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Question 1 of 130
A 27-year-old woman has had a sudden onset of a dark area inferior to fixation in the left eye earlier in the day. Examination
reveals a visual acuity of 20/20 in each eye and an area of retinal whitening that corresponds to a branch coming from the
superotemporal retinal artery. Which of the following is least likely to be associated with this condition?
A history of migraine
Question 2 of 130
In which of the following quadrants are retinal dialyses most often found following blunt trauma?
Inferotemporal, superonasal
Superonasal, inferonasal
Superotemporal, superonasal
Inferotemporal, superotemporal
Please select an answer
Feedback: Blunt trauma may result in a variety of retinal breaks including retinal dialyses, macular holes, giant retinal tears,
horseshoe retinal tears, operculated retinal tears, and large, necrotic, sometimes posterior retinal breaks often associated
with chorioretinitis sclopetaria. Retinal dialyses, however, are the most common retinal breaks found following blunt ocular
trauma. Retinal dialyses resulting from blunt trauma are most often found in the inferotemporal and superonasal quadrants.
All patients with a history of blunt trauma need to be given a careful retinal examination with scleral depression to look for
retinal breaks after their pain, iritis, or hyphema, if any, has resolved.
Question 3 of 130
Which of the following statements is least accurate regarding acquired color vision defects?
Acquired color vision defects may result from macular or optic nerve disease.
The Farnsworth-Munsell 100-hue test may be used to detect discrimination loss in patients with acquired color vision
defects.
Pseudoisochromatic plates may not be reliably used to detect acquired color vision defects.
Please select an answer
Feedback: Acquired color vision defects may occur as the result of optic nerve or retinal disease that may or may not be
hereditary. Acquired color vision defects are variable, producing mild to severe color defects of variable types. Fluid in or
under the macula more often affects the blue-yellow (tritan) axis than the red-green axis. Degenerative retinal conditions
such as Stargardt's disease often produce a red-green defect. Optic nerve disease, such as Leber's hereditary optic atrophy,
tends to affect the red-green axis more than the blue-yellow axis. Pseudoisochromatic plates are helpful in screening for X-
linked color vision defects, but are not reliable in detecting acquired color defects. Sensitive tests of color discrimination,
such as the Farnsworth-Munselll 100-hue test, may be the best for detecting variable and sometimes mild acquired color
defects.
Question 4 of 130
According to the Early Treatment Diabetic Retinopathy Study (ETDRS), which of the following clinical findings is not used to
determine if a patient has very severe nonproliferative (preproliferative) diabetic retinopathy?
Those with hemoglobin C and Sickle thalassemia have the most serious ocular complications.
"Salmon-patch" lesions, "black-sunburst" lesions, and "sea fans" are all signs of proliferative sickle cell retinopathy.
Please select an answer
Feedback: Approximately 10% of North American blacks of Central and West African origin have abnormal hemoglobin:
approximately 8% to 9% have AS hemoglobin, 0.4%, SS disease, 0.1% to 3% SC disease, and 0.5% to 1.0% S
thalassemia. Salmon-patch and iridescent spot lesions are due to intraretinal hemorrhages, while black-sunburst lesions are
due to subretinal hemorrhage and arise from hyperplasia of the retinal pigment epithelium. Sea fans are fronds of
neovascularization that extend from the retina into the vitreous and are therefore signs of proliferative retinopathy. A
prospective clinical trial has demonstrated the efficacy of argon laser scatter photocoagulation therapy for proliferative sickle
cell retinopathy. Prolonged loss of visual acuity and vitreous hemorrhage were reduced in treated eyes compared with
controls. Scatter photocoagulation proved to be effective and safe in the treatment of patients with sea-fan
neovascularization.
Question 6 of 130
Within several hours of an accident, you see a 23-year-old farmer who injured his right eye while hammering on a bearing.
His visual acuity is 20/200 OD and 20/20 OS, and he has a definite relative afferent pupillary defect. His anterior segment is
clear, except for some cells and flare in the anterior chamber. A vitreous haze obscures fine details of the posterior pole;
however, you see sheathing of some of the peripheral retinal vessels. The management of endophthalmitis in this situation
should not include which of the following strategies?
Echography and/or CT scan for identification and localization of an intraocular foreign body
The nuclear material need not be surgically removed immediately; resultant inflammation or increased intraocular
pressure may be managed medically.
The cataract surgeon should attempt to irrigate the lens fragments from the anterior vitreous if they are visible.
Removal of the lens fragment by a vitreoretinal surgeon may be indicated, depending on its size, the resultant
inflammation, and intraocular pressure control.
Question 8 of 130
Which type of hemoglobinopathy puts a patient most at risk for developing proliferative retinopathy?
SS
AC
AS
SC
Please select an answer
Feedback: Normal hemoglobin is referred to as "A," with amino acid substitutions producing either "S" (sickle hemoglobin)
or "C," and inadequate globin chain synthesis producing "Thal" (thalassemia). Patients homozygous for S hemoglobin have
sickle-cell anemia and manifest severe systemic complications from this hemoglobinopathy; rarely, however, do they have
proliferative retinopathy. Patients who are heterozygous for one of the sickle hemoglobins (AS or AC) generally have a more
benign systemic course and also occasionally, but rarely, have retinopathy. Patients who are heterozygous for two abnormal
hemoglobins (SC or SThal) tend to have mild anemia and a benign systemic course compared to patients with sickle-cell
disease; however, they are most likely to develop proliferative retinopathy.
Question 10 of 130
Which of the following statements does not accurately describe routine evaluation of patients with diabetes mellitus?
Pregnant diabetic women should be examined in the first trimester and, at a minimum, every 3 months thereafter.
Newly diagnosed diabetics under the age of 30 should have their first ophthalmologic examination within 5 years of the
onset of their disease.
Newly diagnosed diabetics 31 years of age or older should have their first ophthalmologic examination at the time of
diagnosis.
Routine follow-up of a diabetic under the age of 30 should take place every 2 years at a minimum, if there has been no
evidence of diabetic retinopathy to date.
Please select an answer
Feedback: Studies have demonstrated a relationship between the prevalence and severity of diabetic retinopathy and the
duration of diabetes mellitus. In patients diagnosed with diabetes up to the age of 30, diabetic retinopathy was detected in
18% of patients having the disease for 3-4 years, but increased to 80% in patients who had been diabetic for 15 years or
more. Significant retinopathy, however, rarely develops prior to puberty; and in patients between 10 and 30 years of age, it
usually is not seen until the patient has diabetes for 6-7 years. Therefore, most young-onset diabetics who develop
significant retinopathy will have the retinopathy discovered if their initial ophthalmic examination is within 5 years of their
being diagnosed with diabetes. In diabetics diagnosed after age 30, significant retinopathy has been found in 3% of patients
at the time of diagnosis; therefore, an initial examination should be performed on diagnosis of the diabetes mellitus and
annually thereafter. Diabetic retinopathy can progress rapidly during pregnancy; therefore, pregnant diabetic women need to
be followed carefully, with examinations performed in the first trimester and, at a minimum, every 3 months until delivery.
Question 11 of 130
Which of the following is not an indication for immediate or early pars plana vitrectomy in a penetrating injury?
Vitreous incarceration in a posterior scleral wound that cannot be closed by an external approach
Early endophthalmitis
Retinal break(s) should be located within the superior two-thirds of the fundus.
Aphakic or pseudophakic patients have the same rate of success with pneumatic retinopexy as phakic patients.
Patients with proliferative vitreoretinopathy (PVR) grade C or higher or severe glaucoma should not be considered
candidates for pneumatic retinopexy.
Question 13 of 130
In the evaluation and treatment of diabetic retinopathy, what is fluorescein angiography least useful for?
