Oculoplasty and Orbital Disease (Ptosis, Entropion, Thyroid Eye Disease, Orbital Tumors) MCQs

Ophthalmology · 86 free questions with answers & explanations.

1. A 45-year-old woman has bilateral exophthalmos, lid lag, and injection over the lateral rectus insertion on slit-lamp examination. Orbital MRI shows bilateral fusiform enlargement of extraocular muscles sparing the tendons. The MOST likely diagnosis is:
2. In assessing the severity of congenital ptosis for surgical planning, the MOST important measurement is:
3. The MOST common primary orbital tumor in adults is:
4. A patient with thyroid eye disease (TED) develops compressive optic neuropathy. The MOST sensitive clinical indicator of this complication is:
5. Cicatricial entropion (inward rotation of eyelid due to scarring) differs from involutional (senile) entropion in that cicatricial entropion:
6. A 40-year-old woman presents with bilateral proptosis, lid lag, and chemosis. Her TSH is suppressed. On Hertel exophthalmometry, proptosis measures 25 mm bilaterally. Corneal exposure keratopathy is developing. Which feature would indicate the need for urgent orbital decompression rather than conservative management?
7. A 60-year-old man presents with congenital-appearing ptosis since childhood, reduced levator function (4 mm), and absence of the upper lid crease. Jaw-winking phenomenon is elicited. Which surgical procedure is most appropriate?
8. A 70-year-old man has right lower lid involutional entropion with trichiasis causing corneal abrasion. Everting sutures provide temporary relief. The definitive surgical repair that corrects both horizontal lid laxity and posterior lamellar vertical deficiency is:
9. A 55-year-old woman presents with a unilateral slowly progressive proptosis for 2 years. CT orbit shows a well-defined, homogeneously enhancing intraconal mass with no bony erosion, moulding around the optic nerve. The most likely diagnosis is:
10. A 45-year-old woman with known Graves' disease presents with proptosis, lid lag, and visual acuity of 6/60 bilaterally with dyschromatopsia and relative afferent pupillary defect. Hertel exophthalmometry shows 24 mm bilaterally. MRI orbit shows fusiform enlargement of inferior and medial recti with sparing of tendons. What is the most appropriate immediate management?
11. A child with congenital ptosis is referred for evaluation. The margin reflex distance-1 (MRD1) is 0 mm (corneal light reflex at upper lid margin) and levator function is 2 mm. The preferred surgical procedure is:
12. A 70-year-old man presents with a unilateral lower lid that turns inward, causing chronic tearing and corneal irritation. Examination shows that the lid margin inverts on sustained downgaze but returns to normal position with manual lid eversion. The most likely diagnosis and mechanism is:
13. An orbital cavernous hemangioma (cavernous venous malformation) in an adult has the following MRI characteristics — EXCEPT:
14. The clinical activity score (CAS) is used to guide immunosuppressive treatment in thyroid eye disease. A CAS score of ≥3/7 indicates:
15. A 40-year-old presents with unilateral ptosis, MRD1 of 1 mm, levator function of 4 mm, and a poor lid crease. The MOST appropriate surgical procedure is:
16. In Graves' (thyroid-related) orbitopathy, the MOST commonly enlarged extraocular muscle on CT/MRI of the orbits is:
17. A 35-year-old woman with progressive proptosis has CT showing a well-circumscribed, smooth, ovoid intraconal orbital mass with homogeneous density that enhances uniformly. The MOST likely diagnosis is:
18. A 5-year-old boy presents with a superotemporal orbital mass present since birth, which transiently increased in size with upper respiratory infection. CT shows an extraconal cystic lesion with fat-density contents at the fronto-zygomatic suture. The diagnosis is:
19. The Werner classification (NOSPECS) of thyroid orbitopathy grades orbital involvement from 0 to 6. Which class corresponds to exposure keratopathy due to incomplete lid closure?
20. A patient presents with a 3 mm ptosis, absent lid crease, and poor levator function (< 4 mm). The MOST appropriate surgical procedure is:
21. In thyroid eye disease (Graves' orbitopathy), the MOST reliable indicator of disease activity for treatment planning is:
22. A 60-year-old man presents with painless progressive proptosis, non-pulsatile, with resistance to retropulsion. MRI shows a well-defined homogeneously enhancing extraconal mass in the superior orbit with 'moulding' around the globe. The MOST likely diagnosis is:
