1.
A 22-year-old university student has blurred distance vision that becomes clear with a −4.00 diopter spectacle correction. Without correction, parallel rays from a distant object focus anterior to the retina. How does the prescribed lens improve vision?
2.
A 60-year-old man develops a lower motor neuron facial nerve palsy. Several weeks later, he has persistent watering and ocular irritation. Examination shows outward turning of the lower eyelid with the lacrimal punctum displaced away from the globe. Which complication has developed?
3.
A 6-year-old child has visual acuity of 6/6 in the right eye and 6/24 in the left eye. The left eye has significant uncorrected hypermetropia, but fundoscopy and other ocular examinations are normal. After appropriate spectacle correction, a persistent interocular visual difference remains. Which treatment is most appropriate?
4.
A patient with progressive unilateral proptosis develops worsening visual acuity, impaired colour discrimination, and a relative afferent pupillary defect in the affected eye. The optic disc initially appears normal. Which complication should be suspected?
5.
A 34-year-old obese woman reports persistent headache, pulsatile tinnitus, and brief episodes of visual dimming on standing. Visual acuity remains nearly normal, but fundoscopy reveals bilateral swollen optic discs with obscuration of the disc margins. Which investigation should generally precede lumbar puncture in this patient?
6.
A 38-year-old woman presents with gradually progressive prominence of both eyes and intermittent diplopia. Examination shows lid retraction, conjunctival congestion, and restricted elevation of one eye. Intraocular examination is otherwise unremarkable. Which underlying disorder is most likely?
7.
A 50-year-old man with long-standing alcohol misuse and a severely deficient diet develops slowly progressive, painless, symmetric visual loss. Colour vision is impaired and bilateral centrocecal scotomas are demonstrated. There is no optic-disc swelling. Which diagnosis is most likely?
8.
A 62-year-old woman develops severe visual loss, pain, hypopyon, and vitreous haze several days after intraocular surgery. Infectious endophthalmitis is strongly suspected. What is the most appropriate immediate treatment principle?
9.
A 24-year-old contact-lens wearer presents with severe ocular pain, redness, photophobia, and rapidly decreasing vision. Slit-lamp examination shows a central corneal epithelial defect with a dense stromal infiltrate and a small hypopyon. What is the most appropriate immediate management principle?
10.
A 2-year-old child is brought because the parents have noticed a white reflection from the right pupil in several photographs. Examination shows reduced fixation and a convergent squint in that eye. Ocular imaging reveals a solid intraocular retinal mass containing calcification. Which diagnosis is most likely?
11.
A 59-year-old woman complains of marked glare while driving at night and difficulty seeing in bright sunlight despite relatively preserved visual acuity in ordinary room lighting. Slit-lamp examination reveals an opacity immediately anterior to the posterior lens capsule. Which type of cataract is most consistent with these symptoms?
12.
A 26-year-old laboratory worker accidentally splashes an alkaline cleaning solution into his right eye. He presents within 10 minutes with severe pain, blepharospasm, conjunctival whitening, and blurred vision. What is the most appropriate immediate management?
13.
A 30-year-old man undergoes removal of a traumatically damaged crystalline lens from one eye. The fellow eye has normal vision. He develops marked image-size difference and poor binocular tolerance when a high-plus spectacle lens is prescribed. Which method of optical rehabilitation is most appropriate?
14.
A 47-year-old teacher with previously normal distance vision notices increasing difficulty reading small print, particularly in dim light. Distance visual acuity remains 6/6 in both eyes, and near vision improves with convex lenses. Which physiological change is primarily responsible?
15.
A 48-year-old man with poorly controlled diabetes is admitted with fever and Staphylococcus aureus bacteremia. During admission, he develops floaters, ocular pain, and marked reduction of vision in one eye. There is no history of ocular trauma or surgery. Examination reveals hypopyon and dense vitreous inflammation. Which route of infection is most likely?
16.
A 63-year-old man with poorly controlled diabetes develops severe ocular pain and markedly elevated intraocular pressure. Slit-lamp examination shows abnormal new vessels over the iris and in the anterior chamber angle. Which process is principally responsible for this form of secondary glaucoma?
17.
A 54-year-old woman presents with sudden severe headache followed by diplopia and complete ptosis of the right eye. When the lid is elevated, the eye is positioned downward and outward and the pupil is markedly dilated. Which underlying cause requires particularly urgent exclusion?
18.
A 60-year-old hypermetropic woman develops sudden severe ocular pain, headache, nausea, and blurred vision with coloured haloes after spending several hours in a dark cinema. Examination shows a red eye, hazy cornea, mid-dilated poorly reactive pupil, and markedly raised intraocular pressure. Which mechanism most likely initiated this attack?
19.
A 55-year-old man presents with sudden diplopia and drooping of the right upper eyelid. Examination shows a dilated poorly reactive right pupil, and the right eye rests in a downward and outward position. Which neurological lesion best accounts for these findings?
20.
