Refractive Mgmt/Intervention: Question 1 of 90

Refractive Mgmt/Intervention
Question 1 of 90
Of the three posterior curves of a contact lens, which is the steepest?
Peripheral curve
No generalization can be made
Base curve
Secondary curve
Please select an answer
Feedback: The posterior surface of the contact lens is shaped to try to approximate the corneal surface. The normal cornea
is aspheric, meaning that it is steeper in the center and gradually flattens in the periphery. To approximate this gradual
change in anterior corneal curvature, the base curve of the contact lens (the central posterior portion) is steepest, as is the
normal central cornea. The lens then flattens out toward the periphery, which means that the secondary curve is flatter than
the base curve, and the peripheral curve is flatter still. Exceptions to this generalization are found in specialty lenses, such
as refractive surgery lenses (that is, those used after radial keratotomy), where a flatter base curve may be indicated to
better approximate the change in corneal shape after surgery.
Question 2 of 90
Which contact lens material has the highest Dk value?
Fluoropolymer
38% HEMA lens
68% HEMA lens (hydroxyethylmethacrylate)
PMMA (polymethylmethacrylate)
Feedback: A common measure of oxygen permeability of a contact lens material is its Dk value; this notation stands for the
diffusion coefficient for oxygen movement in the material (D) multiplied by the solubility constant of oxygen in the particular
material (k). The oxygen permeability of a material also depends, inversely, on the thickness of the material (increasing the
thickness decreases oxygen permeability). For this reason, another measurement is also included: Dk/L, where L is the
thickness of the material in question. Because the anterior surface of the cornea gets most of its oxygen supply through the
tear film, use of a contact lens decreases oxygen flow to the tears and therefore to the anterior corneal surface. For this
reason, to maintain normal corneal physiology, contact lens materials that allow for increased oxygen permeability are
probably advantageous in maintaining the normal physiology of the cornea. PMMA lenses do not allow any oxygen
penetration and are rarely used in the United States today. Soft contact lenses do allow some oxygen to penetrate, and the
oxygen transmissibility improves with increasing water content. However, the most oxygen-permeable materials for contact
lenses today are those used for rigid gas-permeable lenses, such as silicon acrylate material and fluoropolymer. Whereas
soft contact lenses usually have a Dk of about 30, the newer rigid gas-permeable materials have Dk values of 100, and
some are as high as 300. All else being equal, greater oxygen permeability is probably best, particularly for compromised
corneas (eg, after penetrating keratoplasty).
Question 3 of 90
Which of the following patients is most likely to have an undercorrection following strabismus surgery?
A +2.00D hyperope wearing glasses whose esotropia measures 25Δ
A +10.00D hyperope wearing glasses whose exotropia measures 30Δ
A -10.00 D myope wearing glasses whose exotropia measures 50Δ
A -10.00 D myope wearing contact lenses whose exotropia measures 40Δ

Feedback: High-minus and high-plus spectacles have a prismatic effect when strabismic deviations are measured in front of
the glasses, as we would expect from Prentice's rule (Δ =h(cm)D). Plus lenses decrease the measured deviation-whether
esotropia (ET), exotropia (XT), or hypertropia (HT). In contrast, minus lenses increase the measured deviation, regardless of
the type of deviation. The true deviation is changed by approximately (2.5) x D%, where D is the spectacle power in
diopters. High-plus lenses provide base-in prism if the patient is exotropic, and base-out prism if the patient is esotropic;
thus, the true deviation is really larger than what is measured in front of the high-plus spectacle. The opposite is true for
patients wearing high-minus spectacles. A patient with spectacle corrected -10.00 D myopia whose XT measures 50Δ really
has a 40Δ exotropia and is likely to be overcorrected if surgery is performed for 50 Δ of exotropia. However, a patient with
contact lens-corrected -10.00 D myopia with 40Δ XT is not at risk for over or undercorrection due to measurement errors.
Lower levels of ametropia (less than 5 D) do not significantly change the measured deviation. Thus, a patient with 2 D of
hyperopia will not have a significant error introduced during prism and alternate cover testing. A patient with high hyperopia
who is wearing glasses while measurements are obtained is most likely to be undercorrected. A patient with spectacle-
corrected +10.00 D hyperopia whose XT measures 30Δ really has a 40Δ deviation and is likely to be undercorrected if
surgery is performed for 30Δ. In contrast, high-minus spectacles minimize, and high-plus spectacles exaggerate, the
cosmetic appearance of ocular misalignment.
Question 4 of 90
Contrast sensitivity loss in the low-vision patient may adversely affect the performance of specific tasks. Which of the
following statements is least accurate?
Travel-related tasks and mobility issues are most affected by lowfrequency contrast sensitivity loss.
Telemicroscopes (eg, loupes) are often helpful when low vision is accompanied by impaired contrast sensitivity.
High-frequency contrast sensitivity loss particularly aggravates nearpoint tasks and reading performance.
A 3x magnifier with supplemental halogen illumination can rival a 5x magnifier using only ambient lighting.
Feedback: Patients with low vision who have similar visual acuities seem to function quite differently; contrast sensitivity can
often predict and quantify this functional disparity. Several charts are available to test contrast sensitivity (Vistech, Bailey Hi-
La, Felli-Robson). Individuals with high-frequency contrast sensitivity loss seem to have more difficulties with near-point
tasks and reading performance. Because these activities often use highly contrasting objects of regard, greater
magnification from simple or specialized lenses that minimize transmission loss is indicated. Extra lighting improves
functional performance in this population, and a 3x magnifier with supplemental (internal) halogen illumination can rival a 5x
magnifier using only ambient lighting. A lower-powered magnifier typically permits a wider field of view (because of its larger
optic), thus creating a more usable low-vision device. Media opacities (including cataracts) and optic nerve pathology
commonly result in poor contrast sensitivity, indicating the need for increased illumination, deliberate use of high-contrast
materials, and glare control. Travel-related tasks and mobility issues are most affected by low-frequency contrast sensitivity
loss, because environmental and positional clues are typically based on subtle lighting and the perception of often indistinct
natural boundaries. The presence of impaired low-frequency contrast sensitivity should prompt greater orientation and
mobility training. As with any optical system containing multiple lenses, telemicroscopes (eg, loupes) attenuate image quality
with each lens's optical filtering effect, thus dampening the overall contrasting qualities of the object of interest, an
undesirable phenomenon for individuals with impaired contrast sensitivity. For this reason, low-vision patients with reduced
contrast sensitivity should avoid telescopic devices where supplemental illumination is not reasonably available.
Question 5 of 90
Some patients with low vision have better reading function binocularly, whereas others read better monocularly. Which of
the following is least accurate?
When both eyes have substantially asymmetric macular function (eg, 0020/60, as 20/400), retinal rivalry may limit
binocularity at near, and thus may affect print localization, cause text jump, and worsen visual blur.
Worth four-dot testing at near is helpful in assessing peripheral fusion and binocular low-vision potential.
Asymmetric eccentric fixation enhances binocularity by providing similar extrafoveal acuity in each eye, regardless of
retinal correspondence.
Binocular reading should be explored when the visual acuity of each eye is within two lines of each other.
Feedback: Decreased visual acuity associated with eccentric fixation can limit binocularity due to rivalry of the central and
peripheral fusional mechanisms. It is often necessary to occlude the eye with poorer acuity (particularly within the bifocal
segment) to avoid visual confusion and visual blur from competing images. Binocular potential is good if the patient fuses
the Worth four-dot at near (the projected lights stimulate the peripheral retina and demonstrate that peripheral retinal fusion
is present). Patients with nonsymmetric eccentric fixation preferences can have symmetric extrafoveal 20/200 acuities, but
could be unable to read binocularly. Nonsymmetric eccentric fixation can be determined qualitatively for each eye
individually (with a direct ophthalmoscope or a scanning laser ophthalmoscope) or by a diplopic response with the Worth
four-dot test at near. When visual acuities are reasonably similar, binocular performance is most realistic, but this may
require base-in prisms to compensate for relative convergence insufficiency if high-add reading lenses are needed.
Asymmetric eccentric fixation enhances binocularity by providing similar extrafoveal acuity in each eye, regardless of retinal
correspondence.
Question 6 of 90
Three and 9 o'clock staining does not indicate which of the following?
Rotation of lens
Blinking problems
Corneal desiccation
Poor contact lens fit

Feedback: Three and 9 o'clock staining is a common result after contact lens use; it describes superficial punctate staining
at the 3 and 9 o'clock positions in the peripheral cornea. Typically, these are areas of poor wetting that may develop
because of a patient's incomplete blink or decreased blink response, or from a poor-fitting lens that doesn't allow the tear
film to ride over the cornea. The condition is typically seen in gas-permeable lens wearers when the lens diameter is smaller
than the corneal diameter, a situation that may leave these areas exposed and open to desiccation. Generally, to address
this issue, it is necessary to refit with a lens that has greater lens movement and allows an increased exchange of tear film.
Changing to a totally different lens design and even considering soft contact lens wear, if appropriate, may also be helpful.
Question 7 of 90
A 26-year-old man had a cataract extraction with a scleral-sutured lOL 2 years ago, after he developed a traumatic cataract
with marked zonular dehiscence. Six months ago, his eye was quiet and his best-corrected visual acuity was 20/30+2 with -
1.25 sphere. Yesterday he was hit in the pseudophakic eye. Today he complains of blurred vision, and a slit-lamp
examination shows that the lens is rotated about its vertical axis. Assuming the lens is not displaced anteriorly or posteriorly,
what would you would expect him to be?
Lless myopic, with with-the-rule astigmatism
Less myopic, with against-the-rule astigmatism
More myopic, with with-the-rule astigmatism
More myopic, with against-the-rule astigmatism

Feedback: Tilting a plus lens about its axis increases the spherical power of the lens and induces about three times as
much cylinder of the same sign in the axis of tilt. In this example, a plus 10L tilted about the vertical axis will cause that lens
to have more plus power and plus cylinder with its axis at 90°. The corrective lens must neutralize the induced sphere and
cylinder. Thus, the patient will be more myopic because of the induced plus sphere. Similarly, he requires minus cylinder
correction, axis 90°, to compensate for the induced cylinder (against-the-rule astigmatism).
Question 8 of 90
Which of the following can not cause astigmatism?
Right medial rectus resection and right lateral rectus recession
Pellucid marginal degeneration
A staphyloma extending into the macula
Lenticular dislocation in Marfan syndrome

Feedback: Strabismus surgery has been documented to cause astigmatism or to change the refractive error, an important
fact to keep in mind when performing strabismus surgery in the amblyogenic age group. Only the image-forming
components of an optical system (the cornea and lens in the eye) can cause true astigmatism. Pellucid marginal
degeneration causes corneal astigmatism, and lenticular dislocation causes lenticular astigmatism. A tilted retina cannot
cause astigmatism, although it does cause a type of "curvature of field." The blurred ocular imagery resulting from a tilted
retina cannot be corrected with astigmatic contact or spectacle lenses.
Question 9 of 90
In prescribing telescopic devices for low vision, you must consider the optical design of the telescopic system and the tasks
to be addressed. Which of the following statements accurately describes this situation?
Positioning the telescope so that the exit pupil of the telescope coincides with the entrance pupil of the patient's eye
ensures the largest field of view and maximum light transmission.
A low-power minus lens used as a "reading cap" over the objective is positioned inside the telescope's exit pupil
(between the optical center and the focal point) to reduce individual accommodative effort and permit a closer near focus.
The Galilean telescope has a plus objective and a minus ocular lens and produces a real and inverted image.
Aligning the telescope's optical axis with the patient's optical axis minimizes distortion, even when the patient has an
eccentric visual axis of an extrafoveal preferred retinal locus.
Feedback: A Galilean telescope has a plus objective and a minus ocular lens as the eyepiece, but produces a virtual, erect
image. In contrast, the astronomical (Keplerian) telescope has a plus objective and a plus ocular lens, which creates a real,
inverted image, and must have some type of image-inverting system (such as a specialized prism) to provide the viewer with
a correctly oriented spatial image. Positioning and alignment of the telescope is crucial to maximizing performance. By
positioning the telescope so that the exit pupil of the telescope coincides with the entrance pupil of the patient's eye (a
position relatively close to the eye), the largest field of view and maximum light transmission is allowed. Aligning the
telescope's optical axis with the patient's preferred retinal locus (whether foveal or extrafoveal) minimizes distortion; this is a
particularly important consideration when mounting the telescope into a spectacle, where eccentric alignment is relatively
permanent. A plus lens, corresponding to the dioptric equivalent of the working distance, is used as a "reading cap" over the
objective of a standard telescope. This reduces the patient's accommodative effort and permits a closer near focus, thereby
increasing the utility of this device.
Question 10 of 90
What is the maximum time an extended-wear cosmetic contact lens should be worn?
7 days
30 days
Up to the practitioner
Up to the patient
Feedback: There is an increased risk of corneal infection with extended-wear use of contact lenses. This phenomenon is
best documented for soft contact lens use, because soft contact lenses are the most commonly used. In the United States,
nearly 80% of patients use soft lenses; the rest primarily wear rigid gas-permeable lenses. Because of the significantly
increased risk of infection with extended-wear use, the FDA has mandated that soft lenses can only be used for up to 7
days. Within this time frame, however, the actual length is up to the practitioner and the patient's needs. In general, if a
patient is able to remove and replace a lens with ease, daily wear lens use is recommended to decrease the risk of
complications.
Question 11 of 90
While performing retinoscopy on a 3-year-old, the retinoscopic reflex is neutralized by -3.00 sph OD and +3.50 sph OS.
Assuming a working distance of 67 cm, what is the best prescription to give?
-4.50 sph OD, +2.00 sph OS
-4.50 sph OD, plano OS
-3.00 sph OD, +3.50 sph OS
-3.00 sph OD, plano OS

Feedback: Because 6.5 D of anisometropia is almost certainly amblyogenic if left uncorrected, the full cycloplegic refraction
should be given, even in the hyperopic eye. In contrast to adults, children accept anisometropic corrections easily, but may
have decreased stereopsis.
Question 12 of 90
If the potential visual acuity obtained prior to cataract surgery is better than the acuity obtained postoperatively, which of the
following is not a possible cause?
Postsurgical cystoid macular edema
A pupil that was dilated during testing
An irregular corneal surface
Amblyopia
Feedback: Cystoid macular edema may decrease acuity after cataract surgery. An irregular surface from scarring or
astigmatism can produce a falsely good prediction of visual acuity, because the pinhole effect avoids the irregular areas
during preoperative testing. A large stimulus may test parafoveal retinal areas, overestimating the acuity in amblyopic eyes.
Dilating the pupil may help prevent a falsely poor reading, not cause a falsely good reading.
Question 13 of 90
A new patient wishes to be fitted with contact lenses for an upcoming ski trip. He plans to wear the contact lenses only for
recreational activities. His refractive correction is -6.00 +0.25 x 090 OU. Which type of lenses should you recommend?
Rigid gas-permeable (RGP) lenses
PMMA lenses
Spherical soft hydrogel lenses
Toric soft lenses

Feedback: Patients who plan to wear contact lenses only on an occasional basis, such as for sporting activities, do best
with soft contact lenses. RGP lenses have a longer adaptation time and are not suited to occasional wear. Soft lenses have
a shorter adaptation period and can usually be worn on an occasional basis. In addition, patients who wear lenses in this
pattern often prefer, and do best with disposable lenses, because there is less concern about when the lenses were last
used. Also, they are easy to transport and can easily be stored in the blister packaging in which they are commonly sold. A
toric soft lens is not necessary for this small amount of astigmatism.
Question 13 of 90
A new patient wishes to be fitted with contact lenses for an upcoming ski trip. He plans to wear the contact lenses only for
recreational activities. His refractive correction is -6.00 +0.25 x 090 OU. Which type of lenses should you recommend?
Rigid gas-permeable (RGP) lenses
PMMA lenses
Spherical soft hydrogel lenses
Toric soft lenses

Feedback: Patients who plan to wear contact lenses only on an occasional basis, such as for sporting activities, do best
with soft contact lenses. RGP lenses have a longer adaptation time and are not suited to occasional wear. Soft lenses have
a shorter adaptation period and can usually be worn on an occasional basis. In addition, patients who wear lenses in this
pattern often prefer, and do best with disposable lenses, because there is less concern about when the lenses were last
used. Also, they are easy to transport and can easily be stored in the blister packaging in which they are commonly sold. A
toric soft lens is not necessary for this small amount of astigmatism.
Question 14 of 90
Which of the following statements is not consistent with the American Academy of Pediatrics and the American Academy of
Ophthalmology's Joint Policy Statement on Protective Eyewear for Young Athletes?
A child with no refractive error and normal acuity should wear recreation spectacles with polycarbonate lenses to play
racquetball.
A child with a best-corrected visual acuity of 20/20 OD and 20/60 OS should wear recreational spectacles to participate
in wrestling.
A child with normal visual acuity and a history of traumatic hyphema with angle recession should wear an approved
street-wear frame that meets ANSI Standard No Z87.1 with polycarbonate lenses to run track.
A child with normal visual acuity who is a 9 D myope should wear contact lenses and recreational spectacles with
polycarbonate lenses over them to participate in a soccer league.
Feedback: The American Academy of Pediatrics and the American Academy of Ophthalmology published a Joint Policy
Statement regarding protective eyewear for young athletes in August 1996, outlining their recommendations for participation
in various types of sports. Functionally one-eyed patients (those with a best-corrected acuity of less than 20/40 in the
poorer-seeing eye, assuming that the amblyopia therapy has been accomplished) and athletes who have had eye surgery or
trauma, and whose ophthalmologists recommend eye protection, should wear protective eyewear while participating in
sports. In addition, "functionally one-eyed patients and those who have had an eye injury or surgery must not participate in
boxing, wrestling, or martial arts," because protective eyewear is not permitted in these sports. Frames that meet ANSI
Z87.1 (ANSI Z87.1-1989 American National Standard Practice for Occupational and Educational Eye and Face Protection
New York: American National Standards Institute, Inc., 1989;14.) are easily identified by the marking "Z87/1" on the temples
and front of the frame.
Question 15 of 90
An established contact lens patient calls at 4:00 PM on a Friday afternoon complaining of red eyes when wearing his contact
lenses. What should you do?
Suggest switching to a new contact lens cleaning regimen
See the patient immediately
Ask about redness and discomfort when not wearing the lenses
Schedule a visit for Monday