Determining the presence of clinically significant diabetic macular edema prior to recommending photocoagulation
Determining the location of diffuse retinal leakage from incompetent retinal capillaries or intraretinal microvascular
abnormalities prior to photocoagulation
Please select an answer
Feedback: The Early Treatment Diabetic Retinopathy Study defined clinically significant diabetic macular edema by
biomicroscopic examination of the macula, and not by fluorescein angiography. Therefore, recommendations for
photocoagulation should be based on biomicroscopic determination of: (1) retinal thickening at or within 500 microns of the
center of the fovea; (2) hard exudate at or within 500 microns of the center of the fovea, if associated with thickening of
adjacent retina; or (3) a zone or zones of retinal thickening 1 disc area or larger, any part of which is within 1 disc diameter
of the center of the fovea. Fluorescein angiography may be useful in evaluating the presence and location of capillary
closure, particularly when there is clinically unexplainable visual loss. Fluorescein angiography is also useful prior to
photocoagulation to determine the location of leaking retinal microaneurysms or areas of diffuse retinal leakage that require
treatment.
Question 14 of 130
A vitreous biopsy of a 66-year-old patient demonstrates cryptococcal organisms on fungal stain and culture. Which of the
following statements does not accurately describe endogenous ocular cryptococcal infections?
Ocular involvement frequently is the result of direct extension along the optic nerve or by hematogenous spread.
Question 15 of 130
A 60-year-old man presents with a 3-day history of photopsias and new floaters in his left eye. His visual acuity is 20/20 OU.
Slit-lamp examination shows mild nuclear sclerosis and clear anterior vitreous bilaterally. On fundus examination, a posterior
vitreous detachment (PVD) is seen only in the left eye. Which of the following statements best describes this situation?
Myopia, diabetic retinopathy, vitreous hemorrhage, and surgical aphakia all predispose the patient to vitreous
detachment at an earlier age.
If hemorrhage or pigment granules are not present in the vitreous, depressed examination of the peripheral retina is
not necessary.
Approximately 15% of patients who present with acute, symptomatic PVD will have a retinal tear.
In the majority of cases, when the fellow eye develops a PVD it will likely respond in the same way (ie, symptoms,
complications) as the first eye did upon developing PVD.
Please select an answer
Feedback: Symptomatic PVD is characterized by photopsias and/or floaters, symptoms that may also occur with the
development of a retinal tear. Since approximately 15% of patients presenting with an acute, symptomatic PVD will have a
retinal tear, all such patients should have a dilated examination of the peripheral retina with indirect ophthalmoscopy and
scleral depression to look for peripheral retinal breaks. The presence of hemorrhage or pigment (Shafer's sign) in the
vitreous correlates highly with the presence of a retinal break. However, absence of Shafer's sign does not negate the need
for careful examination of the peripheral retina. Posterior vitreous detachment is more common with increasing age, but
myopia, vitreous hemorrhage, surgical aphakia, and diabetic retinopathy, particularly following panretinal photocoagulation,
all have been associated with the development of posterior vitreous detachment at an earlier age. Fellow eyes of patients
who have developed a PVD in one eye most often follow a similar course (symptoms, complications) when a PVD develops.
Question 16 of 130
Which of the following statements does not accurately describe central retinal artery occlusion?
Emboli more commonly cause retinal arterial occlusions than thrombosis or vascular narrowing from atherosclerosis.
Long-term survival is decreased in patients who have had retinal artery occlusions.
Please select an answer
Feedback: Retinal arterial occlusions may occur from many causes including embolism, thrombosis, or narrowing from
atherosclerosis, vasculitis, arterial spasm as in migraine, and extravascular compression. Of the many potential causes,
emboli originating from the carotid arteries are the most common cause of retinal artery occlusion. Multiple reports have
noted decreased life expectancy for patients with retinal artery obstructions. Since the central retinal artery supplies the
inner retina, the B-wave is diminished on the electroretinogram. Iris neovascularization and neovascular glaucoma occur
infrequently (approximately 5%) following central retinal artery occlusion. The development of iris neovascularization may
not always be the direct result of the retinal artery occlusion, since significant carotid artery narrowing has frequently been
noted on the ipsilateral side.
Question 17 of 130
A 32-year-old man presents without complaints for routine examination. On indirect ophthalmoscopy, multiple patches of
peripheral lattice degeneration containing multiple atrophic retinal holes are noted in the superior retina OD. Lattice
degeneration without retinal breaks is noted inferiorly OS. Which of the following statements regarding prophylactic
treatment is most correct?
Both of the patient's eyes should be prophylactically treated with laser photocoagulation or cryoretinopexy.
Only the patient's right eye should be prophylactically treated with laser photocoagulation or cryoretinopexy.
If there is a prior history of retinal detachment in the left eye, prophylactic laser photocoagulation or cryoretinopexy
should be considered in the right eye.
The patient's right eye should receive prophylactic treatment with laser photocoagulation or cryoretinopexy prior to
cataract surgery.
Please select an answer
Feedback: Lattice degeneration occurs in 6% to 8% of the population, with 20% to 30% of patients with lattice degeneration
also having coexisting retinal holes. The decision to treat prophylactically is based on the risk of developing a retinal
detachment without treatment, how much the treatment will reduce the risk of retinal detachment, and the risks of treatment.
The rate of retinal detachment in eyes with lattice degeneration has been estimated to be less than 1%. Retinal breaks
following cataract surgery are less likely to be associated with lattice degeneration than with the development of new flap
tears. There are no studies documenting the value of prophylactic treatment in eyes with lattice degeneration except in the
fellow phakic eyes with lattice degeneration of previous retinal detachment patients. In untreated eyes, a 2.5 times greater
risk (1.8% vs 5%) of a new tear or detachment was found than in treated eyes.
Question 18 of 130
A 24-year-old man with a 10-year history of insulin-dependent diabetes mellitus presents with a visual acuity of 20/25 OD
and 20/200 OS. Examination of the macula in the right eye demonstrates hard exudates and retinal thickening within 500
microns of the foveal center. A small area of flat retinal neovascularization is present in the right eye off the superotemporal
arcade. The vitreous in the right eye is clear. Examination of the left eye demonstrates diffuse retinal thickening throughout
the macula, scattered hard exudates, and blot hemorrhages. Marked neovascularization of the disc is present in the left eye,
as well as nasal retinal neovascularization with mild vitreous hemorrhage. What is the best sequence of photocoagulation
treatment for this patient?
Question 19 of 130
The Diabetes Control and Complications Trial was a multicenter, randomized clinical trial in which insulin-dependent diabetic
patients with either no retinopathy, or mild to moderate nonproliferative retinopathy, were treated either with conventional
insulin therapy, or intensive insulin therapy, that consisted of either three or more insulin injections daily, or an insulin pump.
Which of the following statements does not accurately describe the findings of this trial?
No transient early worsening of retinopathy with intensive insulin therapy was noted in patients with mild to moderate
retinopathy, as reported in previous trials.
In patients with mild to moderate nonproliferative retinopathy, intensive therapy reduced the development of
proliferative or severe nonproliferative retinopathy by 47%, compared to conventional insulin therapy.
In patients initially without retinopathy, intensive insulin therapy reduced the risk of onset of retinopathy by 76%
compared to patients in the conventional therapy group.
In patients initially with mild to moderate nonproliferative retinopathy, intensive insulin therapy slowed the progression
of retinopathy by 54%, compared to patients in the conventional therapy group.
Please select an answer
Feedback: The Diabetes Control and Complications Trial demonstrated that intensive insulin therapy that maintained serum
glucose at much tighter, lower levels than conventional therapy: (1) reduced the risk of development of retinopathy in
patients without retinopathy by 76%; (2) reduced the risk of development of proliferative or severe nonproliferative
retinopathy in patients with mild to moderate nonproliferative retinopathy by 47%; and (3) slowed the progression of
retinopathy by 54% in patients with mild to moderate nonproliferative retinopathy. With intensive therapy, however, patients
with mild to moderate retinopathy often experienced a transient worsening of their retinopathy over the first year of
treatment. Ultimately, these patients demonstrated a significant reduction in the risk of progression of their retinopathy, the
development of proliferative or severe nonproliferative retinopathy, or the need for photocoagulation, as compared to
patients treated with conventional therapy.