A 65-year-old man complains that his near vision has unexpectedly improved and he can again read without his previous reading glasses. However, his distance vision has gradually deteriorated. Slit-lamp examination shows increasing central nuclear lens opacity. Which refractive change best explains the improvement in near vision?
21.
A 21-year-old student develops redness and watering of the right eye followed two days later by similar symptoms in the left eye. Examination shows follicular conjunctival reaction and a tender preauricular lymph node. Several classmates have recently had similar symptoms. Which diagnosis is most likely?
22.
A 35-year-old man has recurrent episodes of unilateral painful red eye associated with photophobia. He also reports episodes of inflammatory lower-back stiffness that improve with activity. Slit-lamp examination confirms acute anterior uveitis. Which systemic association is most likely?
23.
A 76-year-old man complains of persistent foreign-body sensation and watering from the right eye. Examination reveals inward rotation of the lower-eyelid margin with the eyelashes rubbing against the cornea. Which eyelid abnormality best explains his symptoms?
24.
A 42-year-old woman develops progressive difficulty seeing objects on both sides while driving. Visual-field testing demonstrates loss of the temporal half of the visual field in each eye. Fundoscopy shows no retinal abnormality. Which site of the visual pathway is most likely affected?
25.
A 44-year-old woman with rheumatoid arthritis develops severe deep ocular pain that wakes her at night. The eye appears diffusely red with a violaceous hue and is markedly tender to palpation. The deep vessels do not blanch after topical vasoconstrictor administration. Which diagnosis is most likely?
26.
A 38-year-old man complains of vertical diplopia that is most troublesome while walking downstairs. Examination shows a right hypertropia that increases on looking to the left and on tilting the head toward the right shoulder. He habitually tilts his head to the left to reduce the diplopia. Which neurological lesion best explains this pattern?
27.
A 7-week-old infant is found to have a dense unilateral congenital cataract obstructing the visual axis. The fellow eye is normal. Which management principle offers the best chance of preserving useful vision in the affected eye?
28.
A 12-year-old boy develops fever, severe pain around the left eye, and eyelid swelling several days after an acute sinus infection. Examination reveals proptosis, painful restriction of ocular movements, reduced visual acuity, and conjunctival chemosis. Which diagnosis is most likely?
29.
A 68-year-old man with a dense mature cataract reports recent flashes of light followed by a shadow in the affected eye. The posterior segment cannot be visualized because of the lens opacity. Which investigation is most appropriate for evaluating the suspected posterior-segment abnormality?
30.
A patient presents with acute primary angle-closure glaucoma. Medical therapy successfully lowers the intraocular pressure and the cornea becomes clear. Which procedure provides definitive treatment of the underlying pupillary-block mechanism?
31.
A 29-year-old man presents with unilateral red eye, photophobia, watering, and reduced vision. Fluorescein staining demonstrates a branching epithelial corneal ulcer with terminal bulbs. Corneal sensation is reduced. Which diagnosis is most likely?
32.
An 8-month-old infant has excessive tearing, photophobia, and progressive enlargement of both eyes. Examination reveals enlarged cloudy corneas, breaks in Descemet membrane, and raised intraocular pressure. Which underlying abnormality best explains these findings?
33.
A 66-year-old man presents 5 days after uncomplicated cataract surgery with rapidly worsening vision, increasing ocular pain, and redness. Examination shows lid edema, circumcorneal congestion, a 2-mm hypopyon, and markedly reduced red reflex. Which diagnosis best explains this postoperative deterioration?
34.
A 72-year-old farmer presents with a slowly enlarging painless lesion on the lower eyelid. Examination shows an ulcerated nodule with pearly rolled margins, surface telangiectasia, and loss of adjacent eyelashes. Which diagnosis is most likely?
35.
A 41-year-old man receiving treatment for pulmonary tuberculosis develops gradual, painless, bilateral reduction of central vision. Colour discrimination is impaired, and visual-field testing shows central scotomas. The optic discs are initially relatively normal. Which diagnosis is most likely?
36.
A patient with established primary open-angle glaucoma develops progressive optic-nerve damage despite having no central visual complaint. Automated perimetry is performed. Which visual-field defect is most characteristic of early glaucomatous damage?
37.
A 68-year-old woman has bilateral age-related cataracts. Visual acuity is 6/18 in the worse eye. She reports that glare and reduced contrast now prevent her from driving safely and performing her usual daily activities. There is no active ocular inflammation. What is the most appropriate management principle?
38.
A 67-year-old woman has a recurrent painless upper-eyelid swelling that has been treated twice as a chalazion but repeatedly develops at the same site. Examination shows thickening of the tarsal plate and loss of several eyelashes. What is the most appropriate next step?
39.
A 21-year-old man is struck around the left eye during a football match. He develops diplopia, particularly on looking upward. Examination reveals reduced sensation over the left cheek and limitation of elevation of the affected eye. Which structure is most likely entrapped?
40.
A 47-year-old man presents with gradual visual blurring, floaters, and minimal ocular pain. Examination shows vitreous inflammatory cells and multiple pale lesions involving the choroid and retina. Which anatomical classification best describes this inflammatory process?
41.
A 32-year-old man is struck in the eye by a sharp metallic fragment while working. He has sudden visual loss and pain. Examination shows a full-thickness corneal wound, shallow anterior chamber, and a peaked pupil pointing toward the wound. What is the most appropriate next management step?
42.
A 27-year-old woman develops painful reduction of vision in one eye over 2 days. Pain worsens with ocular movement, colour vision is disproportionately reduced, and a relative afferent pupillary defect is present. The optic disc appears normal. Which diagnosis best accounts for these findings?
43.
A 57-year-old man with a 15-year history of diabetes complains of gradual distortion of central vision. Fundoscopy shows retinal microaneurysms and hard exudates clustered around the macula. Optical coherence tomography demonstrates increased central retinal thickness. Which condition is principally responsible for his visual complaint?
44.
A 35-year-old man develops rapidly progressive protrusion of one eye several days after head trauma. Examination reveals marked conjunctival chemosis, dilated tortuous episcleral vessels, pulsatile proptosis, and an orbital bruit. Which diagnosis best explains these findings?
45.
A patient with severe intraocular infection develops increasing ocular pain despite treatment. Examination now reveals marked lid edema, proptosis, restricted ocular movements, diffuse scleral involvement, and inflammation extending into the orbital tissues. Which diagnosis best describes this progression?
46.
A 54-year-old woman presents to the emergency department with headache and blurred vision. Blood pressure is 240/140 mmHg. Fundoscopy shows bilateral flame-shaped hemorrhages, cotton-wool spots, hard exudates, and optic-disc swelling. Which management principle is most appropriate?
47.
A 42-year-old woman with chronic anterior uveitis has received irregular treatment for several years. She now has reduced vision. Examination reveals an irregular pupil bound to the anterior lens surface at several points. Which complication has most likely developed?
48.
An 8-year-old child complains of frontal headache after prolonged reading. Unaided distance visual acuity is 6/6 in both eyes, but hypermetropia is suspected because accommodation may be masking the refractive error. Which method provides the most reliable assessment?
49.
A 20-year-old university student has progressively increasing myopia and irregular astigmatism with frequent changes in spectacle prescription. Retinoscopy demonstrates a scissoring reflex, and keratoconus is suspected. Which investigation is most useful for demonstrating the abnormal corneal curvature pattern?
50.
A 52-year-old woman has been using potent topical corticosteroid eye drops for several weeks without supervision. She is asymptomatic, but intraocular pressure is now markedly elevated and the anterior chamber angle is open. Which mechanism best explains this finding?
51.
A 72-year-old man with a long-standing untreated cataract develops sudden ocular pain and redness. The lens appears hypermature, and liquefied lens proteins have leaked through an intact capsule. Intraocular pressure is markedly raised, and the anterior chamber contains numerous macrophages. Which complication is most likely?
52.
A 5-year-old child has a constant inward deviation of the left eye. The angle of deviation remains approximately the same in primary position and in different directions of gaze, and ocular movements are full in both eyes. Which type of ocular deviation is present?
53.
A 28-year-old woman reports painful reduction of vision in the left eye for 3 days. Visual acuity is reduced, colour vision is impaired, and both pupils are equal in size. During the swinging-flashlight test, both pupils constrict when light is directed into the right eye but dilate when the light is moved to the left eye. Which abnormality best explains this finding?
54.
A 58-year-old man undergoes routine examination because his father became blind from glaucoma. Visual acuity is 6/6 in both eyes. Intraocular pressure is repeatedly elevated, gonioscopy shows open drainage angles, and optic-disc examination demonstrates increased vertical cup-to-disc ratio with thinning of the neuroretinal rim. Which diagnosis is most likely?
55.
During refraction of a 19-year-old student, one principal meridian of the eye is found to focus light anterior to the retina while the perpendicular meridian focuses light posterior to the retina. Which refractive error is present?
56.
A 62-year-old woman with newly diagnosed primary open-angle glaucoma requires long-term topical therapy. She has no significant cardiopulmonary disease. A once-daily medication that increases uveoscleral aqueous outflow is selected. Which drug class has this mechanism?
57.
A 69-year-old hypertensive man previously developed sudden painless visual loss due to an ischemic central retinal vein occlusion. Three months later, he presents with severe ocular pain and further visual deterioration. Examination shows new vessels over the iris and markedly raised intraocular pressure. Which complication has developed?
58.
A 64-year-old man with diabetes develops horizontal diplopia that is worse when looking toward the right and when viewing distant objects. Examination shows failure of the right eye to abduct, while other ocular movements are preserved. Which nerve is affected?
59.
A 29-year-old man presents with pain, photophobia, blurred vision, and circumcorneal redness of one eye. Slit-lamp examination shows anterior chamber cells and flare with a small irregular pupil. Which additional treatment is particularly important for preventing painful adhesions between the iris and lens?
60.
A 64-year-old man has intraocular pressures of 25 and 26 mmHg on repeated visits. Gonioscopy shows open angles, but optic discs and automated visual fields remain normal. Which term best describes his current condition?
