of three years,
B- Accomodative esotropia is usually associated with a high hypermetropia.    
C- Essential esotropia is best treated with glasses.
D- Accommodative esotropia must be treated with urgent surgery.

Q96-The following statements are true regarding intermittent eyotropi'a except:
A-The angle of deviation varies with different.directions of gaze.
B-Usually associated with myopia.    
C- Triggered by fatigue, inattention or emotional upset.         
D- Initially treated with full myopic glass correction and observation:

Q97- The following statements are true in the treatment of strabismus except
A- Full cycloplegic correction of refractive error.
B- Treatment of amblyopia by occlusion of the better seeing eye.
C- Extra ocular muscle surgery to restore alignment if glasses fail.      
D- All of the above
Q98- The most propable diagnosis in a sixty years old man with a dome shaped pigmented subretinal lesion is:
A- Retinoblasiotna.
B- Choroidal melanoma.
C- Rhabdomyosarcoma.
D- Persistent hyperplastic primary vitreous,
Q99- In Simple myopic astigmatism :     
A- There is tendency for Eso deviation.
B- Two images are formed, one on the retina and the second is from of the retina.
C- Vision is corrected by spherical concave lenses.
D- There is high incidence of retinal detachment.    

Q100- Regarding cup: disc ratio (CDR), one statement is true:
A- It should be 0.3 and less.                        
B- It should be 0.3 and more,
C- Asymmetry in the cups between the two eyes is a normal finding.
 D- It is not a. useful remark in the follow up of glaucoma patients.

Ql0l- All of the followings are risk factors for development of primary angle closure glaucoma (PACG) except:          
A- Age above sixty years,             
B- Male gender,   
C- Caucasian racial group.                  
D- Positive family history

Q102- The initial treatment of choice for primary open angle glaucoma-(POAG) is:
A- Topical anti glaucoma medication.                                          
B- Laser trabeculoplasty
C- Traheailotomy
D- None of the above

Q103- One of the followings is not a feature of congenital glaucoma:
A- Cornea! haze.
B- Buphthalmos.
C- Break in Descent membrane.
D- Iris neovascularization.

Q104- One of the following anti glaucoma groups is used to enhance the uveoscleral outflow:
A- Beta adrenergic antagonists.           
B- Carbonic anhydrase inhibitors.
C- Prostaglandins.
D- Miotics.

Q105- Timolol eye drop is contraindicated in the following situations except:
A- Bronchial asthma.           
B- Renal stones
C- Third degree heart block.
D- Heart failure.

Q106-The following tonometers depends on the principle of indentation:
A- Schiotz.    
B- Perkins
C- Tonopen                        
D- Goldmann

Q107- Risk factors for the development of primary open angle glaucoma include the following except:
A- Age above sixty years,
B- Positive family history,
C- Hypermetropia.
D- Black race,
Q108- causes of neovascular (mbeotic) glaucoma include the following except:
A- Lens induced glaucoma.
B- Diabetic retinopathy.
C- Central retinal vein occlusion.
D-Ocular ischemic syndrome.

Q109- A middle aged man is presented wish poor vision following a blunt ocular trauma. He has a normal looking fundus and a hypermetropic refraction of about eleven diopters (+11) but no history of wearing
glasses previously. The most likely diagnosis is:
A-Traumatic cataract
B-Traumatic lens dislocation
C- ingle recession glaucoma
 D-Rhegmutogenous retinal detachment
Q110- Regarding the cornea all of the following statements are true except:
A- The cornea acts as a convex lens that changes its power during accommodation process,
B- It has an endothelial monolayer that maintains cornea! relative dehydration.
C-The stroma forms the majority of the corneal thickness.
D- The corneal epithelium is stratified squamous but in contrast to the skin, it is non keratinized.

Q111-Regarding congenital anomalies of the lid:
A- Epicanthal folds are usually unilateral,
B- Cryptophthalmos is a fold of skin that crosses nasal aspect of the palpebral fissure.
C-In Distichiasis an extra row of cilia is present.
D- Ablepharon is a common congnital defect.

Q112- Keratitis due to hypersensitivity (immune) reaction includes all of the following except:
A- Interstitial keratitis.       
 B- Marginal corneal ulcer in a patient with staplylococcal blepharitis.
C- Neurotroplic ulcer
D- Phlyctenular keratoconjuctivitis.

Q113- The following micro organisms can penetrate an intact corneal epithelium except:
A- Corynaebacterium diphtheriae.
B- Gonococci.
C- Chlamydia trachomatis,
D- Streptococci.

Q114- Causes of conjunctival pseudo membrane include all of the following except:
A-Severe adenoviral infection.
B- Gonococcus infection.
C- Steven - Johnson syndrome,
D- Molluscum contagiosum.
Q115- Regarding Trachoma all of the following statements are true except:
A- Corneal opacity is the end stage of the disease process.
B- It is caused by sero types A, B& C.                          
C- It is a disease of poor condition of hygiene.     
D- Treatment is by a single dose of metronidazole with strict personal hygiene

Q116- Conjunctival melanoma may arise from all of the following except:
A- Primary acquired melanosh (PAM) with atypia,
B- Pre-existing nevus.
C- Prlmary acquired melanosis (PAM) without atypia.
D-It may arise de novo.  

Q117- Red eye accompanied by a cornea! lesion (hat stains with fluorcsccin could he seen in:
 A-Acute iritis
B-Angle closure glaucoma,
C- Keratitis
 D- Acute conjunctivitis.
Q118- Uses of slit lamp:       
A- Measurement of IOP by Gold mann tonometer,
B- Minor surgical procedures like corneal.foreign body removal.
C- Laser delivery to the eye,     
D- All of the above

Q119- Uses of direct ophthalmoscope include the following except:
A- Examination of the anterior segment. 
B- Examination of the posterior segment
C- Laser delivery to the eye.     
D- Visuoscopy

Q120- Fluorescein stain:       
A - Its use is totally free from any risk of infection.
B- Pink in colur
C- Stains both epithelial defects and normal epithelial cells.
D- May be used in tonometry