Feedback: Red eyes in contact lens wearers have many possible causes. Some are vision threatening and require
immediate attention, but to assess the seriousness of the problem over the telephone, it is always good to ascertain how the
eyes look and feel without the contact lenses in. If the eyes feel normal, vision is good, and there is no discharge, the
chances are that this is a contact lens problem and not a vision-threatening emergency. Some of the types of problems that
cause irritation with lens wear can be related to lens fit, lens deposits, cleaning solutions, or development of an allergic
reaction (such as giant papillary conjunctivitis), none of which may require an emergency visit.
Question 16 of 90
Which of the following statements does not accurately describe the visual function of low-birthweight infants (<1251 g [2 lb,
12 oz]) with retinopathy of prematurity (ROP)?
The prevalence of blue-yellow (tritan) color vision deficits is 200 times that of the general population.
Temporal macular drag can cause a positive angle kappa, simulating an exotropia.
Myopia is common, especially in infants treated for threshold ROP.
Cortical visual impairment is an unusual cause of visual impairment in children who have had ROP.
Feedback: The visual and ocular sequelae of premature babies in general, and of those with retinopathy of prematurity
(ROP) in particular, are extremely serious, and our understanding of the visual function of these infants is still evolving. It is
widely accepted that these children have a higher incidence of myopia than the general population, and that peripheral
retinal traction can cause temporal drag of the macula. Temporal macular drag causes a positive angle kappa, and the child
can appear to be exotropic with Hirschberg light reflex testing, but are orthophoric with alternate cover testing. The incidence
of red-green color vision deficits in children with a history of ROP is the same as in the general population, but the incidence
of tritan (blue-yellow) defects is much higher. The mechanism of this finding is unclear. Cortical visual impairment is a well
recognized cause of visual impairment in this population and may further compound visual loss caused by cicatricial ROP.
Question 17 of 90
The cornerstone of any low-vision evaluation is obtaining an accurate refraction. which of the following statements does not
accurately describe obtaining an accurate refraction?
The low-vision acuity chart should be positioned at 1 m from the patient to permit greater accuracy in measuring
acuities; this simplifies conversion to the distance refraction by deducting 1 D of sphere from the 1 m manifest.
Retinoscopy is important in determining accurate sphere and cylinder, as well as in assessing media opacities that
may affect low-vision rehabilitation decisions.
Keratometry is helpful in revealing uncorrected astigmatism.
A phoropter with a full 6 D of astigmatic range is ideal for assessing best monocular acuities and any binocular
performance enhancements.
Feedback: Surprisingly, patients with low vision often use eyeglasses that no longer meet their refractive needs. An
accurate refraction provides the clinician with an important foundation on which to base recommendations for low-vision
aids. However, performing an accurate refraction is sometimes difficult, given the patient's poor quality of vision. Inspecting
the red reflex for media opacities and performing an accurate spherocylindrical assessment is essential early in the low-
vision examination. The standard ophthalmic examination routine, though, may not be completely suitable for this. Low-
vision patients often find that the constricted visual field offered through a phoropter compromises eccentric viewing.
Binocular evaluations from behind the phoropter are even more problematic, because the device obstructs assessment of
ocular positioning. The refraction should be performed instead using trial frames with large-aperture trial lenses and should
be subjectively refined using high-power Jackson cross cylinders (±0.50,±1.00), as indicated, for decreasing acuity:
Approximate Jackson Cross-Cylinder Power by Visual Acuity 20/20 or better 0.12; 20/25 to 20/30 0.25; 20/40 to 20/50 0.50;
20/60 to 20/100 1.00. An acuity chart at standard distances (20ft) loses measurement accuracy with visual acuity worse than
20/100. To improve acuity determinations, bring the low-vision chart to 1m in front of the patient. This simplifies converting
the 1-m refraction (a 1-D optical length) to a distance value. One simple method of disclosing uncorrected astigmatism is
keratometry, which should be performed prior to the subjective manifest refraction
Question 18 of 90
An asymptomatic 6-year-old has uncorrected Snellen acuity of 20/50 OD and 20/40 OS. Ductions and versions are full, and
the child is orthophoric at near and distance. Cycloplegic refraction of OD +1.00+4.50x045 and OS +0.50+4.00x135 yields
no improvement in acuity. What is the best course of treatment?
Prescribe +0.75+4.50 x 045 OD, and +0.25 +4.00 x 135 OS
Prescribe the spherical equivalent correction, because there is no change in acuity with correction
Not to prescribe glasses, because there is no change in acuity with correction
Prescribe +0.75+2.25x045OD, and +0.25+2.00x135 OS, because the child might not tolerate the full amount of oblique
cylinder
Feedback: The child has bilateral refractive amblyopia associated with long-standing, uncorrected high astigmatism. This
child's acuity will likely improve with spectacle wear, and may respond to patching if the vision becomes more asymmetric.
Some children respond to amblyopia treatment until 10 years of age, so treatment should not be withheld just because the
child is older than 6. Undercorrecting the astigmatism will jeopardize the amblyopia therapy. Unlike adults, children almost
never complain of meridional distortion; the full astigmatic correction should be prescribed.
Question 19 of 90
Which of the following statements is not accurate regarding changes in a pregnant or lactating woman's eyes?
Hormonal changes can induce an anterior displacement of the lens, causing a myopic shift.
Contact lens intolerance is common during pregnancy and lactation.
Increasing myopia may be a sign of gestational diabetes.
Corneal curvature increases by almost a diopter during the third trimester and while breast-feeding.
Feedback: Pregnancy and lactation induce a number of changes in ocular physiology, and not all of the changes are well
understood. Gestational diabetes can cause increasing lenticular myopia, so sudden myopic changes in refraction should
prompt the ophthalmologist to notify the patient's obstetrician. Contact lens intolerance is common in pregnant women.
Corneal curvature has been documented to increase by almost a diopter in the third trimester; this persists until after the
woman stops breastfeeding. Caution should be exercised when considering refractive surgery on a pregnant or lactating
woman. Lenticular displacement has not been reported.
Question 20 of 90
A patient wants to be fitted for contact lenses. If the patient's spectacle correction is -2.50 +1.25 x 175, what is the correct
minus cylinder form?
-1.25 -1.25 x 175
-3.25 -1.25 x 175
-1.25 -1.25 x 085
-3.25 -1.25 x 085

Feedback:
To transpose from plus to minus cylinder form, the sphere and cylinder are added together to determine the new spherical
value. The sign of the cylinder is changed, and the axis is changed by 90°. {new sphere = -2.50 (old sphere) + (+1.25) (old
cylinder) =-1.25; new cylinder = -1.25; new axis = 175°-90° =85°}
Question 21 of 90
A corneal ring infilitrate may be seen in which one of the following?
Topical anesthetic abuse
Adenoviral infection
Methacillin-resistant staphylococcus aureus infection
Demodex folliculorum
Feedback: It is important to recognize that topical anesthetic abuse may resemble infections with herpes simplex, herpes
zoster, acanthomeba, or pseudomonas.
Question 22 of 90
Phtotherapeutic keratectomy (PTK) with the excimer laser may be effective for which of the following lesions?
Elevated herpetic scars
Depressed corneal scars
Reis Buckler dystrophy
Mild corneal edema from Fuch's dystrophy

Feedback: Elevated scars, Reis Buckler, and granular and lattice corneal dystrophies have shown to be effectively treated
with PTK.
Question 23 of 90
Keratoconus may be associated with which one of the following ophthalmic conditions?
Superior limbic keratoconjunctivitis
Herpes simplex keratitis
Epidemic keratoconjunctivis
Leber's congenital amaurosis

Feedback: Leber congenital amaurosis has been associated with keratoconus, and it has been postulated that this is due to
eye rubbing, the oculo-digital sign, because of poor vision.
Question 24 of 90
Which of the following is most correct regarding pellucid marginal degeneration?
It is easily distinguished from contact lens overwear on topography.
The most ectactic area is just below the area of thinning.
The area of cornea thinning is 1-2 mm in width, and occurs 1-2 mm from the limbus at the 4-8 o'clcock position.
It is not usually seen in women more than 30 years old.

Feedback: The most ectactic area of the cornea is just above the area of thinning. It may be quite difficult to distinguish
Pellucid marginal degeneration from contact lens overwear on one topography, and thus care must be taken when
screening contact lens patients for refractive surgery.
Question 25 of 90
Progression of refractive effect is seen after which one of the following?
LASIK for myopia less than 3 diopters
Radial keratotomy
Conductive keratoplasty
LASIK for hyperopia for more than 3 diopters

Feedback: 43% of RK patients have demonstrated at least 1 diopter of progressive hyperopia from 6 months to 10 years
postoperatively. All the other surgeries listed either are stable, or indeed show a regression of effect over time.
Question 26 of 90
What is the major anterior segment complication of human immunodeficiency virus (HIV)?
Pterygium
Keratitis sicca
Corneal neovascularization secondary to stem-cell deficiency
Cataract
Feedback: Similar to HIV retinopathy, kerratitis sicca appears to be caused by the HIV virus itself.
Question 27 of 90
Filamentary keratitis has been reported after which one of the following procedures?
Ucomplicated LASIK
PRK when a bandage contact lens is used with a topical nonsteroidal anti inflammatory drug
PRK when the operated eye has been patched
LASIK enhancement surgery when the flap is lifted

Feedback: Patching will cause filamentary keratitis. Uncomplicated lasik in a healthy patient should not be associated with
this keratitis.
Question 28 of 90
Under which circumstance is it important to use a Flieringa ring during penetrating keratoplasty?
The patient is phakic
There is a need to control post operative astigmatism
A glaucoma filtering bleb is present
Keratoplasty in infants and children

Feedback: The infantile and pediatric sclera is very contractile and causes significant posterior pressure.
Question 29 of 90
Which one of the following corneal dystrophies is expected to show the fastest recurrence after penetrating keratoplasty?
Macular dystrophy
Schnyder's crystalline dystrophy
Fuch's dystrophy
Reis Buckler dystrophy

Feedback: Fuch's dystrophy tends not to recur. Schnyder's and macular tend to recur slowly over 10 years.
Question 30 of 90
A 51-year-old electrical engineer has a refraction of -2.50 +0.25 x 161 and -2.25 +0.75 x 016; his accommodative amplitude
is 1 D. He has bifocals, but complains of trouble with his intermediate vision. You write a prescription for trifocals, with an
intermediate of +1.50 and a near of +3.00. He returns a week later complaining of "gaps" in his clear vision. Which of the
following measurements would be most consistent with this patient's complaint?
67 and 100 cm, 40 and 33 cm
67 and 100 cm, 25 and 40 cm
infinity and 67 cm, 40 and 33 cm
infinity and 40 cm, 33 and 25 cm

Feedback: Patients with trifocals may notice the gaps between the zones of clear vision provided by the combination of the
add and residual accommodation, particularly if the gaps occur at a distance the patient needs to see clearly. This patient's
accommodation allows him to see clearly with the distance portion of his glasses from infinity to 1 m (100 cm). Through the
intermediate segment, he can see clearly between 67 cm (1/1.50 D) and 40 cm (1/2.50 D). With the near segment, he can
see clearly between 33 cm (1/3.00 D) and 25 cm (1/4.00 D). Thus, the gaps in his near vision are between 100 and 67 cm
and between 40 and 33 cm. The intermediate and near powers can be adjusted to suit his needs, or progressive addition
lenses could be considered if he were motivated enough to learn to tolerate the aberrations they produce.
Question 31 of 90
Which one of the following is a cause of macrostriae following laser in situ keratomileusis (LASIK)?
Eye rubbing or poor flap adherence in the early postoperative period
Disparity created between the curvature, between the posterior flap and the treated corneal bed
Hyperopic treatments
Epithelial basement membrane dystrophy

Feedback: Microstriae, small barely visible folds in the LASIK flap, are fairly common following LASIK in several scenarios,
namely large treatments and some hyperopic treatments. These small striae are generally asymptomatic. Macrostriae
(larger folds in the flap), on the other hand, can significantly affect the post operative visual acuity and frequently result from
movement of the flap relative to the bed postoperatively. This movement can be caused by eye rubbing or simple blinking if
adherence to the bed is poor. For this reason the surgeon should ensure that there is good flap adherence before allowing
the patient to leave the treatment room. Protective shields are also frequently used for the first 24 hours following a LASIK
procedure and nightly thereafter for several days to prevent inadvertent touching of the operative eye.
Question 32 of 90
Which one of the following statements best describes Snellen visual acuity testing?
It measures the refractive error of the eye.
It measures the smallest angle that can be resolved by the eye.
It measures contrast sensitivity.
It measures the resolving power of the retina.

Feedback: Determination of visual acuity really measures the smallest separation of two objects at which they can be
appreciated as two separate objects. This ability is dependent on a large variety of factors including the amount of
uncorrected optical aberrations in the visual system, the health of the photoreceptors, and opacities in the media etc.
Snellen notation records the smallest angle of separation recognized by the patient.
Question 33 of 90
Immediately after finishing laser in situ keratomileusis (LASIK), you are informed that the wrong treatment has been entered.
Instead of -2.50 -1.00 x 180, -1.00 -2.50 x 180 was entered. What should be done?
Ignore the mistake and follow the patient postoperatively, since in plus cylinder format the spherical correction is not
too far off.
Immediately lift the flap to treat +1.50 sphere followed by plano -1.50 x090.
Ignore the mistake and offer the patient a free enhancement if the results are not perfectly satisfactory.
Tell the patient about the mistake. Provide spectacles for the early post operative period, if necessary, and re-evaluate
the patient for a corrective enhancement in 3 months after the refractive results have stabilized.
Feedback: Mistakes happen, and the best approach is to immediately inform the patient. By involving the patient early,
there is no suspicion of the physician “hiding” something. No immediate correction should be undertaken. Allow the
refraction to stabilize for 3 months and re-evaluate the patient.
Question 34 of 90
Peripheral corneal relaxing incisions are contraindicated in patients with which of the following?
History of penetrating keratoplasty
Arcus senilis
Pseudophakic patients
Terrien's marginal degeneration

Feedback: Relaxing incisions, to reduce astigmatism, can be very helpful in treating low levels of naturally occurring
astigmatic error, or in post operative cataract or PKP patients to decrease astigmatism. They are contraindicated in patients
with corneal thinning disorders, such as Terrien’s marginal degeneration, due to the risk of corneal perforation and
unanticipated refractive results.
Question 35 of 90
How is the risk of epithelial ingrowth after laser in situ keratomileusis (LASIK) affected?
It is increased if a corneal abrasion develops
It is nearly eliminated by the use of mitomycin C intraoperatively
it is higher in hyperopic treatments
It is increased by treatments for higher levels of refractive error

Feedback: Epithelial ingrowth results when the epithelium gains access to the interface. This risk of this complication is
increased when an epithelial defect occurs over the graft host junction, or in cases of poor flap adherence.
Question 36 of 90
A patient with myopic astigmatism wants laser in situ keratomilus (LASIK). Best corrected visual acuity is 20/15 with
spectacle correction. When screening the patient for the procedure, what is the best method of evaluating the patient's
astigmatism?
Refraction
Computerized corneal topography
Retinoscopy
Keratometry
Feedback: While refractive cylinder is key to planning the astigmatic treatment of LASIK patients, screening should involve
computerized corneal topography. Even patients with good spectacle corrected vision can have topographic features of
“form fruste” keratoconus, and thus should be excluded from the procedure.
Question 37 of 90
Which of the following steps during surgery is critical when implanting a phakic intraocular lens?
Avoid rotation of the implant
Rotate the posterior chamber implant 90 degrees to allow for maximal crystalline lens clearance
Generous amounts of viscoelastic should be used
Leave a very small amount of viscoelastic to prevent pupillary block

Feedback: The least amount of lens rotation is critical to avoid pigment dispersion into the anterior chamber angle.
Viscoelastic should be used sparingly to avoid iris prolaspe.
Question 38 of 90
A patient with no previous ocular pathology develops sudden onset of pain, photophobia, redness, and decreased vision 3
days after uncomplicated laser in situ keratomileusis (LASIK). What would the least likely diagnosis be?
Diffuse lamellar keratitis
Atypical mycobacterial keratitis
Herpes simplex virus (HSV) keratitis
Acanthamoeba keratitis
Feedback: Keratitis following LASIK is always a cause for concern, and good visual outcome depends on the successful
diagnosis and treatment of the underlying cause. Early onset causes can be diffuse lamellar keratitis (DLK) or Herpes
simplex (HSV) keratitis. Atypical mycobacteria have been implicated in several cases of post LASIK keratitis. While
mycobacterial keratitis is though of as a late onset organism, it can appear as early as early as 3 days following LASIK.
Acanthamoeba, however, is very rare following LASIK and generally has a delayed onset (weeks to months) following the
procedure.
Question 39 of 90
Which of the following tests of visual function is most dependent on patient input?
Pupil reactivity to light
Visually evoked potentials
Snellen visual acuity testing
Opticokinetic drum testing

Feedback: Visual acuity measurement involves more than being able to see the optotypes. The patient should be
cooperative, understand the optotypes, be able to communicate with the physician, and many more factors. If any of these
factors is missing, then the measurement will not represent the patient's real visual acuity. Visual acuity is a subjective test,
meaning that if the patient is unwilling or unable to cooperate, the test cannot be done. A patient being sleepy, intoxicated,
or having any disease that can alter the patient's consciousness or his mental status can make the measured visual acuity
worse than it actually is.
Question 40 of 90
A patient has irregular astigmatism following creation of a severely decentered laser in situ keratomileusis (LASIK) flap.
Which of the following treatment options is the safest initial option to correct the vision?
Rigid gas permeable contact lenses
Lamellar keratoplasty
Transepithelial phototherapeutic keratectomy
Recutting of the flap followed by a custom LASIK procedure

Feedback: Decentered ablations frequently result in irregular astigmatism. Unfortunately, irregular astigmatism is very
difficult to treat with currently available technology. Frequently, however, corneal remodeling will result in a reduction of the
amount and degree of irregularity, and no patient should have an enhancement before 3 months of healing has occurred.
For this reason, a hard contact lens is the best option for the early restoration of vision.
Question 41 of 90
Which of the following patients is an appropriate candidate for laser in situ keratomileusis (LASIK)?
15-year-old with RX -3.00 + 1.00 X 90
37-year-old with RX -12.00 + 1.00 X 90
23-year-old with RX +6.00 + 2.00 X 90
23-year-old with RX -5.00 +2.00 X 90

Feedback: Patient selection is key to successful LASIK procedures. The best candidates are low to moderate myopes with
low degrees of astigmatism. Treatment of high degrees of hyperopia (> + 4.00) are unreliable and disallowed by many
lasers. Additionally, very high myopia, although treatable, is associated with deleterious aberrations and suboptimal quality
of vision. Lasik should not be performed in juvenile patients except under very unusual circumstances.
Question 42 of 90
Which of the following causes of vision loss would be least likely to benefit from low vision aids?
Wet macular degeneration with bilateral central disciform scars
Retinitis pigmentosa
Advanced glaucoma
Cognitive visual impairment

Feedback: Cognitive visual impairment results from an inability of the brain to process the visual input. For this reason,
magnification of the visual image would not be expected to improve visual function
Question 43 of 90
Which of the following procedures cannot correct hyperopia?
radial keratotomy (RK)
laser in situ keratomileusis (LASIK)
thermokeratoplasty
conductive keratoplasty
Feedback: Radial keratotomy is a procedure in which radial incisions are created in the corneal periphery so as to flatten
the corneal center. As such, it is a procedure to correct myopia. Some incisional approaches to correct hyperopia have been
suggested (hex-k), but have not proven useful.
Question 44 of 90
A soft contact lens wearer presents with acute development of a 5 mm fluffy paracentral corneal infiltrate, a retrocorneal
inflammatory plaque, and hypopyon. What is the etiologic agent?
Fusarium species
Unable to be determined from the description
Acanthamoeba
Staphylococcus aureus
Feedback: It is very difficult, if not impossible, to determine the etiology of an infectious agent by clinical appearance alone.
While the appearance may suggest etiologies, the practitioner must perform diagnostic testing (cultures etc.) before
instituting treatment in significant disease.
Question 45 of 90
Which of these candidates would be the best choice for astigmatic keratotomy?
42.5D at 15; 48D at 105
42.75D at 25; 43D at 115
42D at 40; 44D at 70
42D at 70; 44D at 160

Feedback: Astigmatic keratotomy is a good choice for reducing low levels of regular astigmatism. Generally this procedure
can be relied upon to reduce up to 2.5 to 3.00 D of cylinder. This procedure should not be employed for irregular or non-
orthogonal astigmatism, high astigmatic errors, or trivial levels of astigmatism
Question 46 of 90
Which of the following intraocular lens (IOL) types is not suitable for implantation in a patient with proliferative diabetic
retinopathy and significant cataract?
Foldable acrylic IOL
Foldable silicone IOL
Polymethylmethacrylate (PMMA) lens with prolene haptics
All-polymethylmethacrylate (PMMA) IOL

Feedback: Silicone IOLs are contraindicated in patients who currently have, or are likely to require, silicone oil during
vitreoretinal surgery. The silicone oil can form droplets on the lens optic, reducing visual acuity and visualization of the
fundus. Acrylic and PMMA lenses are compatible with silicone oil.
Question 47 of 90
Which of the following best describes dome magnifiers (for example, Visolett magnifiers)?
The magnified field of view appears dimmer under the dome, so extra illumination is usually required.
All sizes of dome magnifiers made of the same optical glass have the same magnification.
The use of high-add spectacles produces distortion within the magnified image.
These magnifiers should be held several centimeters above the reading material.
Feedback: Dome magnifiers are constructed from high-quality optical glass, or plastic material, and are available in a
variety of powers depending on size, dome curvature, refractive index, and internal optical designs. They are constructed
with a wide, often flat, bottom surface for placement directly on the material of interest. Holding dome magnifiers at any
height above the text degrades performance. Because of the absorptive properties of the glass or plastic and the absence of
an internal illumination source (as is found with hand-held self-illuminated stand magnifiers), patients using these devices
typically benefit from extra environmental illumination. However, direct illumination, such as from a gooseneck lamp or from
broad, high-intensity fluorescent lighting, may produce aggravating glare off the dome, and is often rejected by users. These
dome magnifiers, like all the stand magnifiers, are suitably used with the patient's preexisting spectacle add, being held at
the optical distance calculated for the spectacle optics and the magnifier's design. Many patients locate this preferred
distance with minimum clinical assistance and without extensive mathematical calculations. The combination of spectacles
and magnifiers does not produce extra distortion, but can adversely affect viewable visual field and binocular performance
depending on optic size and device proximity to the user.
Question 48 of 90
What is the appropriate depth for placement of intrastromal corneal ring segments (INTACS) in a myopic cornea?
1/3 corneal thickness
Subepithelial
2/3 corneal thickness
Just above Descemet's membrane

Feedback: In order for corneal ring segments to perform properly, implantation depth is critical. Too deep or too shallow can
result in erosion and sub optimal effect.
Question 49 of 90
Which of the following would not diminish HIV transmission from the use of trial contact lenses?
Use of enzymatic cleaner, followed by copious saline irrigation
Using a hydrogen peroxide disinfection system for cleaning trial lenses
Heat-sterilizing soft contact lenses used for contact lens fitting
Disposing of trial lenses after each use

Feedback: HIV has been detected in the tear film of infected patients, but the risk of transmitting this virus by contact lenses
is probably small and has not been documented. In order to decrease the risk of contamination with trial lenses, the Centers
for Disease Control (CDC) recommends sterilizing lenses prior to reuse. Heat sterilization, hydrogen peroxide systems, or
chlorhexidine-based chemical disinfection are all appropriate methods of cleaning prior to reuse. Enzymatic cleaning is not a
recommended method for disinfection prior to reuse.
Question 50 of 90
In which of the following cases may intrastromal corneal ring segments (INTACS) be helpful?
To correct the refractive error in an eye with corneal thickness of 350 microns
In a contact lens intolerant eye with keratoconus
To correct the refractive error in an eye with a refraction of -5.50 +0.75 X 90
To correct the refractive error in an eye with a refraction of +2.50 + 0.75 X 180
Feedback: Intrastromal ring segments, once touted for the treatment of low to moderate myopia, are currently being
employed for the treatment of corneal ectasias. To date, the data is still not conclusive as to what role they will play in these
disorders.
Question 51 of 90
Five years ago, a patient underwent bilateral 16-incision radial keratotomy with a 3 mm optical zone. This patient has now
developed 4 mm posterior subcapsular cataracts in each eye. His vision is limited to 20/50 visual acuity OU due to the
cataracts, and IOL implantation is planned. What is the least accurate method for determining the corneal K readings to be
used for IOL calculation in this patient?
Automated keratometry
Calculation of K readings from preoperative radial keratometry K readings and the change in refraction
Manual keratometry
Calculation of change in refraction with and without a hard contact lens

Feedback: Manual keratometry is the least accurate of all methods for determining corneal power. The manual keratometer
measures two points approximately 3.2 mm apart to determine the corneal power in a given meridian. The nearer the optical
zone of the keratorefractive procedure is to the 3.0 mm diameter, the more inaccurate the manual keratometer. Automated
keratometers use a slightly smaller sample diameter of approximately 2.6 mm, which is why automated instruments perform
slightly better. The change in refraction with and without a contact lens can be very accurate, but it is limited by the patient's
visual acuity as a result of the cataract. Although calculating K readings from the corneal power prior to the keratorefractive
procedure and the change in refraction is very accurate, the values are not always available to the cataract surgeon. Some
corneal topographic instruments do provide accurate corneal power measurements of irregular corneas, but these systems
are not always available. The patient's course following the cataract surgery is often similar to the acute postoperative period
following radial keratotomy, with an immediate hyperopic overcorrection that decreases over a few days or weeks.
Knowledge of these changes helps to prepare the surgeon and patient for the visual changes during the immediate
postoperative period.
Question 52 of 90
An intraocular lens (IOU) placed in the capsular bag, following phacoemulsification and continuous-tear capsulorrhexis, has
moved axially toward the cornea over the first 6 weeks after surgery as a result of contraction of the capsule. What would
the expected refractive change be from the anterior axial movement of an IOL?
Hyperopic shift
No effect
Myopic shift
Not determinable
Feedback: The anterior movement of any plus corrective lens (spectacle lens, contact lens, crystalline lens, or IOL)
increases the effective power of the lens. The shift in refraction is therefore always in a myopic direction with anterior
displacement. For a 20.0 D intraocular lens in the posterior chamber, the myopic shift is approximately 1.9 D of myopia for
every millimeter of anterior displacement. For a 20.0 D anterior chamber lens, the shift is approximately 1.2 D of myopia for
every millimeter of anterior displacement. An axial posterior displacement would have exactly the opposite effect, causing a
hyperopic shift. Some of the variability of IOL calculations is due to our inability to predict the exact final axial position of the
IOL prior to surgery.
Question 53 of 90
You examine a healthy 6-month-old child with uncertain visual acuity, but definitely showing a reduced visual interest. The
clinical examination is unrevealing, and further testing is scheduled. Which of the following is most accurate regarding the
child's visual impairment and its educational implications?
The child should be referred immediately to the district school system so special education assessment for visual
impairment can begin.
The absence of nystagmus now and over the next 2 years is an indication that special education vision services are
probably not necessary now and will not be necessary in the future.
The physician should wait to refer a child with a possible visual impairment to the special education system until the
diagnosis is established or legal blindness is confirmed.
Federal law mandates that the visually impaired child, beginning at age 3, be identified to the special education
system.
Feedback: Federal and state laws mandate immediate referral of any child, regardless of age, suspected of having a
potential visual impairment that may affect his or her normal progression in milestones or academics. Upon notification by
the clinician, the local school district will begin an intervention schedule tailored to the infant's needs based on an evaluation
by a professional multidisciplinary team. The presence or absence of nystagmus has no bearing on eligibility for services. In
addition, the lack of a diagnosis is no reason to delay referral. Clinical prognostic statements to the special educators,
although helpful for long-range education planning, are not essential for implementing the academic and adaptive training.
Question 54 of 90
Which of the following statements best describes the incorporation of prism into refractive correction?
Small amounts of base-down prism can be incorporated into contact lenses to compensate for a vertical imbalance.
Small amounts of horizontal prism in the bifocal segment can be induced by decentering progressive addition lenses,
especially if a higher-power addition is used.
High-plus and high-minus aspheric lenses can be decentered according to Prentice's rule to induce horizontal, vertical,
or oblique prism.
Prism should always be split between the right and left eyes for optimum appearance and function.
Feedback: If prism is needed in a progressive addition lens (PAL), it must be ground onto the back of the lens. Horizontal or
vertical decentration of a PAL causes problems due to improper location of the progressive corridor. Similarly, aspheric and
hyperaspheric lenses cannot be decentered to induce prism, because the patient will not be viewing through the optically
sound portion of the lens. Prism must be ground onto the aspheric lens rather than decentering it. Prism ballast is often used
to improve the fit of a contact lens and can also be used therapeutically. Approximately 2.5-3.0 base down can be
manufactured in a rigid lens, and 4 base down in a soft lens. Prism is not always split between the eyes; it is often placed
before one eye alone. For example, slab-off and reverse slab-off lenses have prism only in front of one eye. With smaller
amounts of prism, monocular prism may be less expensive for the patient and cosmetically inapparent. Larger prism
corrections may need to be split between the eyes for ease of manufacture, weight, and cosmesis.
Question 55 of 90
An air traffic controller with 4 D of myopia and 1 D of accommodative amplitude wants single-vision glasses for viewing a
video screen 80cm in front of her. If she uses half of her accommodative reserve, what power lenses should she be given?
-3.00 sph
-2.75sph
-3.50sph
-3.25sph
Feedback: If the patient was fully corrected for distance, she would be able to see comfortably 2m in front of her using half
of her accommodative reserve. The refractionist must supply the remainder in the glasses. The specified viewing distance,
80cm, is 1.25 D from the patient. Because the patient can provide 0.5 D, the ophthalmologist must provide the additional
0.75 D in the glasses. Thus, to meet the patient's requirements, the single vision glasses should be -3.25 sph
Question 56 of 90
Of the following methods, which is the most accurate way to assess visual acuity in a cooperative 4-year-old?
Linear HOTV
Isolated illiterate Es
Linear Allen pictures
Isolated Allen pictures

Feedback: Testing with isolated optotypes is often a faster way to assess acuity in a child than testing with linear optotypes;
however, use of the former may mask amblyopia because of the crowding phenomenon. Thus, testing acuity with linear
optotypes is always preferred over testing with isolated optotypes. Tumbling Es are subject to reversals in children and thus
have a poorer testability rate than HOTV optotypes. Allen pictures are often used for vision testing in preschoolers, but they
are not as difficult as HOTV or Snellen acuity optotypes. A slight decrease in acuity may be noted when switching from an
easier test (such as Allen) to a more difficult one (such as Snellen).
Question 57 of 90
Which of the following statements best describes antireflection coatings on eyeglasses?
They are always clear and colorless.
They work by destructive interference of reflected light.
They decrease reflections by producing a matte surface.
They are applied by a dipping process.

Feedback: Tints can be applied by a dipping process, but antireflection coatings can not. Antireflection coatings are thin-film
crystalline substances applied by vacuum evaporation/deposition techniques. The surface created is entirely smooth and
specular, not matte; a matte surface would interfere with vision. Reflection is decreased by destructive interference of light
reflected from the front and back surfaces of the coating. Destructive interference is only maximal at a peak wavelength for a
given coating, and wavelengths at the ends of the visible spectrum are often partly reflected, giving a slight purple color to
these coatings.
Question 58 of 90
Which of the following eyes would not be a candidate for astigmatic keratotomy during cataract surgery with IOL
implantation?
43.50/45.75@004, cycloplegic refraction +3.50 +2.00 x 005
42.50/44.67@057, cycloplegic refraction +2.50 +0.25 x 60
44.00/45.87@105, cycloplegic refraction -2.25 -2.00 x 016
43.37/43.50@026, cycloplegic refraction -4.50 +2.50 x 025

Feedback: Astigmatic keratotomy is sometimes combined with cataract surgery to reduce postoperative astigmatism. The
surgeon should be cognizant of situations in which lenticular astigmatism is a contributory factor. The eyes in two of the
responses have corneal astigmatism alone and are candidates for astigmatic keratotomy. The eye in the other incorrect
response has corneal astigmatism that is compensated for by lenticular astigmatism. When the cataract is removed, the
corneal astigmatism will be manifest; thus, astigmatic keratotomy is a consideration, even though the patient does not have
significant astigmatism on refraction. The preferred response has an essentially spherical cornea, but significant astigmatism
during refraction. When the cataract is removed, the lenticular contribution to the astigmatism should no longer be a factor.
In this case, astigmatic keratotomy would create, rather than relieve, astigmatism.
Question 59 of 90
Ultraviolet absorbing lenses do not help to protect against which of the following?
Pterygium
Eyelid cancers
Age-related macular degeneration
Cortical cataract
Feedback: There is increasing evidence that both the light we see and the light we don't see may have potentially damaging
effects on the eye and ocular adnexa, particularly the ultraviolet (UV) wavelengths. About 5% of our total solar radiation is
ultraviolet; of that, 90% is UV-A and 10% is UV-B. UV-A(400-320 nm) produces suntans and photosensitive reactions; UV-B
(320-290 nm) causes sunburns and is associated with skin cancer; UV-C (290-100 nm), the most hazardous, is absorbed by
the ozone layer. Visible light may also be responsible for ocular damage. Ultraviolet damage to the human crystalline lens
has been addressed by a number of animal and epidemiological studies. Cataract formation has been documented in
rabbits after both chronic and short-term, highintensity exposure to UV-B. The strongest association is between UV-B
exposure and cortical cataract formation; this association was borne out by both the Beaver Dam Eye Study, and a
population-based survey of Maryland watermen. Pterygium formation and the development of climatic droplet keratopathy
are associated with UV-A, UV-B, and visible light exposure. The cause of age-related macular degeneration (ARMD) is
multifactorial, and visible light may play a role in its pathogenesis. Although ultraviolet light exposure is associated with
cataractogenesis, there is no evidence that UV-B or UV-A exposure is related to ARMD. Prevention of potential eye and
adnexal damage with absorptive lenses and wide-brimmed hats is a simple approach to concerns about UV radiation.
Ophthalmologists may wish to consider recommending spectacle lenses that block ultraviolet light to decrease a patient's
risk of cortical and posterior subcapsular cataracts, eyelid cancers, pterygium, and climatic droplet keratopathy. Decreasing
the incident visible light with tinted lenses while outdoors may be desirable both for comfort and to decrease the risk of
ARMD, but lens color is not indicative of UV-blocking abilities. Spectacle lenses are most commonly made of plastic (CR-39
or polycarbonate) and absorb a substantial portion of UV-A radiation and almost all UV-B.14 UV transmittance can be
decreased further by invisible chromophores incorporated into the lens material without affecting the transmission of visible
light. Glasses should fit close to the face. Widebrimmed hats can further decrease incident radiation.
Question 60 of 90
Closed-circuit television systems provide great assistance for many individuals with low vision. Which of the following
statements accurately describes this?
Closed-circuit television systems have the ability to present black letters on a white background, or white letters on a
black background. This reverse polarity is useful for patients with photophobia, who prefer to read black letters on a white
background.
Many people who successfully use closed-circuit television systems also use other optical aids for specific tasks.
Like many magnification systems, closed-circuit television requires the user to be at a specific distance for proper
usage.
Patients who can no longer benefit from standard magnification systems also cannot be helped with closed-circuit
television systems.
Feedback: A closed-circuit television (CCTY) reading system consists of a television camera that relays a magnified image
to a television monitor screen. The patient therefore can adjust magnification for a relatively comfortable (and variable)
reading distance. Patients find that using CCTY is less tiring than other aids, because of the more comfortable distance from
the screen. Advantages include the greater range of magnification, the use of binocularity in patients who benefit from using
both eyes, and the ability to do useful work more easily than with regular spectacle or other magnifiers. There are
disadvantages as well, including slow reading speed, the weight of the CCTV units, and the expense of these units in
comparison with other magnifying devices. Reverse polarity is an important feature of CCTV; patients who experience
photophobia prefer white letters on a black background, since the illumination can be intense and a white background
causes a glare effect. Many patients, particularly young patients who have considerable difficulty with standard magnification
systems, are able to work full or part time using the CCTV system. Many people successfully use a combination of regular
low-vision optical aids and the CCTV system.
Question 61 of 90
Which one of the following statements accurately describes the spherical equivalent power of a Jackson cross cylinder?
The spherical equivalent of a Jackson cross cylinder always equals one half the cylinder power.
The spherical equivalent of a Jackson cross cylinder lens can be calculated only if the difference in the cylindrical
powers of the lens is known.
The spherical equivalent of a Jackson cross cylinder is always zero.
The spherical equivalent of a Jackson cross cylinder lens always equals the cylindrical power.
Feedback: A Jackson cross cylinder lens consists of two cylindrical lens of equal but opposite power orthogonal to each
other (e.g. +0.25D X 90 degrees -0.25D X 180 degrees). Therefore, the power of a Jackson cross cylinder is zero, making it
useful to detect astigmatism without changing the spherical equivilent of the lens system.
Question 62 of 90
Which of the following slit-lamp findings best differentiates infectious keratitis from diffuse lamellar keratitis?
Iris neovascularization
Conjunctival injection
Granular infiltrates
Keratic precipitates
Feedback: Granular infiltrates and conjunctival injection can be seen with DLK and infectious keratitis, however, keratic
precipitates are usually seen only with infectious keratitis and are not part of the clinical findings of DLK. Iris
neovascularization is not associated with DLK or infectious keratitis.
Question 63 of 90
At which of the following stages of diffuse lamellar keratitis is lifting of the flap and irrigation of the lamellar bed most
commonly performed?
Dense, central, stromal scarring with fixed flap folds
Fine, powdery, granular haze in the lamellar periphery
Clumped, white, granular haze - densest in the central lamellar interface
Fine, white, granular haze throughout the lamellar interface

Feedback: Clumped, white, granular haze - densest in the central lamellar interface describes stage 3 of DLK and is less
likely to respond to topical steroid drops and more likely to progress to corneal scarring unless the flap is lifted and irrigated.
Therefore it is the preferred choice. Fine, powdery, granular haze in the lamellar periphery and fine, white, granular haze
throughout the lamellar interface describe stages 1 and 2 of DLK, which usually respond to topical steroid drops. In these
cases, surgical intervention is not necessary. Dense, central stromal scarring with fixed flap folds describes stage 4 of DLK.
Although lifting the flap with irrigation is the appropriate therapy, it is not the stage at which this is most commonly
performed.
Question 64 of 90
A patient with a small, vertical misalignment of the eyes complains of diplopia when reading. Which of the following
therapies has the best chance for resolving the patient's complaints?
Placement of a neutralizing prism over the near segment of the glasses
Orthoptic exercises
Laser in situ keratomileusis (LASIK)
Fogging the distance segment of one eye

Feedback:
Use of prism over the near segment in a patients glasses will result in fusion at near in this patient. In a myope this may be
accomplished by "slab-off" or removal of a wedge or "slab" of the inferior lens curve in the region of the add. None of the
other choices will result in fusion at near in a patient with a vertical misalignment. Orthoptic exercises may play a role in a
patient with a horizontal misalignment, but not a vertical misalignment.
Question 65 of 90
A patient with longstanding, vertical misalignment of the eyes has lost his glasses. He comes to your office for a new
prescription. Which of the following strategies represents the most appropriate use of therapeutic prisms?
Prescribing half the maximum amount of prism the patient will tolerate while still maintaining fusion
Prescribing the minimum amount of prism necessary to achieve fusion
Prescribing the maximum amount of prism the patient will tolerate at fusion
Prescribing twice the minimum amount of prism necessary to achieve fusion

Feedback: In general, the minimum amount of prism that is necessary to achieve fusion is prescribed to patients with
diplopia.
Question 66 of 90
What is the best way to diagnose epithelial basement membrane dystrophy (EBMD)?
Broad-beam tangential illumination by slit lamp
Hruby lens evaluation at the slit lamp
Fluorescein staining
Lissamine green staining

Feedback: Fluorescein stain and lissamine green stain will reveal disruptions in the corneal epithelium which may or may
not be present in EBMD. The Hruby lens is used to look at the retina. Broad-beam tangential slit-lamp evaluation will show
the map-dot fingerprint findings present in EBMD.
Question 67 of 90
Which one of the following medications is commonly used to perform cycloplegic refractions?
Tropicamide 1%
Alcaine 1%
Atropine 1%
Norepinephrine 2.5%
Feedback: Tropicamide and atropine both paralyze the ciliary muscle. However, the duration of action of atropine is too
long to make it an attractive choice. Alcaine is a topical anesthetic and thus not the appropriate choice. Norepinephrine
prevents constriction of the pupil, which results in dilation.
Question 68 of 90
What is the primary force preventing flap dislocation in the immediate postoperative period following LASIK?
Peripheral fibrosis
Endothelial-pump function
Central fibrosis
Lid position
Feedback:
Central and peripheral fibrosis are responsible for late flap adherence. In the early postoperative period, there hasn't been a
chance for fibrosis to occur. The endothelial pump creates corneal stromal dehydration or "suction pressure" which is
responsible for early flap adherence. Eyelid position does not play a significant role in flap adherence.
Question 69 of 90
Which of the following applications is an appropriate use of therapeutic prisms?
Increasing fusional amplitudes
Increasing accommodative amplitudes
Increasing convergence amplitudes in accommodative esotropia
Increasing divergence amplitudes in convergence insufficiency

Feedback:
Asthenopia and even dipolopia can result from inadaquate vergence capability. This fusional deficiency can be treated by
improving fusional amplitudes with orthoptic exercises. Nevertheless, prisms may still be necessary to achieve comfortable
binocularity if convergence exercises are inadequate.
Accommodative insufficiency (AI)involves the inability of the eye to focus at near and is commonly seen with convergence
insufficiency. The use of prisms will not improve AI; however, orthoptic exercises may play a role in increasing
accommodative amplitudes. Accommodative esotropia is caused by untreated hyperopia. When these patients use their
near vision (and thus accommodate), they can have a reflex crossing of the eyes (esotropia). The appropriate treatment is
hyperopic spectacle correction.
Question 70 of 90
What principal factor(s) determine the magnitude of refractive correction associated with laser ablative surgery for myopia?
Pupil size
Keratometry readings
Shape and depth of the ablation
Corneal thickness
Feedback:
Among these options, the only one that influences the amount of refraction correction in myopic laser refractive surgery is
ablation depth and shape. Keratometry readings affect the initial, and consequently the final refraction, but not the
magnitude of correction (change).
Question 71 of 90
A patient who wears soft contact lenses is being treated for a corneal ulcer. Initial gram stain and cultures were negative.
There has been no improvement in their clinical findings after 3 days of fortified antibacterial antibiotics, and the patient
continues to complain of severe pain. What is the most likely causative microbe?
Acanthamoeba
Yersinia
Coagulase negative staphylococcus
Adenovirus
Feedback:
One of the hallmarks of Acanthamoeba keratitis is severe eye pain. This patient is also a contact lens wearer, a known risk
factor for Acanthamoeba. Acanthamoeba is resistant to fortified antibacterial therapy. These factors and the initial negative
gram stain and culture results should raise the suspicion for Acanthamoeba. Coagulase-negative Staphylococcus should
respond to fortified antibiotic therapy, making this an unlikely answer. Yersinia is an uncommon cause of keratitis.
Adenovirus typically does not cause severe eye pain.
Question 72 of 90
What higher-order aberration is most commonly increased in keratoconus eyes?
Horizontal coma
Spherical aberration
Trefoil
Vertical coma
Feedback: Because of the location of the displaced cone, vertical coma is most commonly found in patients with
keratoconus. The other abberations are not characteristic of keratoconus.
Question 73 of 90
By what physical process does excimer laser modify tissue?
Photodisruption
Photothermalizaton
Photoablation
Photocoagulation
Feedback: Photothermalization and photocoagulation both describe the absorption of energy as heat with subsequent
structural change by denaturing tissue proteins. Argon and krypton lasers application are examples of these processes.
Photodisruption describes of tissue rupture such as the posterior lens capsule disruption, which results from collapse of a
highly-energetic plasma bubble. The Nd:YAG (Neodynium: Yttrium-Aluminum-Garnet) laser is an example of this process.
Photoablation results in the cleavage of covalent chemical bonds in tissue proteins. The excimer laser is an example of this
process.
Question 74 of 90
Which of the following wavelengths is produced by the excimer laser?
400 nm
121 nm
700 nm
193 nm
Feedback: The excimer laser produces a wavelength of 193 nm. The photons generated by the excimer laser are directly
absorbed by the cornea and have enough energy to break carbon-carbon and carbon-nitrogen bonds. The cleavage of
carbon bonds to structural proteins, especially collagen of the cornea results in tissue loss or ablation. Small collagen
derived fragments are produced and a volume of corneal tissue is removed. The commercially available argon-fluoride
excimer laser produces peak energy at 193 nm. No clinically significant energy is produced at 121 nm. Wavelengths from
400-700 nm are in the visible spectrum and are not produced by the excimer laser and would not have a significant effect on
the cornea.
Question 75 of 90
Graft stromal melting is most commonly associated with which of the following complications of penetrating keratoplasty
(PKP)?
Premature removal of sutures
Delayed epithelial healing
Premature discontinuation of topical steroids
Delayed removal of sutures

Feedback: Premature removal of sutures can result in graft dehiscence or unpredictable changes in the refractive error.
Delayed suture removal can have minimal to no effect on the refractive error. Premature discontinuation of topical steroids
may predispose a patient to graft rejection. Delayed epithelial healing can start a cycle resulting in stromal melting that can
be difficult to control. For this reason, epithelial healing delayed for longer than 2 to 3 weeks postoperatively should be
aggressively treated.
Question 76 of 90
In patients receiving laser-in-situ-keratomileusis (LASIK), epithelial basement membrane dystrophy (EBMD) increases the
risk for what complication?
Buttonhole flap
Diffuse lamellar keratitis (DLK)
Macrostriae
Free cap flap

Feedback: EBMD predisposes patients to epithelial defects following LASIK. Epithelial defects predispose patients to DLK,
making it the preferred choice. Buttonhole flaps seem to be associated with steep corneas, whereas free cap flaps seem to
be associated with flat corneas. Macrostriae are associated with flap dislocation, which can be caused by many things, such
as eye rubbing, but not to EBMD.
Question 77 of 90
Which of the following is the most reliable indicator that adequate suction has been obtained by a microkeratome?
Pupil dilation
Patient discomfort or pain
Eye rotation with keratome
Changes in size and color of patient's fixation target

Feedback: All these may be indicators of adequate suction by a microkeratome, however, pupil dilation is the most reliable
of these. Eye rotation is possible with pseudosuction and absence of any suction. Changes in the size and color of the
fixation target are an indication that the elevation of IOP has disrupted blood flow to the optic nerve or retina. This effect can
be seen with suction, pseudosuction, or simply by pressing on the globe with the suction ring without applying suction.
Patient discomfort or pain is not a reliable indication that suction has been achieved.
Question 78 of 90
What is the best nomogram to use when programming the excimer laser for refractive ablation?
One based on a published study
One calculated from the surgeon's refractive outcomes
One based on the largest cohort from trusted colleagues
One utilized in Food and Drug Administration (FDA) clinical trials for my excimer laser
Feedback: To best compensate for individual surgeon differences, each surgeon's treatment nomogram should be based
on his or her own clinical outcomes. Published studies, FDA trial results, and collections of outcomes from trusted
colleagues are useful starting points but are not likely to be as accurate as a nomogram based on one's own ongoing
results.
Question 79 of 90
Which of the following findings would help to exclude a diagnosis of forme fruste keratoconus (FFKC)?
Best spectacle corrected vision of 20/20 or better
Asymmetric bow-tie astigmatism
Average keratometry of 48 diopters
1.5 diopters of astigmatism at 120 degrees

Feedback: Although patients with FFKC can certainly have a best spectacle corrected vision of 20/20, all the other answers
support the diagnosis of FFKC, making this the preferred choice.
Question 80 of 90
What are the excited molecules that generate light energy in an excimer laser?
Argon and fluoride
Neodymium: yttrium-aluminum-garnet
Argon
Holmium: yttrium-aluminum-garnet
Feedback: The Nd:YAG laser is used for posterior capsule opacities. The Ho:YAG laser has been used for LTK. The argon
laser is used for ALTs in an effort to lower IOP. Excimer stands for "excited dimer" but in ophthalmology is often applied to a
laser that generates light using the interaction of argon and fluoride (F-). This type of laser should more correctly be called a
exiplex laser because it utilizes an excited complex rather than a single molecular species or dimer.
Question 81 of 90
A 64-year-old man who underwent a 4-incision radial keratometry 15 years ago has had a gradual return of myopia. Which
of the following is the most likely explanation?
Progressive myopia due to gradual corneal flattening
Cataract
Posterior staphyloma
Myopic regression
Feedback:
The onset of a myopic shift 15 years after RK, especially in a 64-year-old patient, is most likely due to a cataract than to
changes in corneal curvature. Hyperopia, not progressive myopia, would result from corneal flattening. Posterior
staphyloma is a congenital defect and would not result in a myopic shift in this patient.
Question 82 of 90
What is a primary concern of a decentered, laser in-situ keratomileusis (LASIK) flap?
Regression of refractive error
Proximity of the hinge to the limbus
Proximity of the flap edge to the limbus
Proximity of the flap edge to the visual axis

Feedback: Regression of refractive error is not a realistic concern in patients with a decentered LASIK flap, and proximity of
the hinge or flap edge to the limbus is not a concern as long as the visual axis is not disturbed. Proximity of the flap edge to
the visual axis is a concern because a flap edge that is in the visual axis could lead to an unpredictable ablation pattern.
Question 83 of 90
When performing a cycloplegic refraction for refractive surgery planning, which of the following medications is most useful?
1% cyclopentolate
1% cyclopentamide
1% tropicamide
1% tropicalate
Feedback:
It is important to know a patient's true refractive error, so it is necessary to paralyze accomodation by administering
cyclopentolate. Although longer acting cycloplegics may be used, these are not well-tolerated by adults in a typical
outpatient setting.
Question 84 of 90
Which of the following best describes cognitive visual impairment?
Patient with a visual acuity worse than 20/200 in both eyes
Central nervous system disease resulting in loss of vision
Patient who fully comprehends the effect of visual impairment on daily activities
Patient with a known diagnosis of dementia who complains of loss of vision

Feedback: Cognitive visual loss impairment is defined as loss of vision from central nervous system disease. The amount of
vision loss and the patient's chief complaint are not part of the definition.
Question 85 of 90
A 44-year-old man complains of eye fatigue and intermittent blurred vision with near activities. In addition to testing distance
and near visual acuities, what is another important parameter should be assessed?
Glare testing
Pupil function
Contrast sensitivity
Accommodative amplitude
Feedback: This patient's symptoms are consistent with accomodative insufficiency. As such, it is important to know the
accomodative amplitudes as well as distance and near vision. Contrast sensitivity, glare testing, and pupil function would
not add any meaningful information to this patient's assessment
Question 86 of 90
A soft contact lens wearer presents with acute onset of a 3-mm, fluffy paracentral corneal infiltrate, a retrocorneal
inflammatory plaque, and a hypopyon. The most appropriate therapy is hourly application of which of the following
combinations of medications?
Ofloxacin 0.3% and moxifloxacin 0.5%
Vancomycin 5% and cefazolin 5%
Vancomycin 5% and tobramycin 1%
Moxifloxacin 0.5% and tobramycin 0.3%

Feedback: A significant corneal ulcer should be treated with broad-spectrum fortified antibiotics until the infectious
microorganism has been identified. Moxifloxacin 0.5%, tobramycin 0.3%, and oflaxacin 0.3% are not fortified in strength and
therefore inappropriate in a patient with a paracentral infiltrate that could spread to involve the visual axis if not adequately
treated. Vancomycin 5% and cefazolin 5% are fortified antibiotics, but they have a similar spectrum of coverage (gram
positive organisms).
Question 87 of 90
Which one of the following interventions is the preferred management option for a 25-year-old patient with large pupils and a
nocturnal visual disturbance continuing a year after laser in situ keratomileusis (LASIK)?
Topical brimonidine 0.15% at night when driving
Topical 4% pilocarpine t.i.d.
Reassurance that there is nothing wrong
Reassurance that the symptoms will go away

Feedback: Topical brimonidine for night vision is well-tolerated and will result in a mild pupillary constriction. This will
hopefully alleviate some of this patients complaints. Reassurance that there is nothing wrong will not address the night
vision problems. Additionally, reassurance that the symptoms will go away is unrealistic this far out from surgery.
Pilocarpine may alleviate his symptoms, but has a high incidence of brow ache (especially at 4%), among other things and is
not likely to be well-tolerated. It would be reasonable to try a lower concentration of pilocarpine in someone who has not
responded to brimonidine treatment.
Question 88 of 130
Which of the following management option is preferred for an elderly patient with irreversible visual impairment who has
difficulty writing checks and reading bills?
Referral to low-vision services
Early cataract surgery
Transfer to an assisted-living facility
Over-the-counter (OTC) reading glasses

Feedback: Early cataract surgery and OTC reading glasses will not improve this patient's irreversible vision loss. Transfer
to an assisted-living facility would not be appropriate in a patient who is able to live independently. A referral to a low-vision
specialist could allow this patient to optimize the vision they have and function better with the use of low-vision aids.
Question 89 of 90
A preoperatively emmetropic and orthotropic patient is given the following glasses after bilateral cataract surgery: -0.50 -2.00
x 179 OD, +1.50 -1.00 x 90 OS, with +2.50 add OU located 1 cm below the optical center of the glasses. How much relative
prism is induced when this patient looks through the top of his bifocals?
4Δ base-down over the right eye
4Δ base-up over the right eye
10Δ base-up over the right eye
10Δ base-down over the right eye

Feedback:
The amount of prism induced by the bifocals is equal in each eye and is canceled out. When this patient looks downward,
only the power in the 90-degree meridian is deviating light. We can use Prentice's rule to calculate the prismatic effect of
these lenses:
OD: -2.5D x 1 cm = 2.5Δ base-down
OS: +1.5D x 1 cm = 1.5Δ base-up
When these prism results are combined, the amount of induced prism is equivalent to 4Δ base-down over the right eye.
Question 90 of 90
A patient develops reduced vision 1 week following monocular laser in situ keratomileusis (LASIK). Intraocular pressure
measures 7 mm Hg with applanation. Digital pressure assessment suggests highly elevated pressure. Which one of the
following slit-lamp examination findings best explains the cause of this discrepancy?
Epithelial ingrowth
Angle closure
Diffuse lamellar keratitis
Pocket of fluid in the flap interface
Feedback: With the presence of a fluid pocket in the flap interface, applanation pressure will often seem artificially low.
Digital palpation will overcome this and reveal an elevated IOP. This pressure-induced stromal keratitis consequently results
in a decrease in visual acuity.
Collected from www.aao.org (self assessment)

By Dr. AlBaraa AlQassimi

Refractive Mgmt/Intervention: Question 1 of 90

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Refractive Mgmt/Intervention

No generalization can be made

38% HEMA lens

68% HEMA lens (hydroxyethylmethacrylate)

A +2.00D hyperope wearing glasses whose esotropia measures 25Δ

A +10.00D hyperope wearing glasses whose exotropia measures 30Δ

A -10.00 D myope wearing glasses whose exotropia measures 50Δ

A -10.00 D myope wearing contact lenses whose exotropia measures 40Δ

Poor contact lens fit

Lless myopic, with with-the-rule astigmatism

Less myopic, with against-the-rule astigmatism

More myopic, with with-the-rule astigmatism

More myopic, with against-the-rule astigmatism

Right medial rectus resection and right lateral rectus recession

Pellucid marginal degeneration

A staphyloma extending into the macula

Lenticular dislocation in Marfan syndrome

-4.50 sph OD, +2.00 sph OS

-4.50 sph OD, plano OS

-3.00 sph OD, +3.50 sph OS

-3.00 sph OD, plano OS

Postsurgical cystoid macular edema

A pupil that was dilated during testing

An irregular corneal surface

Rigid gas-permeable (RGP) lenses

Spherical soft hydrogel lenses

Toric soft lenses

Rigid gas-permeable (RGP) lenses

Spherical soft hydrogel lenses

Toric soft lenses

Suggest switching to a new contact lens cleaning regimen

See the patient immediately

Schedule a visit for Monday

Myopia is common, especially in infants treated for threshold ROP.

Keratometry is helpful in revealing uncorrected astigmatism.

Prescribe +0.75+4.50 x 045 OD, and +0.25 +4.00 x 135 OS

Not to prescribe glasses, because there is no change in acuity with correction

Contact lens intolerance is common during pregnancy and lactation.

Increasing myopia may be a sign of gestational diabetes.

-1.25 -1.25 x 175

-3.25 -1.25 x 175

-1.25 -1.25 x 085

-3.25 -1.25 x 085

Topical anesthetic abuse

Methacillin-resistant staphylococcus aureus infection

Elevated herpetic scars

Depressed corneal scars

Reis Buckler dystrophy

Mild corneal edema from Fuch's dystrophy

Superior limbic keratoconjunctivitis

Herpes simplex keratitis

Leber's congenital amaurosis

It is easily distinguished from contact lens overwear on topography.

The most ectactic area is just below the area of thinning.

It is not usually seen in women more than 30 years old.

LASIK for myopia less than 3 diopters

LASIK for hyperopia for more than 3 diopters

Corneal neovascularization secondary to stem-cell deficiency

PRK when the operated eye has been patched

LASIK enhancement surgery when the flap is lifted

The patient is phakic

There is a need to control post operative astigmatism

A glaucoma filtering bleb is present