Question 20 of 130
Which of the following statements about peripheral uveitis is least likely?
The most common causes of reduction in visual acuity in peripheral uveitis are cystoid macular edema and vitreous
debris.
An indication for initiating treatment for peripheral uveitis is a reduction in visual acuity to less than 20/25.
Lyme disease, Fuchs' heterochromic cyclitis, Toxocara canis, toxoplasmosis, and retinoblastoma are included in the
differential diagnosis of peripheral uveitis.
Please select an answer
Feedback: Peripheral uveitis (formerly called pars planitis) is a panuveitis that most commonly occurs bilaterally in patients
under age 30. Symptoms most frequently include floaters and painless decrease in vision. Characteristic ocular findings
include pars planaora serrata exudate (snowbank), vitreous debris, posterior subcapsular cataract, cystoid macular edema,
optic disc edema, and retinal vasculitis. Less commonly, retinal neovascularization, peripheral angiomalike lesions, and
tractionallrhegmatogenous retinal detachment may develop. Decrease in visual acuity most commonly occurs as the result
of either vitreous debris or cystoid macular edema. Fluorescein angiography may demonstrate cystoid macular edema, optic
nerve papillitis, and retinal vascular staining. There are no diagnostic tests specific for peripheral uveitis; diagnosis is based
on the clinical appearance and the exclusion of other diagnoses. Other ocular inflammatory conditions involving the anterior
and posterior segments that present without pain or injection should be considered, including Lyme disease, Fuchs'
heterochromic cyclitis, Toxocara canis, juvenile rheumatoid arthritis, and toxoplasmosis. In younger children, retinoblastoma
must also be considered in the differential diagnosis. Initial therapeutic intervention with corticosteroids is started if visual
acuity decreases below 20/40, but earlier therapy may be considered in certain clinical situations.
Question 21 of 130
Which of the following constitutes a pertinent clinical feature of neovascular AMD?
Drusen
Subretinal fluid
Acute iridocyclitis
Cataract
Question 23 of 130
Epiretinal membrane is most commonly associated with which one of the following conditions?
Uveitis
Trauma
Question 24 of 130
What are the characteristics of a stage-3 macular hole?
Full-thickness hole greater than 400 microns in diameter, with or without a cuff of subretinal fluid with a total posterior
vitreous detachment (PVD), with or without an operculum
Full-thickness hole greater than 400 microns in diameter, with or without a cuff of subretinal fluid
Please select an answer
Feedback: A stage-3 macular hole is a full-thickness hole greater than 400 microns in diameter, with or without a cuff of
subretinal fluid. A stage-1 hole is characterized by a deep foveal yellow spot or ring. A stage-2 hole is a full-thickness hole
less than 400 microns in diameter. A stage-4 hole is a full-thickness hole greater than 400 microns in diameter, with or
without a cuff of subretinal fluid with a total posterior vitreous detachment (PVD), with or without an operculum.
Question 25 of 130
Which one of the following represents the most significant risk factor for the development of diabetic retinopathy?
Systemic hypertension
Hyperlipidemia
Question 26 of 130
Which one of the following epidemiologic factors is most closely associated with central retinal arteriolar occlusion?
Male gender
Pulmonary fibrosis
Thrombocytopenia
Please select an answer
Feedback: Male gender is an epidemiologic factor closely associated with central retinal arteriolar occlusion. This condition
occurs most commonly in the seventh decade of life. There is no known association between central retinal arteriolar
occlusion, and thrombocytopenia or pulmonary fibrosis.
Question 27 of 130
Which of the following is a risk factor for idiopathic central serous chorioretinopathy?
Anticoagulant use
Coexisting cancer
Pregnancy
Female gender
Please select an answer
Feedback: Idiopathic central serous chorioretinopathy has been associated with pregnancy. Additional associations include
lupus, organ transplantation, hemodialysis, and corticosteroid use. The disorder is more common in men. There is no known
association with coexisting cancer or anticoagulant use.
Question 28 of 130
What is the most common etiology of the vitreomacular traction syndrome?
Inflammatory disease
Idiopathic
Metabolic disease
Vascular occlusion
Please select an answer
Feedback: The vitreomacular traction syndrome represents persistent vitreous macular and/or peripapillary traction in an
eye with a partial posterior vitreous detachment. This condition is most commonly idiopathic. It may also be associated with
inflammatory diseases, vascular occlusions, and metabolic diseases. It is most prevalent in patients more than 60 years old.
Question 29 of 130
Branch retinal venous occlusion is most commonly associated with which systemic disease?
Osteoarthritis
Hypothyroidism
Diabetes insipidus
Arterial hypertension
Please select an answer
Feedback: Risk factors for branch retinal venous occlusion include diabetes mellitus, hypertension, hyperlipidemia, and
primary open angle glaucoma. Branch retinal venous occlusion is most commonly associated with systemic hypertension.
Question 30 of 130
Pattern macular dystrophies typically present in which period of life?
3rd decade
2nd decade
1st decade
4th decade
Please select an answer
Feedback: Pattern macular dystrophies typically present in the 4th to 6th decade of life. This, along with their commonly
autosomal dominant inheritance, differentiates these disorders from other macular dystrophies and degenerations.
Question 31 of 130
Which one of the following patient characteristics is associated with the increased quality of fluorescein angiographic
images?
Question 32 of 130
Which one of the following is included in first-line therapy for macular-threatening toxoplasmosis chorioretinitis?
Oral antibiotics
Topical cycloplegics
Topical antibiotics
Intravenous antibiotics
Please select an answer
Feedback: First-line therapy for macular-threatening toxoplasmosis chorioretinitis includes oral antibiotics, including
sulfadiazine, primethamine, and folinic acid. Peripheral lesions may be treated with clindamycin or Bactrim. Oral steroids
may be used as an adjuct, but only 24 hours after starting antibiotics. Topical antibiotics and IV antibiotics have no role in
toxoplasmosis therapy. Topical cycloplegics are typically not necessary.
Question 33 of 130
What is the presumed cause of venous obstruction in branch retinal vein occlusion?
Embolism
Pregnancy
Please select an answer
Feedback: There is no evidence that intravenous administration of flurescein has an adverse effect on the developing fetus,
but traditionally fluorescein angiography is avoided in pregnant women.
Question 35 of 130
When performing cataract extraction surgery, what are the signs of expulsive choroidal hemorrhage?
Hypopyon
Floppy iris
Please select an answer
Feedback: Expulsive choroidal hemorrhage is one of the most devastating acute complications of intraocular surgery. It is
caused by prolonged ocular hypotension, which causes rupture of a choroidal vessel, and allows suprachoroidal
hemorrhage to go unchecked. As the hemorrhage expands quickly, the intraocular contents may begin to extrude, resulting
in wound gape, vitreous presentation, and iris prolapse.
Question 36 of 130
Which of the following interventions is the most appropriate management following fluorescein angiography?
Administer aspirin
Presence of drusen
Please select an answer
Feedback: When evaluating a choroidal nevus, the presence of subretinal fluid, hemorrhage, orange pigmentation, and
thickness greater than 3 mm should increase suspicion for malignant transformation to choroidal melanoma. Presence of
drusen on the lesion is a reassuring sign of chronicity.
Question 38 of 130
A 42-year-old woman from Mexico, who has two pet cats, presents with a yellow-white lesion in the macula with overlying
vitritis. Adjacent to the lesion is a pigmented retinal scar. Visual acuity in the affected eye is 20/80. What is the most
appropriate intervention?