23. Dysthyroid optic neuropathy (DON) in Graves' orbitopathy is MOST commonly caused by which mechanism?
24. In the Hertel exophthalmometer, the 'base' value recorded at each measurement session is important because:
25. A patient with thyroid eye disease (Graves' orbitopathy) has proptosis of 22 mm (normal < 18 mm), compressive optic neuropathy, and corneal exposure. The most urgent intervention is:
26. Measurement of the levator palpebrae superioris function (levator function) in ptosis assessment is clinically performed as:
27. A 70-year-old man presents with gradual lower lid inturning causing corneal irritation. On examination the lid turns inward only when he forcibly closes his eye but is normal at rest. This type of entropion is classified as:
28. In a child with a large left upper eyelid hemangioma causing mechanical ptosis and occlusion amblyopia, the priority treatment is:
29. A 60-year-old man presents with unilateral lower eyelid inturning where the lid margin and lashes touch the globe, worsening with eye closure. Distraction test shows > 8 mm lid displacement from the globe. Which surgical procedure is most appropriate?
30. A patient with thyroid eye disease (TED) has proptosis of 26 mm, exposure keratopathy, and compressive optic neuropathy. Visual acuity has dropped from 6/6 to 6/24 over 3 weeks despite IV methylprednisolone. What is the next best step?
31. A 5-year-old child presents with ptosis of the left upper eyelid with a margin-reflex distance-1 (MRD1) of −1 mm (pupil covered), absence of a lid crease, and levator excursion of 3 mm. Which surgical approach is most appropriate?
32. A 30-year-old man presents with slowly progressive painless proptosis, a firm orbital mass that displaces the globe inferomedially, and CT showing a well-circumscribed homogeneous lesion in the superior orbit with moulding to adjacent structures. MRI shows homogeneous low T1 and high T2 signal. What is the most likely diagnosis?
33. During evaluation of ectropion, the 'snap-back' test is performed by pulling the lower eyelid downward and releasing. In involutional ectropion, which finding on snap-back test and distraction test indicates lateral canthal tendon laxity?
34. A 3-year-old child presents with unilateral complete ptosis since birth. On examination, the levator function is 2 mm and the contralateral lid shows a lag on downgaze. The BEST management is:
35. A 68-year-old man has lower eyelid inturning causing corneal irritation. The tarsal plate appears normal in size. He has significant horizontal lid laxity on snap-back test. The MOST appropriate surgical correction is:
36. In thyroid eye disease (Graves' orbitopathy), the MOST commonly affected extraocular muscle, and its characteristic pattern of CT involvement, is:
37. The Clinical Activity Score (CAS) in thyroid eye disease uses which TOTAL score to define 'active' disease requiring immunosuppression?
38. A 7-year-old girl has a smooth, non-tender bluish inferior medial orbital swelling that increases with crying and the Valsalva manoeuvre. MRI shows a heterogeneous lesion with fluid-fluid levels. The MOST likely diagnosis is:
39. Cavernous sinus thrombosis secondary to orbital cellulitis is distinguished from orbital apex syndrome by the presence of:
40. A 50-year-old man with a known history of cutaneous melanoma presents with a unilateral exudative retinal detachment and a dome-shaped pigmented choroidal mass on B-scan ultrasonography. Ultrasound shows high initial spike followed by low internal reflectivity. The most likely diagnosis is:
41. A 35-year-old patient with sarcoidosis presents with decreased vision. Fundus examination reveals periphlebitis with 'candle wax drippings' (perivenous exudates), disc edema, and anterior uveitis with large mutton-fat keratic precipitates. The pathological finding in sarcoid uveitis is best described as:
42. A 55-year-old patient with longstanding diabetes develops a new onset of blurred vision in the right eye. Fundus examination shows a microaneurysm at the foveal center and hard exudates forming a circinate ring around the macula. OCT confirms macular thickening. This represents:
43. A 60-year-old patient with Wilson's disease is found to have bilateral golden-brown ring-like deposits on the peripheral Descemet's membrane of both corneas, most visible at the 6 and 12 o'clock positions with slit-lamp examination in retroillumination. This sign is:
44. A 40-year-old man with AIDS (CD4 count 28 cells/µL) presents with a painless progressive scotoma and sees a white opaque area encroaching on his visual field. Fundus shows a granular, white retinal opacity with haemorrhages along vessels ('pizza pie' or 'crumbled cheese and ketchup' appearance). The most likely diagnosis and treatment are:
45. A 55-year-old hypertensive patient is found to have an arteriovenous (AV) nicking at the superior temporal arcade on routine fundoscopy. There are also flame-shaped haemorrhages and cotton wool spots near the disc, with disc oedema. This fundus picture is most consistent with which grade of hypertensive retinopathy using the modified Keith-Wagener-Barker (KWB) classification?
46. A 50-year-old man presents with a painless, amelanotic, rapidly growing raised choroidal lesion. B-scan ultrasonography shows a dome-shaped choroidal lesion with internal acoustic hollowness. Orbital MRI shows T1 hyperintensity and T2 hypointensity. The MOST likely diagnosis based on MRI characteristics is:
47. A 40-year-old patient with type 1 diabetes mellitus presents with bilateral cataracts showing snowflake opacities in the subcapsular region. This type of cataract is also called 'metabolic cataract' and is associated with which biochemical pathway?
48. A 45-year-old patient with known sarcoidosis presents with bilateral anterior uveitis, posterior synechiae, and vitreous 'snowball' opacities. Fluorescein angiography shows periphlebitis (candle-wax drippings). Which granuloma-forming pathological process is responsible, and what is the characteristic histopathological finding in sarcoid granulomas?
49. A 65-year-old patient with uveal melanoma of the ciliary body shows extrascleral extension on MRI. The Collaborative Ocular Melanoma Study (COMS) findings most relevant to medium-sized choroidal melanoma management are:
50. In diabetic retinopathy, the ETDRS (Early Treatment Diabetic Retinopathy Study) defined 'clinically significant macular edema' (CSME) using which criteria that still guide treatment decisions?
51. In Wilson's disease, the Kayser-Fleischer ring in the cornea results from copper deposition in which specific corneal layer, and at what location does it first appear?
52. In uveal melanoma, the COMS (Collaborative Ocular Melanoma Study) large tumor trial compared enucleation with pre-enucleation radiation. The medium tumor trial compared enucleation with iodine-125 brachytherapy. The key conclusion of the medium tumor trial regarding mortality was:
53. In diabetic macular edema, the DRCR.net Protocol T trial directly compared three anti-VEGF agents. The trial found that at 1 year, which agent was statistically superior for eyes with baseline visual acuity of 20/50 or worse?
54. The earliest ocular manifestation of sarcoidosis that can be detected on slit-lamp examination even before systemic symptoms is:
55. Ocular melanoma most commonly arises from which uveal structure, and what is the most common site of metastasis?
56. Diabetes mellitus causes a characteristic retinopathy. The severity classification according to the International Clinical Diabetic Retinopathy Severity Scale (ICDRSS) places 'Proliferative Diabetic Retinopathy' (PDR) in stage V. The hallmark distinguishing feature from severe NPDR (Stage IV) is:
57. Cavernous haemangioma of the orbit is the most common primary benign orbital tumour in adults. On MRI, its characteristic signal is:
58. In uveal melanoma, the COMS (Collaborative Ocular Melanoma Study) showed that compared to enucleation, pre-enucleation radiotherapy for large tumours:
59. In sickle cell retinopathy, the Goldberg classification Stage III represents which pathological change?
60. Hydroxychloroquine (HCQ) retinal toxicity is best monitored using which combination of tests per the 2016 AAO revised guidelines?
61. Uveal melanoma metastasizes almost exclusively to the liver (90% of metastases). The mechanism that explains liver tropism includes which recently identified pathway?
62. In a patient with tuberous sclerosis complex (TSC), bilateral astrocytic hamartomas of the retina present as mulberry-shaped calcified lesions near the optic disc. TSC is caused by mutations in TSC1 (hamartin) or TSC2 (tuberin). The molecular pathway disrupted is:
63. Hydroxychloroquine-induced retinal toxicity (bull's-eye maculopathy) is screened using which current AAO (American Academy of Ophthalmology) 2016 guideline-recommended modality?