Question 40 of 130
Which of the following conditions is typically associated with dense vitritis?
Sarcoidosis
Toxoplasmosis
Please select an answer
Feedback: Toxoplasmosis typically presents as vascular sheathing and retinal necrosis, often adjacent to an old scar, with a
dense vitritis. Sometimes the vitritis is so dense that is resembles a "headlight in the fog". Sarcoidosis and PIC typically have
little, if any, vitritis. ARN may present with vitritis, but it is typically not as dense as that which accompanies toxoplasmosis.
Question 41 of 130
Late onset complications (> 6 weeks) of scleral buckle procedures includes which of the following?
Retinal incarceration
Buckle extrusion
Choroidal neovascularization
Choroidal detachment
Please select an answer
Feedback: Buckle extrusion is an uncommon complication of scleral buckle procedure. It may be accompanied by pain,
bleeding, and infection. Treatment is to remove or modify the buckle. Retinal incarceration and choroidal detachment are
early complications of scleral buckle procedure. Choroidal neovascularization is not a complication of scleral buckle
procedure.
Question 42 of 130
The technique of fluorescein angiography includes which of the following procedures?
Question 43 of 130
On routine ophthalmoscopic examination, a 62-year-old woman is noted to have asymptomatic, bilateral, smooth peripheral
elevations in the inferotemporal retina that extend slightly posterior to the equator. Visual acuity is 20/20 OU. Which of the
following statements best relates to this situation?
Laser demarcation along the posterior border of these lesions will prevent extension into the macula.
Retinal detachment frequently occurs in such a case if an inner layer retinal break is present.
Retinal detachment will not occur unless a retinal break is present in the outer layer or full thickness retina.
Please select an answer
Feedback: Senile, or acquired, retinoschisis is present in up to 4% of normal patients over age 40. This frequently bilateral
condition typically develops from a splitting of the outer plexiform layer in the peripheral retina. Smooth, tense, peripheral
retinal elevations develop, most commonly in the inferotemporal quadrant, although less frequently other quadrants may be
involved. Retinal breaks may develop in either or both the inner or outer retinal layers, or the adjacent full thickness retina.
Retinal detachments associated with retinoschisis occur infrequently, but may develop when either an outer layer retinal
break alone or both inner and outer layer retinal breaks are present. Retinal detachments associated with senile
retinoschisis are rare and typically progress slowly; therefore, outer layer breaks may not routinely require prophylactic
treatment. Retinal cryotherapy, or scatter photocoagulation, may be used over the area of retinoschisis and outer layer
retinal hole formation if the detachment progresses. Typically, senile retinoschisis does not progress posteriorly. Attempts to
demarcate the area of retinoschisis by laser photocoagulation will not prevent posterior extension. Unlike in juvenile
retinoschisis, macular function remains normal.
Question 44 of 130
In a patient with postoperative, appositional choroidal effusion or hemorrhage following cataract surgery, which of the
following diagnostic tests is most useful?
Fluorescein angiography
B-scan ultrasonography
Please select an answer
Feedback: In a patient with postoperative, appositional choroidal effusion or hemorrhage following cataract surgery, B-scan
ultrasonography is often helpful, and sometimes essential in making the diagnosis. Fluorescein angiography, optical
coherence tomography, and transillumination of the sclera are rarely helpful.
Question 45 of 130
The parents of a 2-year-old girl report that she has had "bobbing eyes" and light sensitivity since birth. In your office, the girl
shows good visual attention, but has bilateral pendular nystagmus and squints in bright light. The retina appears normal, but
the foveal reflex is blunted. Dark-adapted scotopic electroretinogram (ERG) responses are normal, but light-adapted
photopic signals are greatly diminished. No relatives are similarly affected. What condition does this patient most likely
have?
Achromatopsia
Stargardt's disease
Please select an answer
Feedback: The early onset of photophobia and nystagmus point to a congenital cone dysfunction. The loss of photopic ERG
response, including photopic flicker response, and the patient's essentially normal rod function confirm the generalized cone
abnormality. While CSNB can reduce acuity and cause nystagmus, the congenital loss of night vision from rod system
abnormalities would cause an abnormal scotopic ERG. CSNB is frequently an X-linked recessive trait that affects males. In
Leber's congenital amaurosis, overall vision is very limited, because of generalized retinal dysfunction that causes loss of
both rod and cone ERG responses. Stargardt's disease becomes evident during the grade school and teenage years and
typically shows a nearly normal rod and cone ERG. Achromatopsia causes total color blindness from a congenital absence
of cone photoreceptors. It is autosomal recessive and rarely affects more than the current generation. Ultimate acuity ranges
from 20/100 to 20/200 and is best in dimmer light or with sunglasses.
Question 46 of 130
Which of the following statements does not accurately describe the use of indirect ophthalmoscopy to screen for retinopathy
of prematurity?
Screening should be repeated biweekly on neonates who demonstrate retinopathy of prematurity on the initial
examination.
Screening should be performed on all premature neonates with a birth weight of less than 1300g.
Screening should be performed on all premature neonates of less than 30 weeks gestation.
Please select an answer
Feedback: Multiple risk factors have been associated with the development of retinopathy of prematurity in premature
neonates, including low birth weight, low gestational age, oxygen therapy apnea, sepsis, and others. Premature infants with
a birth weight of 1300g or less, of gestational age of 30 weeks or less, or who require supplemental oxygen, are particularly
at greater risk of developing retinopathy of prematurity. Initial examination of the peripheral retina by indirect
ophthalmoscopy in these neonates is recommended prior to hospital discharge, or by 4 to 6 weeks of age. Repeat retinal
examinations are performed every 2 weeks until the retina becomes fully vascularized, or retinopathy of prematurity is noted.
If retinopathy of prematurity develops, weekly examinations should be performed to watch for possible progression to
threshold disease.
Question 47 of 130
The early manifestations of idiopathic juxtafoveolar retinal telangiectasis does not include which of the following?
Asymmetric presentation
Please select an answer
Feedback: Many patients with idiopathic juxtafoveolar retinal telangiectasis present with symptoms in one eye only. The
early angiographic findings reveal late staining of the retina, often in an oval configuration. The earliest clinical feature is
graying of the retina temporal to the fovea. Only in the later stages of the disease does pigmentary migration occur. This
acquired form of idiopathic juxtafoveolar retinal telangiectasis usually presents in the middle-aged to elderly population. Most
patients retain good vision in at least one eye. The most common cause of visual loss is atrophy of the retinal pigment
epithelium. Choroidal neovascular membranes may also occur.
Question 48 of 130
An increased rate of proliferative vitreoretinopathy (PVR) has not been associated with which of the following?
Scleral buckling surgery, rather than closed vitrectomy, for the repair of retinal detachment
Cryoretinopexy
Vitreous hemorrhage
Question 49 of 130
A 64-year-old man is referred to you because of an elevated, brown choroidal mass involving the inferior quadrant of his left
eye. On echographic examination, the lesion shows a pattern highly consistent with malignant melanoma. A subsequent
metastatic workup is completely negative. Which of the following factors is not predictive of subsequent metastatic disease?
Extrascleral Extension
Cell type
Please select an answer
Feedback: A variety of factors have been shown to increase the risk of subsequent tumor-related death following
enucleation or radiation therapy for malignant melanoma. Tumors composed primarily of epithelioid cells (versus spindle A,
spindle B, or mixed-cell type) have a poor prognosis. Extrascleral extension of the tumor is also a grave prognostic sign.
Kaplan-Meier survival curves show a steadily worsening prognosis with every 2mm increase in the largest tumor dimension.
Tumors that involve the anterior choroid, particularly the ciliary body, have also been shown to have a poor prognosis.
Extension through Bruch's membrane is not predictive of later metastatic disease.
Question 50 of 130
Which of the following retinal defects is least likely to be associated with traumatic injury?
Round hole
Retinal dialysis
Choroidal rupture
Please select an answer
Feedback: Retinal dialysis, choroidal rupture, and horshoe retinal tears are commonly associated with severe ocular
trauma. Round retinal holes are commonly associated with atrophic processes or posterior vitreous detachment.
Question 51 of 130
A 35-year-old man complains of gradually decreasing vision in his right eye over at least the last year. His visual acuity is
20/200 OD and 20/20 OS. The anterior segment is normal in both eyes. Fundus examination of the right eye shows a heavy
accumulation of lipid in the posterior pole. The left fundus is completely normal. Which of the following would not be a
probable cause of the exudate?
Question 52 of 130
Which of the following is the strongest indication for prophylactic treatment (cryopexy or laser surgery) to prevent
rhegmatogenous retinal detachment?
High myopia and lattice degeneration with new onset of floaters in a phakic patient
An asymptomatic flap tear in an eye with a cataract that is about to be rendered pseudophakic
An atrophic hole in a phakic patient whose other eye developed a retinal detachment
Lung and breast cancer are the most common primary sources of metastatic ocular tumors.
Question 54 of 130
A 30-year-old woman complains of blurred central vision in the right eye for the past 3 days. Multiple chorioretinal lesions
are noted in both eyes. Which of the following findings is most consistent with a diagnosis of acute posterior multifocal
placoid pigment epitheliopathy (APMPPE)?
Heroin
Methoxyflurane
Canthaxanthine
Tamoxifen
Please select an answer
Feedback: Crystalline deposits in the retina are a toxic manifestation of tamoxifen, an anti-estrogen drug used in the
treatment of metastatic breast carcinoma; methoxyflurane, a nonflammable inhalant general anesthetic agent that may
produce oxalosis; and canthaxanthine, an oral skin-tanning agent marketed outside the United States. Talc retinopathy,
another form of crystalline retinopathy, occurs in drug abusers who inject multiple crushed tablets of Ritalin or methadone
intravenously; it does not occur from heroin use. The differential diagnosis of crystalline retinopathy also includes Bietti's
crystalline dystrophy, Sjogren-Larsson syndrome, nephropathic cystinosis, gyrate atrophy, and oxalosis.
Question 56 of 130
A 58-year-old woman has no particular complaints on first-time routine examination. She has not had a dilated fundus
examination before. Visual acuity is normal in each eye, but you find a peripheral area of retina that is thin and elevated in
the right eye. You would like to know whether the appearance of the retina is due to retinoschisis, or a rhegmatogenous
retinal detachment. Which of the following is least likely to indicate retinoschisis?
Hyperopia
Question 58 of 130
A 67-year-old man complains that within the last 2 weeks he has had a severe loss of vision in the right eye. His visual
acuity is 20/400 OD and 20/25 OS. Examination of the anterior segments shows only mild nuclear sclerosis bilaterally.
Fundus examination of the right eye shows disc edema, dilated and tortuous retinal veins, and multiple superficial intraretinal
hemorrhages. Which of the following additional findings is least likely to be present in this patient?
Gentamicin toxicity
Please select an answer
Feedback: The whitening of the retina occurring from phototoxicity is transient and usually located inferior to the fovea,
because of the rotation of the globe from the superior rectus muscle bridle suture. Within hours, the retinal swelling resolves;
however, it often leads to a stippled retinal pigmentary disturbance. Acute retinal necrosis occurs from mistakenly injecting
gentamicin instead of miochol or other drugs intracamerally, or from accidental injection of gentamicin through the sclera at
the conclusion of surgery. Doses only slightly greater than 200 micrograms (subconjunctival injections are routinely 20
milligrams or 20,000 micrograms) may produce severe retinal vascular occlusion within minutes, and therefore attempts to
irrigate gentamicin from the vitreous cavity using pars plana vitrectomy techniques may be futile. Acute anterior ischemic
neuropathy is associated with disc swelling without retinal whitening. Branch retinal artery occlusion is not associated with
retinal hemorrhage, and the whitening of the retina is localized to the distribution of the affected branch retinal artery.
Question 60 of 130
Which of the following statements is most consistent with a 66-year-old man with asteroid hyalosis in his right eye
complaining of loss of vision?
Asteroid hyalosis and optic disc drusen are easily recognizable echographically.
The macula can readily be evaluated in an eye with asteroid hyalosis using the excitor and barrier filters of a fundus
camera.
Dense asteroid hyalosis seldom produces loss of vision or the sensation of vitreous floaters.
Asteroid bodies usually occur unilaterally and appear white in an aphakic or pseudophakic eye.
Please select an answer
Feedback: Asteroid hyalosis is unilateral in nearly 75% of cases and seems to be more prevalent in patients with diabetes.
It seldom results in any visual disturbance, although it may hinder evaluation of the ocular fundus. Asteroid bodies and optic
disc drusen exhibit characteristic patterns echographically. Because asteroid bodies do not emit fluorescent light, they are
invisible during fluorescein angiography, and therefore details of the posterior fundus can be readily photographed.
Question 61 of 130
A 70-year-old man comes to your office for the first time complaining of poor vision in his recently operated left eye. Your
initial examination reveals an early nuclear sclerotic cataract in the right eye, and pseudophakia in the left eye. His best-
corrected visual acuity is 20/70 OD, which you judge to be consistent with his cataract, and 20/60 OS. Which of the following
findings points most strongly toward retinal disease as a cause of the decreased acuity in the left eye?
Question 62 of 130
A fluorescein angiogram shows perifoveal capillary leakage in the early and mid-angiogram, and a petalloid or stellate
pattern in the latest frames. Which of the following statements does not accurately describe this retinal disease process?
Disc staining commonly occurs in the late frames of the fluorescein angiogram.
Extracellular cystoid spaces within the outer plexiform layer are typically seen histopathologically.
Ultraviolet-blocking intraocular lenses have been shown statistically to improve visual outcome by reducing the
perifoveal capillary leakage.
Please select an answer
Feedback: Ultraviolet-blocking intraocular lenses have, in some studies, been shown to decrease the incidence of
fluorescein angiographically demonstrated cystoid macular edema. However, no statistically significant evidence has yet
been reported to support the hypothesis that the visual outcome is better with ultraviolet-blocking intraocular lenses.
Question 63 of 130
Which of the following is not a characteristic of diode-red laser light?
Question 64 of 130
You see a 26-year-old man with a 15-year history of insulin-dependent diabetes mellitus for the first time. His visual acuity is
20/20 OU. Fundus examination of the right eye reveals the vitreous to be clear. No neovascularization is visible on the disc
or elsewhere; however, there are numerous microaneurysms, venous beading, and rare cotton-wool spots. Examination of
the left fundus also reveals a clear vitreous with no blood present, but there is a frond of elevated neovascularization arising
from the disc, and another small patch of neovascularization away from the disc along the inferonasal arcade. If the diabetic
retinopathy were asymmetric between the eyes on initial presentation, what would the most likely explanation be?
A fluorescein angiogram should be obtained to detect or rule out the presence of clinically significant macular edema.
If the patient's diabetic control has been poor, normalizing the blood glucose level and decreasing the glycosylated
hemoglobin will decrease the risk of progression to proliferative retinopathy.
If there is a small area of thickened retina, with its center 500 microns temporal to the center of the fovea, immediate
focal laser photocoagulation surgery can be considered.
A ring of exudate, 500 microns in diameter that extends to within 1disc diameter of the center of the macula, can be
considered an indication for immediate focal laser photocoagulation.
Please select an answer
Feedback: The Early Treatment Diabetic Retinopathy Study shows that immediate treatment, even with 20/20 acuity, is
preferable to deferred treatment. The diagnosis of clinically significant macular edema is a clinical decision based on careful
examination of the fundus with biomicroscopy, usually with a fundus contact lens. Fluorescein leakage alone does not meet
the definition of clinically significant macular edema. The diagnosis depends on documenting any of the following: (1)
thickening of the retina at or within 500 microns of the center of the macula; (2) hard exudates at or within 500 microns of the
center of the macula, if associated with thickening of the adjacent retina (not residual hard exudates remaining after the
disappearance of retinal thickening); (3) a zone or zones of retinal thickening 1disc area or larger, any part of which is within
1disc diameter of the center of the macula. The Early Treatment Diabetic Retinopathy Study concludes that treatment of
eyes with clinically significant macular edema is preferable to no treatment during the follow-up period, but does not
specifically address the question of when treatment should be initiated, ie, immediate treatment or deferral if visual acuity is
still 20/20. The role of glucose control in the progression of diabetic retinopathy remains unclear. In some cases, rapid
improvement of control has been associated with accelerated progression of retinopathy.
Question 66 of 130
Metamorphopsia on Amsler grid testing is least compatible with which of the following?
Prompt vitrectomy if ultrasound examination shows unequivocally that the peripheral retina is detached
Observation for at least 6 months to allow for spontaneous clearing of vitreous blood if all tests demonstrate no retinal
detachment
Prompt vitrectomy if ultrasound examination shows clearly that the macula is detached
Question 68 of 130
Which of the following findings is the least urgent indication to obtain a fluorescein angiogram in a 67-year-old woman who
has slightly decreased vision in one eye?
Multiple intraretinal hemorrhages involving an arcuate patch of retina, including the macula
Question 70 of 130
You see a 26-year-old man with a 15-year history of insulin-dependent diabetes mellitus for the first time. His visual acuity is
20/20 OU. Fundus examination of the right eye reveals the vitreous to be clear. No neovascularization is visible on the disc
or elsewhere; however, there are numerous microaneurysms, venous beading, and rare cotton-wool spots. Examination of
the left fundus also reveals a clear vitreous with no blood present, but there is a frond of elevated neovascularization arising
from the disc and another small patch of neovascularization away from the disc along the inferonasal arcade. Which of the
following statements would be most accurate about the left eye of the patient?
Over the next 5 years, the risk of severe visual loss can be reduced by at least 50% with peripheral retinal
photocoagulation.
If there is also clinically significant macular edema, peripheral retinal photocoagulation can be expected to reduce it.
According to criteria established by the Diabetic Retinopathy Study, the patient does not have high-risk characteristics
yet, because there is no vitreous hemorrhage.
Xenon-arc photocoagulation is less effective than argon laser surgery in reducing the risk of severe visual loss.
Please select an answer
Feedback: The Diabetic Retinopathy Study shows that with the treatment protocol employed, the risk of severe visual loss
is reduced by at least 50% over the period of observation. However, improvement in macular edema is not associated with
peripheral retinal treatment. Under the protocols tested in major trials, the treatment of high-risk proliferative retinopathy is
not directed at specific targets, but rather at the periphery and midperiphery, sparing the macular area. High-risk
characteristics, as defined by the Diabetic Retinopathy Study, include (1) neovascularization of the disc (NVD) greater than
114 to 113 of the disc area; (2) vitreous or preretinal hemorrhage associated with less extensive NVD, or with
neovascularization elsewhere (NVE), 112 of the disc area or more in size. Xenon-arc photocoagulation was found to have a
similar effect to that of argon laser photocoagulation in reducing severe visual loss, but was associated with slightly
increased side effects.
Question 71 of 130
In which situation is optical coherence tomography most accurate?
Undilated pupil
Media opacification
Question 72 of 130
Which one of the following represents a relevant aspect of the epidemiology of juvenile retinoschisis?
Outer retinal lamina breaks are more common than inner lamina breaks.
50% of those with foveal radiating retinal folds also have peripheral retinoschisis.
Please select an answer
Feedback: In juvenile retinoschisis, 50% of those with foveal radiating retinal folds also have peripheral retinoschisis.
Retinal detachment occurs in 5-20%. Retinal breaks may develop in inner lamina (75%) or outer lamina (13%). Female
carriers cannot be clinically identified.
Question 73 of 130
Which one of the following is contraindicted in the evaluation of a possible intraocular foreign body?
Orbital X-rays
Ultrasonography
Please select an answer
Feedback: The magnetic field utilized in performing magnetic resonance imaging could result in movement of a ferrous
intraocular foreign body, resulting in further tissue damage. The other imaging modalites listed do not pose this threat.
Question 74 of 130
Which of the following describes a pertinent clinical feature of acute retinal necrosis?
Question 75 of 130
Which one of the following represents a risk factor for the development of atrophic retinal holes?
Young age
Hyperopia
Macular degeneration
Please select an answer
Feedback: Atrophic retinal holes are associated with a family history of such holes, or of lattice degeneration. In addition,
they are associated with increasing age and axial myopia. There is no association with macular degeneration.
Question 76 of 130
Which one of the following best describes the maculopathy of chloroquine and its derivatives?
Most cases occur between 20 and 50 years of age and more commonly in females.
Question 78 of 130
What is a pertinent element in the history of a patient with suspected albinism?
Absence of nystagmus
Onset in adulthood
Question 79 of 130
Which one of the following is a symptom of central serous chorioretinopathy?
Pain
Photophobia
Metamorphopsia
Please select an answer
Feedback: Metamorphopsia is a common presenting symptom of central serous chorioretinopathy. Pain, peripheral visual
field loss, and photophobia are not typically associated with this condition.
Question 80 of 130
Which one of the following is a risk factor for hypertensive retinopathy?
African-American ethnicity
Young age
Malnutrition
Please select an answer
Feedback: Risk factors for hypertensive retinopathy include African-American ethnicity, advanced age, obesity, and
noncompliance with antihypertensive therapy.
Question 81 of 130
A patient develops a hemorrhagic choroidal detachment following cataract surgery. Their intraocular pressure remains in the
normal range. Which of the following developments is most likely?
Proliferative vitreoretinopathy
Posterior uveitis
Question 82 of 130
What is the most frequent complication associated with pars plana vitrectomy and membrane peeling?
Accelerated cataractogenesis
Glaucoma
Retinal tear
Please select an answer
Feedback: Cataract is the most frequent complication associated with pars plana vitrectomy for phakic patients. Accelerated
cataractogenesis leads to cataract surgery in 50% of patients within 2 years of vitrectomy. Glaucoma, retinal tears, and
retinal pigmented epithelial disturbances occur at a frequency of less than 5%.
Question 83 of 130
A 28-year-old man with acquired immunodeficiency syndrome (AIDS) presents with isolated retinal nerve fiber layer infarcts.
Which of the following statements regarding the patient's condition is most accurate?
HIV retinopathy is the most common cause of isolated retinal nerve fiber layer infarcts in patient with AIDS. Small areas of
retinitis from CNV may simulate cotton-wool spots, but this is not a typical presentation. Pneumocystis choroiditis lesions
can be differentiated from more superficial retinal lesions on examination. Acute retinal necrosis cannot, by definition, be
present in AIDS.
Question 84 of 130
What are the characteristics of a Stage 3 macular hole?
Full thickness hole with surrounding subretinal fluid and no posterior vitreous separation
Full thickness hole with surrounding subretinal fluid and a posterior vitreous separation
Please select an answer
Feedback: The staging system applies only to idiopathic macular holes (IMH), not traumatic or disorder associated macular
holes. A Stage 3 idiopathic macular hole is characterized by adjacent annulus of subretinal fluid without a posterior vitreous
separation. A Stage 4 macular hole is a full thickness hole with a posterior vitreous separation. A Stage 2 macular hole is
defined as a perifoveal or "can-opener"-like hole. Occasionally, surgical repair of idiopathic macular holes will reopen
spontaneously or following surgical intervention. However, hole re-opening is not included in the staging system.
Question 85 of 130
Which of the following is the primary cause of visual loss following branch retinal vein occlusion?
Macular edema
Refractive change
Please select an answer
Feedback: The primary cause of visual reduction following branch retinal vein occlusion is macular edema. Retinal
neovascularization is uncommon, but may be associated with vitreous hemorrhage. Collateral vessel formation may be
associated with visual improvement from normalization of venous luminal pressure. Refractive changes, if found, are
typically secondary to macular edema.
Question 86 of 130
Which of the following features of age-related macular degeneration (AMD) was associated with an increased risk of
choroidal neovascularization development in the AREDS study?
Question 87 of 130
What is the most common cause of visual loss in patients with nonproliferative diabetic retinopathy?
Vitreous hemorrhage
Please select an answer
Feedback: Diabetic macular edema is the most common cause of visual loss in patients with nonproliferative diabetic
retinopathy. Vitreous hemorrhage and traction retinal detachment more typically are associated with proliferative diabetic
retinopathy. Macular pigmentary disturbance may be a manifestation of macular edema, but not the primary cause of visual
loss.
Question 88 of 130
Which of the following is an appropriate management option for a perforating scleral injury?
CT scan
MRI scan
Avoidance of dilation
Scleral depression
Please select an answer
Feedback: An appropriate management option for a scleral perforating injury is a CT scan to rule out the presence of a
retained intraocular foreign body (IOFB). MRI is contraindicated in the setting of possible IOFB. Scleral depression is
contraindicated as intraocular contents could be extruded. All traumatized eyes should undergo dilated examination in the
clinic or operating room to evaluate for associated injuries such as traction retinal detachment or retinal incarceration.
Question 89 of 130
Which of the diagnostic studies is indicated in the evaluation of age-related macular degeneration to detect the presence
of choroidal neovascularization?
Fluorescein angiography
Corneal topography
Fluorescein angiography is indicated in the evaluation of age-related macular degeneration to detect the presence
of choroidal neovascularization.
Question 90 of 130
Which of the following conditions may exacerbate diabetic macular edema?
Hyperthyroidism
Systemic hypertension
Hypokalemia
Atrial fibrillation
Please select an answer
Feedback:
Systemic hypertension may exacerbate diabetic macular edema. Hyperthyroidism, which is unassociated with hypertension,
is not known to worsen diabetic complicatitons. Similarly, hypokalemia and atrial fibrillation are not appreciated to aggrevate
diabetic macular edema.
Question 91 of 130
Diabetic retinopathy is the leading cause of pemanent blindness in which of the following age catagories?
Aspirin
Question 93 of 130
What organisms are responsible for acute retinal necrosis (ARN) and progressive outer retinal necrosis (PORN)?
Question 94 of 130
In a phakic patient, for which of the following retinal breaks is treatment most urgent?
As asymptomatic atrophic retinal holes have a low incidence of progression to retinal detachment; treatment is not usually
indicated. Atrophic retinal holes are rarely caused by traumatic. Blunt trauma is more closely associataed with retinal
dialysis.
Question 96 of 130
Which of the following conditions is most commonly associated with posterior vitreous detachment (PVD)?
Axial myopia
Emmetropia
Astigmatism
Hyperopia
Please select an answer
Feedback: Of the refractive errors listed, axial myopia is most commonly associated with posterior vitreous detachment
(PVD). This is thought to be related to the increased axial length present in this condition. The increased incidence of PVD
correlates with the increased incidence of retinal tears and detachment in this population.
Question 97 of 130
Vision threatening ocular toxoplasmosis is commonly treated with which oral antibiotic regimen?
Folinic acid
Pyrimethamine
Vancomycin
Penicillin
Please select an answer
Feedback:
Pyrimethamine has historically been the most commonly used oral antibiotic in treating vision-threatening ocular
toxoplasmosis. Other options include sulfadiazine or triple-sulfa, azithromycin, and clindamycin. Folinic acid is not an
antibiotic.
Question 98 of 130
For non-exudative age-related macular degeneration, which of the following conditions is associated wtih a risk of vision
loss?
Diabetes mellitus
Question 99 of 130
For a patient with a diabetic mid-peripheral traction retinal detachment, what complication is of primary concern when
applying initial panretinal photocoagulation?
Retinal neovascularization
Cortical cataract
Please select an answer
Feedback: In proliferative diabetic retinopathy, panretinal photocoagulation may result in the contraction of fibrovascular
tissue, exacerbating tractional retinal detachment, resulting in macular detachment. Although this may also result in retinal
breaks and combined traction-rhegmatogenous retinal detachment, this is uncommon. Panretinal photocoagution reduces
retinal neovascularization and has no known direct impact on cortical cataract formation.
Golf ball
Paint ball
Metal-on-metal projectile
Fist
Please select an answer
Feedback: An ocular perforating injury has both entry and exit wounds. This requires two penetrations of the sclera. Blunt
trauma such as a fist, golf ball or paint ball will cause a scleral rupture, but are not capable of creating a perforating ocular
injury.
Question 101 of 130
Although a number of adjunctive procedures remain controversial in the surgical management of macular holes, which of the
following steps is crucial to high hole-closure rates?
Supine positioning
Retinal microaneurysms
Retinal neovascularization
Vitreous hemorrhage
Please select an answer
Feedback: Retinal microaneurysms are a clinical finding in moderate nonproliferative diabetic retinopathy. Venous beading
in 2 or more quadrants is characteristic of severe nonproliferative diabetic retinopathy. Retinal neovascularization and
vitreous hemorrhage is seen in proliferative diabetic retinopathy
2
Please select an answer
Feedback: A giant retinal tear is defined as a tear extending 90 degrees or more circumferentially about the retinal
periphery. This equates to a circumferential extent of 3 or more clock hours.
Idiopathic macular holes are most prevalent in female patients 50 - 80 years old. The risk of fellow eye involvement has
been reported in the range of 1-25%. Macular holes successfully repaired within 6 months of onset have a high likelihood of
visual improvement.
Question 107 of 130
Which of the following tests is the most specific and sensitive for diagnosing an idiopathic macular hole?
B-scan ultrasonography
Fluorescein angiography
Please select an answer
Feedback: The high resolution of current-generation optical coherence tomography makes this test more specific and
sensitive for diagnosing an idiopathic macular hole than the other techniques.
C-reactive protein
Plasma homocysteine
Granulomatous inflammation
Macular edema
Please select an answer
Feedback: The vitreomacular traction syndrome results from the incomplete separation of the posterior vitreous hyaloid
from the macula with resulting macular distortion and edema. The condition is idiopathic and is not typically associated with
retinal pigment epithelial tears, granulomatous inflammation, or choroidal neovascularization.
Question 110 of 130
Which of the following is the most common cause of visual loss in patients with nonproliferative diabetic retinopathy?
Vitreous hemorrhage
Neovascular glaucoma
Retinal neovascularization
Please select an answer
Feedback: Diabetic macular edema is the most common cause of visual loss in patients with nonproliferative diabetic
retinopathy. Retinal neovascularization, vitreous hemorrhage, and neovascular glaucoma are all findings in proliferative
diabetic retinopathy.
Atrial fibrillation
Hyperthyroidism
Hypertension
Renal insufficiency
Please select an answer
Feedback: Retinal arteriolar macroaneurysm is highly associated with systemic hypertension. There is no known
association between retinal arteriolar macroaneurysm and hyperthyroidism, atrial fibrillation, or renal insufficiency.
100%
5%
25%
45%
Please select an answer
Feedback: If one parent had unilateral retinoblastoma, the probability of the parent's first child having retinoblastoma is 7-
15%. If one parent had bilateral retinoblastoma, the probability of the parent's first child having retinoblastoma is 45%. If a
parent had a retinoblastoma and one sibling has a retinoblastoma (demonstrating autosomal dominance) the probability of
the each child's sibling will develop a retinoblastoma is 45%. Retinoblastoma has a 90% penetrance lowering the probabiity
from 50 to 45% for affected family members.
Question 113 of 130
A 7-year-old child presents with leukocoria. Based upon it incidence in this setting, what is the most likely posterior
segment lesion to be noted on ophthalmoscopic examination?
Ocular toxocariasis
Choroidal neovascularization
Asteroid hyalosis
Please select an answer
Feedback: Of the choices given, ocular toxocariasis is the most likely diagnosis. Retinoblastoma is unlikely to present with
leukocoria at this advanced age. Asteroid hyalosis is uncommon in youth and does not present with a retinal mass lesion.
Idiopathic sclerochoroidal calcification and choroidal neovascularization are uncommon in youth and do not typically present
with leukocoria.
Pars plana vitrectomy, retinal reattachment with perfluorocarbon liquid, laser photocoagulation, and complete fluid-gas
exchange
Gram-negative rods
Gram-positive diplococci
Atypical mycobacteria
Please select an answer
Feedback: Gram-positive coagulase-negative micrococci are the most common organisms isolated in endophthalmitis
following cataract surgery. Gram-negative organisms, atypical mycobacteria, and gram-positive diplococci are less
commonly associated with endophthalmitis in this setting.
Question 116 of 130
What feature is a risk factor for the development of age-related macular degeneration?
Family history
Obesity
Middle-Eastern ethnicity
Please select an answer
Feedback: Family history has been identified as a risk factor for the development of age-related macular degeneration;
obesity, Middle-Eastern ethnicity, and dark iris color have not.
Wyburn-Mason syndrome
Sturge-Weber syndrome
Ehlers-Danlos syndrome
Please select an answer
Feedback: Angioid streaks and blue sclera are both found in those affected by Ehlers-Danlos syndrome. Angiod streaks
may also be associated with sickle cell disease, pseudoxanthoma elsticum and Paget's disease of bone. The is no known
association between angioid streaks or blue sclera and the Sturge-Weber, Von Hippel-Lindau, or Wyburn-Mason
syndromes.
Intraretinal hemorrhage
Macular edema
Collateral vessels
Iris neovascularization
Please select an answer
Feedback: Panretinal photocoagulation is indicated to treat anterior segment neovascularization complicating central retinal
venous occlusion. PRP has not shown a benefit in treating macular edema, intraretinal hemorrhage, and would not be
expected to have any effect on collateral vessels
Question 119 of 130
What feature found in embolic central retinal artery occlusion (CRAO) is helpful in confirming the diagnosis?
Jaw claudication
Retinal pallor
Ocular pain
Subacute onset
Please select an answer
Feedback: Embolic central retinal artery occlusion (CRAO) causes retinal pallor which is often appreciated as a "cherry red
spot" due to relative retinal translucency at the fovea. However, retinal pallor is helpful to confirm a CRAO, but is not
specific for embolic CRAO. Pain, intermittant or subacute onset and jaw claudication suggest an inflammatory cause of
central artery occlusion. A minority of CRAOs are due to temporal arteritis, which may present with bilateral CRAO. A stat
CRP and/or sedimentation rate should be obtained if an emboli or other feature confirming embolic CRAO cannot be
confirmed on initial examination.
Macular edema
Neovascular glaucoma
Choroidal neovascularization
Subretinal hemorrhage
Please select an answer
Feedback: Macular edema is the most common complication of branch retinal venous occlusion (BRVO). Choroidal
neovascularization, subretinal hemorrhage, and neovascular glaucoma are not commonly associated with BRVO.
Retinal angioma
Racemose aneurysm
The image demonstrates a retinal capillary hemangioma or angioma typical of those occuring in von Hippel-Lindau disease.
Retinal cavernous hemangiomas are composed of clusters of angiomatous retinal vascular lesions. The racemose
aneurysm seen in Wyburn-Mason syndrome consists of a dilated arteriovenous communication in the retinal vasculature.
Choroidal hemangiomas involve anomalous choroidal, not retinal, vasculature
Question 122 of 130
What feature of peripheral degenerative retinoschisis, if present, increases the likelihood of this diagnosis?
Unilateral
Symptomatic
Hyperviscosity
Please select an answer
Feedback: Poor glycemic control is the greatest and most consistently demonstrated risk factor for the development of
diabetic macular edema. Oral statin therapy does not have a proven impact, but has been proposed to lower, rather than
increase the risk of progression of diabetic retinopathy. Hyperviscosity has been associated with venous occlusive disorders,
but not risk of diabetic macular edema. Diabetic macular edema is more common in patients with a longer duration of
diabetes mellitus and with uncontrolled systemic hypertension.
What is the most common cause of vision loss in a patient with a choroidal osteoma?
Vitreous hemorrhage
Retinal detachment
Macular edema
Choroidal neovascularization
Please select an answer
Feedback: Choroidal neovascularization (CNV) is the most common cause of vision loss in patients with choroidal osteoma.
In the absence of CNV, retinal detachment, vitreous hemorrhage, and macular edema are uncommon causes of vision loss
in patients with choroidal osteoma.
Question 125 of 130
What is the most common cause of cystoid macular edema that demonstrates a fluorescein angiographic hyperfluorescent
cystic ("petaloid") pattern?
Retinitis pigmentosa
Niacin
Cataract surgery
Choroidal neovascularization
Please select an answer
Feedback: Of the causes listed, cataract surgery is the most common cause of clinical and angiographic cystoid macular
edema. Retinitis pigmentosa is a rare cause of CME. Although choroidal neovascularization may be associated with cystic
retinal thickening on optical coherence tomography, it rarely demonstrates a hyperfluorescent cystic pattern. Niacin toxicity
does not demonstrate retinal cystic hyperfluorescence.
Observation
Laser photocoagulation
Please select an answer
Feedback: Observation is the preferred initial therapy for acute traumatic choroidal rupture. Intravitreal ranibizumab therapy
or laser photocoagulation may be indicated for choroidal neovascularization which usually presents months to years later.
Pars plana vitrectomy may be indicated for a nonclearing traumatic vitreous hemorrhage in an eye with a coexisting
choroidal rupture, but not for the choroidal rupture itself.
Which of the following is the most-commonly administered therapy for cytomegaloviral retinitis?
Intravenous cidofovir
Intravitreal foscarnet
Intravitreal ganciclovir
Oral valganciclovir
Please select an answer
Feedback: Oral valganciclovir is currently the most-commonly administered therapy for cytomegaloviral retinitis. Less-
commonly used therapies include intravitreal ganciclovir, intravitreal foscarnet, and intravenous cidofovir.
Question 128 of 130
What predisposing factor contributes to an accelerated development of hydroxychloroquine maculopathy?
Obesity
Adolescence
Please select an answer
Feedback: The coexistence of renal and/or hepatic disease represents a risk factor for the development of
hydroxychloroquine maculopathy; youth, obesity, and Northern European ancestry do not.
Intravitreal vancomycin
Intravitreal amphotericin
Oral fluconazole
Intravitreal gentamicin
Please select an answer
Feedback: Intravitreal vancomycin is the most-commonly administered antimicrobial agent used in the management
of delayed-onset post-cataract endophthalmitis. Propionobacterium acnes, the most common cause of this entity, is
typically sensitive to vancomycin. Intravitreal gentamicin has the potential for retinal toxicity and is not commonly
used in the management of chronic endophthalmitis. Oral flucanazole and intravitreal amphotericin may be used in
the management of the less-common fungal delayed-onset post-cataract endophthalmitis.