64. In choroidal melanoma, the Collaborative Ocular Melanoma Study (COMS) for medium-sized tumors (2.5-10 mm apical height, ≤ 16 mm basal diameter) demonstrated that:
65. A diabetic patient on insulin develops sudden-onset, painless visual deterioration. Fundoscopy shows scattered dot-blot hemorrhages, microaneurysms, hard exudates, and a distinct zone of retinal whitening at the posterior pole. The most appropriate immediate management is:
66. In sickle cell retinopathy (SCR), the Goldberg classification Stage IV refers to:
67. Hydroxychloroquine (HCQ) toxicity causes 'bull's eye maculopathy'. The Marmor 2016 guidelines recommend baseline and annual screening with SD-OCT and visual field testing. The proposed mechanism of HCQ retinal toxicity involves:
68. A 60-year-old man presents with a choroidal mass. Ultrasonography shows a mushroom-shaped choroidal lesion with acoustic hollowness (choroidal excavation) and high internal reflectivity anteriorly. FFA shows a 'double circulation' (tumour circulation visible before retinal circulation). The most likely diagnosis and first-line treatment is:
69. A 68-year-old man with elevated LDH and β2-microglobulin is found to have bilateral vitritis, subretinal infiltrates, and creamy yellow lesions at the RPE-choroid interface. Vitreous biopsy reveals large atypical B-lymphocytes. This is primary vitreoretinal lymphoma (PVRL). The MOST appropriate systemic investigation is:
70. Choroidal melanoma is the most common primary intraocular malignancy in adults. The Collaborative Ocular Melanoma Study (COMS) found that for medium-sized choroidal melanoma, iodine-125 (I-125) episcleral brachytherapy compared to enucleation resulted in:
71. Choroidal melanoma is the most common primary intraocular tumor in adults. Its metastatic spread characteristically goes first to the:
72. A 55-year-old man with metastatic cancer develops sudden deterioration of vision in one eye. Fundus examination reveals a dome-shaped, orange-brown subretinal lesion in the choroid at the posterior pole, with associated exudative retinal detachment. B-scan ultrasound shows a dome-shaped lesion with high internal reflectivity. FFA shows a 'double circulation' pattern and 'hot spot' early hyperfluorescence. The most likely diagnosis is:
73. A diabetic patient is noted to have neovascularisation of the iris (rubeosis iridis) on slit-lamp examination. The vessels begin at the pupillary margin and extend toward the angle. What is the greatest immediate risk if untreated?
74. A 60-year-old presents with a unilateral dark-brown choroidal mass, 8 mm in diameter, with low internal reflectivity on A-scan ultrasound and 'choroidal excavation' (acoustic shadowing). What is the most likely diagnosis and what is the most important prognostic factor for metastasis?
75. A 35-year-old with type 1 diabetes mellitus presents for routine ophthalmology review. He has no visual complaints. Fundoscopy shows dot-blot haemorrhages, microaneurysms in all quadrants, and 2 areas of IRMA (intraretinal microvascular abnormalities), but no disc neovascularisation. How should he be classified and when should he next be reviewed?
76. A 35-year-old woman with Graves' disease develops proptosis with lid lag, lid retraction, and periorbital edema. CT orbit shows enlargement of extraocular muscles with sparing of the tendinous insertions. Which extraocular muscle is MOST commonly and FIRST affected in thyroid eye disease (TED)?
77. In the NOSPECS classification of thyroid eye disease, which class specifically refers to corneal exposure and involvement?
78. A patient with congenital ptosis has a levator function of 3 mm. The preferred surgical procedure in this case is:
79. A patient presents with a lower eyelid that turns inward, causing the lashes to rub against the cornea. The medial canthal tendon is lax and there is horizontal lid laxity. The most appropriate surgical procedure to correct this involutional entropion is:
80. A 35-year-old woman with Graves' disease presents with bilateral proptosis of 23 mm (Hertel exophthalmometry), restricted upgaze, and compressive optic neuropathy on the left evidenced by an RAPD, desaturated color vision, and early visual field loss. CT orbit shows apical crowding. The MOST urgent intervention is:
81. A 6-year-old boy is referred for unilateral congenital ptosis. Levator function measures 3 mm. MRD1 is 0 mm (upper eyelid covers the pupil). Amblyopia is present. What is the BEST surgical option?
82. An elderly man presents with painful, redness of the right eye with medial canthal fullness and purulent discharge. CT orbit reveals a well-defined cystic lesion in the superomedial quadrant with scalloping of the adjacent orbital wall. The MOST likely diagnosis is:
83. The Clinical Activity Score (CAS) for thyroid eye disease uses 7 parameters in follow-up. The minimum CAS score that defines ACTIVE thyroid eye disease requiring immunosuppressive treatment is:
84. A 55-year-old man presents with painless progressive proptosis over 2 years. CT shows a well-encapsulated intraconal mass with smooth borders, homogeneous contrast enhancement, and no bone erosion. MRI shows high T2 signal. The MOST likely diagnosis is:
85. A 40-year-old patient presents with bilateral proptosis, lid retraction, and eyelid lag. Hertel exophthalmometry measures 23 mm in the right eye and 21 mm in the left (normal <20 mm). Thyroid function tests reveal hyperthyroidism. The specific sign of superior scleral show (white below upper limbus) is present. Which orbital finding on CT most specifically explains the proptosis in thyroid eye disease?
86. A 55-year-old man presents with slowly progressive, painless unilateral proptosis over 5 years. CT orbit shows a well-defined, encapsulated intraconal lesion with smooth margins, isodense to muscle, which appears to mould around the optic nerve without invading it. The most likely diagnosis is: