Review of Ophthalmology PDF

Review of OPHTHALMOLOGY Must for PG Entrance Examination Seventh Edition Ruchi Rai MBBS, MS, DNB (Ophthalmology), MNAMS PEEPEE PUBLISHERS AND DISTRIBUTORS (P) LTD.® Review of Ophthalmology Published by Pawaninder P. Vij and Anupam Vij Peepee Publis...

Review of OPHTHALMOLOGY Must for PG Entrance Examination Seventh Edition Ruchi Rai MBBS, MS, DNB (Ophthalmology), MNAMS PEEPEE PUBLISHERS AND DISTRIBUTORS (P) LTD.® Review of Ophthalmology Published by Pawaninder P. Vij and Anupam Vij Peepee Publishers and Distributors (P) Ltd. Head Office: 160, Shakti Vihar, Pitam Pura Delhi-110 034 (India) Correspondence Address: 7/31, First Floor, Ansari Road, Daryaganj New Delhi-110002 (India) Ph: 41512412, 23246245, 9811156083 e-mail: [email protected] e-mail: [email protected] www.peepeepub.com © 2019 by Peepee Publishers and Distributors Pvt. Ltd. All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopy, recording, translated, or any information storage and retrieval system, without permission in writing from the editor and the publisher. This book has been published in good faith that the material provided by authors/contributors is original. Every effort is made to ensure accuracy of material, but publisher and printer will not be held responsible for any inadvertent errors. In case of any dispute, all legal matters to be settled under Delhi jurisdiction only. First Edition: 2006 Seventh Edition: 2019 ISBN: 978-81-8445-267-9  Dedicated To my dear mentor Dr Daisaku Ikeda who taught me to live with a “Big Heart and a Big Smile”. “Perseverance is strength. Lets live with the spirit–Still I am Not Discouraged”.  PREFACE TO THE FIRST EDITION Trends are changing, with more and more number of questions being asked from ophthalmology each year in various entrance examinations. In addition, with advances in ophthalmology occurring at a frantic pace, it is becoming increasingly difficult for the students to keep abreast with the latest. In my pursuit to help students cope with this problem, this edition has been reformatted, and is now topic based while the previous one was examination based. Each chapter contains author notes along with the corresponding questions and the key. In every chapter, the notes have been revised extensively to incorporate recent advances and contain all the information related to the questions asked. The book contains the entire latest questions and these questions are included chapter-wise. This makes the learning for the students more easy and methodical. Wish you all the best for a bright future. Ruchi Rai [email protected]  PREFACE TO THE SEVENTH EDITION A very focussed and tailored study is required to crack the PG entrance exams. This edition includes major changes, with two separate sections of image-based and recently asked questions being added chapter-wise. With more illustrations and images, this coloured version of the book is a visual treat for the students. All feedback and criticism is taken with utmost seriousness and is used as a source of continuous refinement. This is the reason for the huge success of the book. Kindly send your feedbacks at [email protected] “Keep Striving Till You Win” Stay blessed ! Ruchi Rai [email protected]  ACKNOWLEDGEMENTS To my dear mentor who inspired me to keep striving harder and become a better version of myself. To my dear parents for always being a strong pillar of support. To my husband, Dr Ashish Rai, for always being by my side. To my lovely angels Ananya and Namya, the blessings of my life. To my dear sister Vijaya, who is the joy and pride of my life. To my family for all the support. To my wonderful friends for always being a source of encouragement and making my life whole. To Dr. Sumer Sethi and the DAMS team for their support and a wonderful working environment. To Mr. Pawaninder P. Vij and Mr. Anupam Vij, Directors, Peepee Publishers and Distributors (P) Ltd., New Delhi for his keen interest and sincere efforts in getting the book published. Ruchi Rai [email protected]  CONTENTS 1. Diseases of Lens ---------------------------------------------------------------------------------------- 1 2. Glaucoma ----------------------------------------------------------------------------------------------- 33 3. Cornea --------------------------------------------------------------------------------------------------- 66 4. Conjunctiva -------------------------------------------------------------------------------------------- 105 5. Sclera and Episclera --------------------------------------------------------------------------------- 127 6. Uveitis -------------------------------------------------------------------------------------------------- 132 7. Orbit ---------------------------------------------------------------------------------------------------- 162 8. Ocular Adenexae ------------------------------------------------------------------------------------- 201 9. Lacrimal Drainage System -------------------------------------------------------------------------- 215 10. Neurophthalmology ---------------------------------------------------------------------------------- 221 11. Fundus ------------------------------------------------------------------------------------------------- 258 12. Vitreous ------------------------------------------------------------------------------------------------ 313 13. Squint and Optics ------------------------------------------------------------------------------------ 317 14. Community Ophthalmology ------------------------------------------------------------------------ 365 15. Embryology ------------------------------------------------------------------------------------------- 371 16. Recent Advances ------------------------------------------------------------------------------------- 374 Appendices -------------------------------------------------------------------------------------------- 379  CHAPTER 1 Diseases of Lens ANATOMY  It is secreted at embryonic stage as a basement membrane of lens epithelium  Lens is biconvex in shape. (Thickest basement membrane in  Diameter: 9–10 mm. the body).  Refractive index: 1.39.  It is thicker anteriorly than posteriorly and at the equator than the poles.  Total refractive power: 16 D–17 D. Capsule is thinnest at the Structure of Lens posterior pole. 2. Anterior epithelium: It constitutes single Equatorial Iris layer of epithelium cells. They are cuboidal Epithelium lens bow at the centre and become columnar at the periphery. 3. Lens fibres: They are of two types: a. Nucleus (old lens fibres). It is further Ciliary divided into: Embryonic (1–3 months body gestation), Foetal, Infantile, Adult. Hexagonal lens fibers Zonules Cortex Capsule b. Cortex (youngest lens fibres). Embr- Embryonic yonic nucleus is the oldest fibres. nucleus 4. Zonules of zinn: They are the suspensory Fig. 1.1: Structure of lens ligaments which support the nucleus. Lens constitutes of: PHYSIOLOGY 1. Lens capsule:  80% of glucose is metabolized anaerobically.  Lens capsule is a thin, transparent, This leads to formation of lactic acid in the hyaline collagenous membrane which lens which diffuses into the aqueous surrounds the lens completely. humour. Hence, absence of lens will lead to  Lens capsule is highly elastic but does decreased lactic acid in the aqueous not have any elastic tissue. humour. 1  2 Review of Ophthalmology  Lens derives its nutrition from aqueous Classification humour. a. Etiologically: (1) Senile (2) Metabolic  Antioxidative system of the lens constitutes (3) Complicated (4) Traumatic (5) Radia- of Vitamin C, i.e., ascorbic acid, Vitamin tional (6) Toxic (7) Electric (8) Skin diseases E and glutathione. The detoxifying (9) Osseus diseases (10) Syndromes. enzymes whic h ar e responsible to b. According to maturity: (1) Immature counteract the oxidative damage in the lens (2) Mature (3) Hypermature. are catalase and superoxide dismutase. Cataract occurs due to the oxidative c. Anatomically: (1) Capsular cataract– damage to the lens. Anterior and Posterior (2) Subcapsular cataract–Anterior and Posterior (3) Cortical  Glutathione plays a central role in cataract (4) Supranuclear cataract (5) protecting the lens from oxidative damage. Nuclear cataract (6) Polar cataract– It is a tripeptide synthesized in the lens. Anterior and Posterior. Its levels are reduced in patients of cataract. Most common cause of acquired cataract is senile cataract.  Myoinositol is actively transported into the lens by sodium dependent carrier mediated mechanism. Its levels are markedly CONGENITAL AND DEVELOPMENTAL reduced in cataract. It is a precursor of CATARACT membrane phosphoinositides which are involved in Na/Ka ATPase function. It also Etiology participates in ascorbic acid transport in a. Heredity: Usually dominant. the lens. b. Maternal factors: Lens 1. Malnutrition. W ater 99% 66% 2. TORCHS infections, i.e., Toxoplas- Na+ 144 20 mosis, rubella, cytomegalovirus, Herpes Na + K + AT Pase and syphilis. K+ 4.5 125 3. Drug: Thalidomide, Corticosteroid. Glucose 6 1 4. Radiation. Lactic acid 7.4 14 Proteins 0.04% (S) 33% c. Foetal or Infantile factor: Active Transport 1. Anoxia. Diffusion 2. Metabolic: (S) Synthesis a. Galactosemia–Galactokinase defi- Fig. 1.2 ciency. Development of lens: Lens develops from b. Neonatal hypoglycemia. lens vesicle which is derived from surface 3. Congenital anomaly: Lowe’s syndrome, ectoderm. Myotonia dystrophica. Cataract 4. Birth trauma. Definition: Any interference in the optical 5. Malnutrition. homogeneity of the lens is called cataract. d. Idiopathic. Diseases of Lens 3 Types CONGENITAL RUBELLA SYNDROME a. Cataracta centralis pulverulenta: It is characterized by the classical triad of– 1. Embryonic nuclear cataract. Cataract, Headache and Deafness. 2. Opacity has powdery appearance. 3. Does not affect vision. b. Zonular/lamellar: MNEMONIC Most common type of congenital cataract CHD (Cataract, Headache and Deafness) causing decreased vision. 1. Involves the foetal nucleus. Ocular Features 2. Etiology may be: 1. Microphthalmos. A. Genetic: Dominant inheritance. 2. Cataract: Pearly nuclear or lamellar. 3. Retinopathy: Salt-pepper retinopathy at B. Environmental: (1) Vitamin D defi- posterior pole. It is non progressive. ciency, (2) Rubella infection in 7th– 8th week of gestation. 4. Glaucoma. 5. Optic nerve abnormalities. 3. Usually bilateral. 6. Other complications: 4. Causes severe visual defect. A. Pendular nystagmus and strabismus. 5. Small linear opacities towards B. Keratitis. equator called Riders are charac- teristic of lamellar cataract. C. Iritis and iris atrophy. D. Extreme refractive error. c. Sutural cataract: Along anterior and posterior sutures. The most common type of cataract in rubella is–Nuclear Pearly. d. Anterior polar cataract. e. Posterior polar cataract. ACQUIRED CATARACT f. Coronary cataract: Occurs in adolescence, 1. Senile Cataract club shaped opacities peripheral in Etiology: distribution.  Heredity. g. Punctate cataract: Also called Blue-dot  Dehydrational crisis in diarrhea and cataract or Cataracta-punctate-cerulea– cholera. Bluish dots in peripheral part of adolescent nucleus and deeper cortex are seen. It is the  UV-Rays. most common type of congenital cataract.  Dietary deficiency of vitamin E,C,B and proteins. h. Total congenital cataract. It is broadly divided into: i. Congenital membranous cataract: It is due to total or partial absorption of congenital  Nuclear. cataract.  Cortical. 4 Review of Ophthalmology Nuclear Cataract: lies right in the pathway of the axial rays, at the nodal point of the eye It occurs due to following factors: (Nodal point of eye is just behind the w Increased age-related nuclear sclerosis. lens) and thus causes an early loss of w Increase in insoluble proteins. visual acuity. w Deposition of pigments like urochrome and melanin. Maturation of Cortical Cataract: Sclerosis makes the lens hard and inelastic 1. Stage of Lamellar Separation. leading to shrunken lens with wrinkled 2. Stage of Incipient Cataract. capsule due to leakage of water. This 3. Immature Senile Cataract (Intumescent causes inability to accommodate and Cataract—It causes frequent change of progressive index myopia. It manifests as presbyopic glasses). “Second sight of old age”. 4. Mature Senile Cataract (Ripe Cataract). Maturation of Nuclear Cataract: 5. Hypermature Morgagnian Cataract. A. Immature cataract. Causes of frequent change of B. Mature cataract. presbyopic glasses are: C. Hypermature nuclear sclerotic cataract. 1. Early cataract (Intumescent cataract). 2. Late stage of primary open angle Nuclear Cataract may be Tinted: glaucoma. A. Amber. 3. Diabetes mellitus (Hyperglycemia B. Brown—Cataracta Brunescens. causes myopic shift and hypoglycemia C. Black—Cataracta Nigra. causes hypermetropic shift). D. Red—Cataracta Rubra. Note: Nuclear cataract causes Hamarlopia (Day w Intumescent cataract is a cause of Blindness). Phacomorphic glaucoma. Causes of Hamarlopia: w Morgagnian cataract is the most common form of senile cataract 1. Central corneal opacities. causing glaucoma. 2. Central lenticular opacities. w Most common complication of 3. Congenital absence of cones. Morgagnian cataract is Phacolytic Cortical Cataract: Decreased levels of Glaucoma. Other complication total protein, amino acids and potassium possible is Phacoanaphylactic alongwith increased concentration of Na+, uveitis. leads to hydration and coagulation of w Most common complication of proteins causing cataract. It is of two types: hypermature nuclear sclerotic cataract is subluxation of lens. 1. Cuneiform: It generally starts as wedge shaped radial spokes from periphery to 2. Metabolic Cataract center. Hence visual disturbances are comparatively at the late stage. a. Diabetes Mellitus: 2. Cupulliform: These are posterior sub- w Causes senile cataract at early age (i.e., capsular opacities. This type of cataract presenile cataract). Diseases of Lens 5 w Typical morphology is Snow-Flake descements membrane is due to Or Snow-Storm Cataract. copper deposition and is patho- w Increased glucose leads to sorbitol gnomic of Wilson’s disease. pathway (Due to saturation of other Note: Fleischer’s ring is iron metabolic pathways like glycolysis and deposition at the base of the cone in krebs cycle. When enzyme hexokinase patients of keratoconus. is saturated or inhibited, sorbitol path- e. Lowe’s Syndrome (Oculocere- way is the only pathway remaining for brorenal syndrome): It is an glucose metabolism. inborn error of aminoacid metabolism. w This sorbitol accumulation in the lens Ocular Features: (Due to Aldose Reductase pathway) 1. Congenital cataract. leads to overhydration of lens causing cataract. 2. Microphakia. b. Galactosaemia: 3. Posterior lentiglobus/Posterior Lenti- conus. w Deficiency of GPUT (Galactose- phosphouridyl transferase) causes Oil 4. Glaucoma. Droplet Cataract. f. Mannosidosis: Deficiency of alpha- w Deficiency of Galactokinase causes mannosidase leads to mannose rich lamellar cataract. oligosaccharides in tissues causing spoke like posterior capsular cataract. c. Hypocalcaemia: Due to decreased parathyroid activity, i.e., Hypoparathy- g. Fabry’s Disease: roidism. w It is due to deficiency of alpha- d. Wilson’s Disease: Wilson’s disease Galactosidase. (Hepatolenticular degeneration) is a rare condition caused by deficiency of Ocular Features: alpha2—globulin, ceruplasmin. It is 1. Spoke like cataract—No impairment characterized by widespread deposition of vision. of copper in the tissues and becomes 2. Vortex Keratopathy. manifest in 3 ways: 1. Liver disease. 3. Complicated Cataract 2. Neurological involvement of the basal ganglion. Clinical Features: 3. Psychiatric features. w It is posterior cortical or more Ocular Features are: commonly posterior subcapsular due to posterior segment disease. 1. Sunflower Cataract: This type of cataract also occurs in blunt trauma w It is anterior cortical due to anterior where it is also known as Rossete segment disease. Cataract. w Most commonly it is Posterior sub- 2. K.F. Ring (Kayser-Fleischer Ring): capsular. Golden brown discoloration of w Spreads axially.  6 Review of Ophthalmology w Has Bread Crumb appearance. 5. Busulphan: It is given for treatment of w Polychromatic luster is the patho- CML. It causes PSC, i.e., posterior sub- gnomic feature of complicated capsular cataract. cataract. 6. Amiodarone: Anterior subcapsular cataract. Also causes vortex keratopathy. Causes: 7. Cu, Fe, Au: Gold is used for the 1. Inflammatory–Iridocyclitis, Pars- treatment of rheumatoid arthritis and planitis, Choroiditis, Endophthalmitis, causes ASC. Corneal ulcer. w Most common ocular compli- 2. Degenerative–Retinitis pigmentosa, cation of steroid is–Glaucoma. Best disease (It is dystrophy of RPE Occurrence of glaucoma is cells), Myopia. genetically monitored. Less common in short term steroid therapy or 3. Tumours. alternate day therapy. 4. Glaucoma–Primary and Secondary. w Oral steroids more commonly 5. Retinal detachment. lead to cataract and topical Hypermetropia is not a degenerative steroids more commonly lead to disease hence complicated cataract glaucoma. does not occur in hypermetropia but w Both phenothiazines (chlorpromazine) occurs in myopia. and chloroquine can cause cataract but phenothiazines are most 4. Toxic Cataract commonly mentioned in relation to cataract formation. Causes: 1. Corticosteroids: Typically discoid, 5. Traumatic Cataract posterior sub-capsular cataract which at a later stage involves anterior Features of Blunt Trauma/ subcapsular region. Steroids both Concussion Injury: systemic and topical are cataracto- 1. Rossette-shaped cataract: It is also genic. called sunflower cataract. It mainly 2. Phenothiazines: Deposition of fine yellow involves posterior cortex first. brown granules under the anterior 2. Vossius ring: It is the imprint of iris capsule in pupillary zone which develop pigment on the anterior capsule of the into large stellate opacities and finally lens, due to blunt trauma. anterior polar cataract. 3. Berlins edema: It is also called 3. Chloroquine: (Not hydroxychloroquine) Commotio Retinae. It is macular edema causes white, flaky posterior sub- after blunt trauma and is morpho- capsular cataract. logically described as “cherry-red spot”. 4. Anticholinesterases: Commonly causes 4. Angle-recession glaucoma: Angle anterior subcapsular cataract. Mainly recession occurs due to tear in ciliary due to long acting miotics like DFP, body after blunt trauma. Glaucoma is Ecothiophate, Demecarium bromide. due to damage in trabecular network. Diseases of Lens 7 6. Radiational Cataract 2. Ptosis—Usually bilateral. w It occurs due to damage to lens by all 3. Pigmentary retinopathy, i.e., salt types of radiations namely UV rays, and pepper fundus. Infrared rays, X-rays/Y-rays or neutrons. 4. Pupillary changes—Light-near w Infrared rays causes “Glass Blower’s” or dissociation. Glass worker’s cataract. 5. Low intraocular—pressure. w MRI has no radiation exposure as it is Hence, we remember its ocular done by ultrasonic energy and not features as 5 Ps. radiations. 2. Atopic dermatitis: Stellate opacities w Most common type of radiational mostly posterior. cataract is Posterior subcapsular cataract. They are punctate subcapsular 3. Diabetes mellitus: It causes snowstorm opacities which mature rapidly. or snowflake opacities. 7. Syndermatotic Cataract SYNDROMES ASSOCIATED WITH These are cataracts which occur due to skin CATARACT diseases. A. Down’s Syndrome Causes: Ocular Features: w Atopic dermatitis is the most common 1. Shortened and slanted palpebral fissure. cause. 2. Neonatal ectropion. w Poikiloderma. 3. Lateral trichiasis and entropion. w Scleroderma. 4. Keratoconus. 8. Pre-Senile Cataract 5. Cataract. These are cataracts which occur in young 6. Brushfield spots are light coloured age. spots on iris. Causes: B. Others w Werner’s syndrome. 1. Myotonic dystrophy: Myotonic dys- trophy or Dystrophia myotonica is a w Rothmund’s syndrome. generalized dominantly inherited myopathy characterized by myotonia of CLINICAL FEATURES OF CATARACT peripheral muscles and muscle wasting. 1. Misty vision with distortion of vision. Ocular Features: 2. Loss of vision. 1. Pre-senile cataract 3. Coloured halos. w “Christmas-tree cataract”— posterior subcapsular, stellate Other causes of coloured halos are: plaque. w Mucopurulent conjunctivitis. w Small iridescent, polychromatic w Acute congestive angle closure crystals. glaucoma.  8 Review of Ophthalmology Finchams Test: It helps to know the 4. Phacoemulsification: Cataract removal cause of halos whether it is due to cataract using phacoemulsification is achieved by or glaucoma. A stenopic slit is passed in ultrasonic fragmentation and aspiration of front of the eye which is seeing the halos, the lens material. The tip of the phaco- if the halos break then it is due to cataract emulsification hand piece is composed of a and if not then it is due to glaucoma. hollow (approximately 1 mm) titanium 4. Black spots in front of eyes. needle that transmits vibrations at a high 5. Glare. speed (30,000 to 60,000 cycles/sec) to emulsify the cataract. These vibrations are 6. Uniocular diplopia or polyopia seen in stage transferred from piezoelectric or magneto- of intumescent cataract. strictive crystals. COMPLICATIONS OF LONG 5. Lensectomy with anterior vitrectomy: Lens in toto with anterior vitreous is STANDING CATARACT removed. This procedure is specially opted 1. Uveitis. in children when ICCE is indicated. This 2. Subluxation or dislocation of lens (In is because in children there is strong nuclear sclerotic cataract). adhesion between posterior surface of lens and anterior hyaloid face of vitreous and 3. Glaucoma: Phacoanaphylactic/Phaco- hence any pulling can cause retinal morphic/Phacolytic. detachment. MANAGEMENT OF CATARACT 6. Mydriatics/optical iridectomy: This procedure can be opted for congenital The first line of treatment in cataract is stationary cataracts but now it is more of surgery. a theoretical purpose and not opted for. Modalities of Treatment of Cataract 7. ECCE with PC IOL with primary posterior 1. ICCE (Intracapsular cataract extraction): It capsulotomy: Primary posterior capsulo- constitutes removal of lens alongwith the tomy is done in children as they are very capsule. The methods of ICCE are: 1. prone to develop posterior capsular Cryoextraction 2. Forceps method (Arrugas opacification after few days of surgery due forceps are used) 3. Irisophake 4. Wire to intense postoperative inflammations. Vectis 5. Indiansmith method (Also called Discission and Needling done in tumbling method). The best method is congenital cataract are now obsolete cryoextraction. Today the only procedures. indication of ICCE is subluxation of lens. Preoperative evaluation of cataract surgery includes: 2. ECCE with PC IOL (Extracapsular cataract extraction): It constitutes removal of lens I. General Examination for: leaving behind the posterior capsule on  Diabetes mellitus. which artificial lens is implanted.  Hypertension. 3. Manual small incision cataract surgery: This is sutureless small incision cataract  Cardiac problems. surgery without using the phacoprobe.  Obstructive lung disorders. Diseases of Lens 9 w Any potential source of infection in the w State of endothelial cells. body like—septic gums, urinary tract E. Intraocular pressure measurement. infection. F. Gonioscopy is not done routinely. It is II. Ocular Examination: only when the IOP is found raised, we A. Retinal function test: can do to assess the state of the angle. 1. Perception of light. SURGICAL TECHNIQUES 2. Projection of rays—Easy test to assess the function of peripheral retina. ECCE (a) Limbal partial thickness incision is made 3. Test for Marcus Gunn pupillary from 10 o’ clock to 2 o’ clock. response. (b) Anterior chamber is formed by viscoelastic } 4. Two light discrimination. through a small full thickness incision. 5. Maddox rod test. Macular function (c) Anterior capsulotomy is done (Can opener 6. Laser interferometry. test technique or Envelope technique). 7. Stereoacuity. (d) Partial thickness limbal incision is made 8. Color perception—It indicates that full-thickness by corneal scissors. optic nerve is relatively normal. (e) Hydrodissection and hydrodelineation is 9. Entoptic visualization is also used to done. indicate retinal function but it is a (f) Nucleus is prolapsed. subjective test where the patient perceives his own vasculature. (g) Cortical matter is aspirated. 10. Indirect ophthalmoscopy. (h) IOL is implanted. B. Objective tests are indicated if some (i) Incision is sutured by radial sutures. retinal pathology suspected. BSS (i.e., Basal salt solution) with glutathione i. ERG—Electroretinogram. is the ideal irrigating fluid in cataract surgery as it resembles the aqueous humour ii. EOG—Electrooculogram. most. iii. VER—Visually-Evoked-Response. After cataract surgery, stitches are removed C. Search for local source of infection: at 6 weeks post-operative, and refraction w Conjunctivitis. should be done after 2 weeks of the suture removal so that any change in corneal w Blepharitis. curvature due to the sutures (tight or loose) w Meibomitis. is stabilized. (But if in the question, 8 weeks w Lacrimal sac infection—lacrimal is not an alternative, we will mark 6 weeks syringing is done. as the correct answer). This schedule is for conventional cataract surgery (with sutures). D. Slit lamp examination of anterior In case of sutureless cataract surgery segment of eye: with phaco, refraction can be done after w Presence of uveitis. 1–2 weeks.  10 Review of Ophthalmology Small Incision Cataract Surgery Advantages: (SICS) 1. Normal life activity regained faster. ECCE can also be done through self-sealing 2. Minimum post-operative astigmatism. small incision, which does not need any Note: sutures. This sutureless surgery can be either by phaco machine, which is called Phaco-  Vitreous haemorrhage and RD occurs emulsification or manually called Non-phaco more commonly in ICCE due to vitreous sutureless cataract surgery. traction. In ECCE since the posterior capsule (PC) is intact this complication 1. Manual small incision cataract is less common. surgery:  Cystoid macular edema (CME) after Procedure: cataract surgery (called Irvine-Gass (a) Triplanar scleral tunnel is made. syndrome) is attributed to both vitreous (b) Anterior chamber is formed by traction and prostaglandins released viscoelastic. during inflammation. As there is an intact PC in ECCE hence again this (c) Anterior capsulotomy is done (Preferably complication is less common in ECCE. CCC, i.e., continues curvilinear capsu- lorrhexis or can opener).  IOL implantation in diabetic patient should be done after PRP (pan-retinal (d) Hydrodissection and hydrodelineation is photocoagulation). But if the patient has done. developed diabetic cataract then IOL (e) Nucleus is first prolapsed in the anterior implantation becomes a prerequisite for chamber and then prolapsed out by proper visualization of fundus and PRP. viscoelastic called viscoexpression.  An uncontrolled glaucoma is a contra- (f) Cortical matter is aspirated and IOL indication for IOL implantation surgery. implanted. If we have to implant a First the glaucoma has to be controlled nonfoldable lens then we need to extend as increased intraocular tension can our scleral incision. lead to per-operative complications. (g) No sutures are required as it is a self-  Phacoemulsification is less preferred in sealing incision. black cataract, i.e., grade 4 or grade 5 nuclear cataract. 2. Phacoemulsification: Procedure: MANAGEMENT OF PEDIATRIC (a) Scleral tunnel with an external CATARACT incision of 3 mm to 3.5 mm is made/ In both bilateral and unilateral cases, Corneal incision can also be made. primary implantation is indicated as soon as (b) Circular curvilinear capsulorrhexis the patient is fit for anesthesia, ideally done. between 2 and 3 months of age. The earlier the surgery is done, the better is the chance (c) Hydrodissection and Hydrodelineation that deep amblyopia can be overcome as the done and lens material emulsified and visual reflexes develop by 5–6 months of age. aspirated along with the cortical Unilateral cases are particularly at a risk of matters. developing deep amblyopia and hence dealt (d) Foldable IOL implanted. with more seriously. Diseases of Lens 11 Management can be divided according to two  PC-IOL–It is of two types J-loop or age groups: C-loop. C-loop is preferred. Best option for 1. Patients younger than 2 years. IOL implantation is posterior capsule as it is most physiological. 2. Patients between 2–8 years. Biometry: Guidelines for the Choice of Intraocular Lens The process of calculating the power of intraocular IOL is known as biometry. 1. < 2 years old: It is done by SRK formula:  Do biometry and undercorrect by 20%. OR SRK–I  Use axial length measurements only. P = A – 2.5 L – 0.9 K A is a constant depending on the surgeon and Axial length IOL diopteric power the type of IOL. 17 mm 28 D L is the axial length and is measured by 18 mm 27 D USG-A scan. 19 mm 26 D K is the keratometry reading (Average of K1 20 mm 24 D and K2) and is measured by Keratometer. 21 mm 22 D SRK-II: It is the corrected form of SRK-I, taking into account any unusual axial length 2. Between 2 years to 8 years: Do biometry of the eye (i.e., too long or too short). and undercorrect by 10%. Hence preferred choice is SRK-II. The undercorrection of the IOL power is done to take into account the myopic shift of power COMPLICATIONS OF CATARACT as the child grows. SURGERY The total diameter of IOL in children should not exceed 12 mm. Operative: 1. SR muscle laceration. IOLS 2. Excessive bleeding during conjunctival flap preparation. Materials: 3. Irregular incision.  Commonly used material of IOL (Non- foldable) is PMMA (Polymethylmetha- 4. Injury to cornea, DM-detachment. crylate). 5. Iris injury and iridodialysis.  Materials for foldable IOLs are: Hydrogel, 6. Accidental rupture of lens capsule. Silicon and Acrylic. 7. Vitreous loss. Types of Non-Foldable IOLs: 8. Expulsive haemorrhage.  AC-IOL-Kelman multiplex. Early Post-Operative:  Iris-supported lens–Worst’s or Singh’s iris 1. Hyphema. claw lenses. 2. Iritis and iris prolapse.  12 Review of Ophthalmology 3. Striate keratopathy. Types: 4. Flat anterior chamber. a. Sunset syndrome: Inferior subluxation 5. Bacterial endophthalmitis: Painful. of IOL. 6. Glaucoma due to retained viscoelastic. b. Sunrise syndrome: Superior subluxa- tion of IOL. Late Post-Operative: c. Lost lens syndrome: Complete dislo- (All are painless conditions) cation of IOL in the vitreous cavity. 1. CME. d. Windshield wiper syndrome: It denotes 2. RD. the movement of the superior haptic with the movement of the head. This 3. Epithelial in-growth. occurs due to implantation of a very 4. Fibrous down growth. small lens in the ciliary sulcus. 5. After cataract. 8. Toxic lens syndrome: It indicates the uveal RD occurs more commonly in aphakes inflammation which occurs due to lens compared to pseudophakes. The patient will material or the ethylene gas used to sterilise present as floaters and sudden loss of vision. the lens.  Most dreaded complication of IOL-Related cataract surgery is–Endophthal- 1. Corneal endothelial damage. mitis. It may be early onset or late onset. 2. Uveitis: Mainly with AC-IOLs and iris-claw lenses. Early Onset: 3. Secondary glaucoma. 1. Staphylococcal epidermidis is the most common organism isolated 4. Anisocoria (difference in size of pupil): from post-surgical endophthalmitis. Commonly when iris claw lenses are implanted. It can also occur in PC-IOL 2. Other organisms are: Staph aureus, implantation when there is iris hook by the Pseudomonas and Proteus. haptic. Late Onset: 5. Cystoid macular edema: Its incidence is 1. Propionobacterium acne. specially more in iris-claw lenses or AC- 2. Fungal infection. IOLs when, there is no posterior capsule. CME after cataract surgery is known as  Most common late complication of “Irvine–Gass Syndrome”. cataract surgery is–After cataract or PCO. 6. UGH syndrome:  Uveitis/glaucoma/hyphema syndrome. After Cataract  Occurs with rigid AC-IOLs.  It denotes opacification of posterior capsule after cataract surgery. 7. Malposition of IOLs:  It is also known as secondary cataract. It causes:  It may present with various morphological a. Astigmatism, if IOL is tilted. forms namely–Elschnig’s pearls, b. Decentration of IOL leads to glare, Soemmering’s rings or just a diffuse halos, rings of light, uniocular diplopia. opacification. Diseases of Lens 13 w Treatment: Homocystinuria: It is an inborn error of (a) Surgical capsulotomy by zeiglers knife. metabolism caused by deficiency of enzyme – Cystathione synthetase leading to increased (b) Laser capsulotomy by Nd-Yag laser level of homocysteine in plasma and urine. It which is a photodisruptive or cutting is characterized by skeletal deformities laser. similar to Marfan’s syndrome and mental handicap. DISPLACEMENT OF THE LENS Ocular Features: Subluxation is partial dislocation of lens. 1. Ectopia lentis in inferonasal direction. Causes: 2. Angle anomaly leading to glaucoma or pupil 1. Congenital—(a) Simple ectopia lentis block glaucoma due to incarceration of lens (Symmetrical and upwards) (b) Ectopia in the pupil. lentis et pupillae (slit shaped pupil displaced 3. Loss of accommodation due to disintegration in opposite direction) (c) Ectopia lentis with of zonules. systemic anomalies (Marfan’s syndrome, Homocystinuria, Weil-Marchesani syndrome Ehlers-Danlos Syndrome and Ehlers-Danlos syndrome). 1. Blue sclera. 2. Traumatic—Blunt trauma. 2. Ectopia lentis. 3. Consecutive or Spontaneous—Hyper- mature cataract, Buphthalmos, High Congenital Anomalies of Lens myopia and Uveitis. A. Colobomas: Marfan’s Syndrome 1. Mostly occurs inferiorly. 1. Megalocornea and Cornea plana. 2. May be associated with defect in iris and choroid. 2. Angle anomaly leading to glaucoma. {M} B. Congenital Ectopia Lentis. 3. Upward/temporal ectopia lentis. C. Lenticonus: It is the conical protrusion of 4. Difficulty in pupil dilatation. the lens. 5. Lattice degeneration and rhegmatogenous Anterior Lenticonus: retinal detachment. Anterior lenticonus occurs in Alport’s The most PROMINENT manifestation of Syndrome. Marfan’s syndrome is Megalocornea. Alport’s Syndrome (Familial haemorrhagic The most COMMON manifestation of nephritis) Marfan’s syndrome is Ectopia lentis. Systemic Features: Weil-Marchesani Syndrome 1. Renal failure. 1. Microspherophakia. 2. Hearing loss. 2. Pupillary block glaucoma. Ocular Features: 3. Ectopia lentis in inferior and forward 1. Posterior polymorphous corneal direction. dystrophy.  14 Review of Ophthalmology 2. Juvenile arcus. E. Lentiglobus: It is a generalised hemis- 3. Pigment dispersion. pherical deformity of the lens. Posterior lentiglobus is seen in Lowe’s syndrome. 4. Anterior lenticonus. F. Microphakia: Lens is small in size. It is 5. Retinal pigmentary changes. seen in Lowe’s syndrome. Posterior Lenticonus: G. Microspherophakia: Small and spherical lens. It occurs in Lowe’s Syndrome–i.e., Oculo- Occurs in: cerebrorenal syndrome. 1. Weil-Marchesani syndrome. D. Congenital cataract. 2. Hyperlysinaemia. NEET DRILL 1. The equatorial diameter of the lens is 15. Lens nucleus is divided as–embryonic 9–10 mm. nucleus–1-3 months of gestation/fetal 2. The equatorial diameter of the lens at birth nucleus–3 months–birth/infantile nucleus- is 6.5 mm. birth–puberty/adult nucleus–in adult life. 3. Thickness of the lens, i.e., the AP 16. Lens is 66% water and 33% protein. diameter is 3.5 mm–5 mm. 17. Antioxidative system of lens constitutes– 4. Radius of curvature of the anterior surface vitamin C, i.e., ascorbic acid, glutathione, is 10 mm. myoinositol that helps in ascorbic acid carrier system and detoxifying enzymes 5. Radius of curvature of the posterior like catalase and superoxide dismutase. surface is 6 mm. 18. Respiratory coefficient of the lens is: 1. 6. Refractive index of the lens is 1.39. 19. Microwave radiations can also cause 7. Refractive power is 16 D–17 D. cataract, proved in animals and claimed 8. Accommodative power of the lens at birth: that there is maximum probability for 14–16 D at birth, 7–8 D at 25 years and humans also. It occurs in due to rise in 1–2 D at 50 years of age. temperature. 9. The pigments responsible for the color 20. Length of incision in phacoemulsification change in the process of development of is 2.75–3.2 mm. cataract are urochrome and melanin. 21. Frequency of the phacoprobe is 40 khz. 10. Snowflake or snowstorm cataract is more 22. Most commonly used foldable IOL is common in type 1 diabetes. acrylic. 11. Cataract in diabetes is due to sorbital 23. MICS, i.e., minimal incision cataract accumulation in the lens and sorbital is surgery: incision is between 1.8 and 2.4 mm. very hyperosmotic. 24. Phaconit: Incision length is 0.9 mm. 12. Lens capsule is thinnest at posterior pole 25. Father of phaco: Charles D Kelman. with the thickness of 4 microns. 26. Causes of ectopia lentis: Marfan’s syndrome, 13. Lens capsule is thickest at equatorial homocystinuria, Weil-Marchesani, Ehlers- region and is 23 microns in thickness. Danlos, sulphite oxidase deficiency, 14. Suspensory ligament or zonules have a hyperlysenemia, Refsum’s disease and diameter of 0.35–1 microns. Sturge-Weber syndrome. Diseases of Lens 15 27. Anterior lenticonus: Alport’s syndrome, 33. The genes responsible for congenital Waardenburg syndrome. cataract: CRY, i.e., crystallines, Cx, i.e., 28. Posterior lenticonus: Lowe’s syndrome. connexins and MIP, i.e., Major Intrinsic 29. Expulsive haemorrhage after cataract Protein. surgery occurs due to bleeding from the 34. The most recent in cataract surgery is posterior ciliary arteries. Femtolaser cataract surgery called LACS, 30. The size of opening of posterior capsulo- i.e., laser assisted cataract surgery. tomy done by NdYAG laser ranges from 2–3 mm to 5–6 mm. 35. Femtolaser is an ultrafast laser, with pulse duration in femtosecond, i.e., 10–15. 31. The insoluble proteins raised in a cataractous lens are: HM3, HM4. 36. Minimum chance of after cataract is seen 32. In nuclear cataract, it is HM4. with Acrylic Hydrophobic IOLSs. MULTIPLE CHOICE QUESTIONS 1. Transport of ascorbic acid to lens is A. The best age to operate him to get the done by: best visual results is four weeks A. Myoinositol B. Choline B. The best age to operate him to get the C. Taurine D. Na/K ATPase best visual results is four months 2. Which of the following does not C. The best age to operate him to get the handle the free radicals in the lens? best visual results is four years A. Vitamin A B. Vitamin E D. The eye is already lost, only cosmetic correction is required C. Vitamin C D. Catalase 6. Which prominent ocular manifes- 3. Typical bilateral inferior sublux- tation is associated with Marfan’s ation of lens is seen in: syndrome? A. Marfan’s syndrome A. Microcornea B. Homocystinuria B. Microspherophakia C. Hyperinsulinemia C. Megalocornea D. Ocular trauma D. Ectopia lentis 4. In which of the following uveitic 7. A child has got a congenital cataract conditions is it contraindicated to put involving the visual axis, which was intraocular lens after cataract detected by the parents right at extraction? birth. This child should be operated: A. Fuch’s heterochromic cyclitis A. Immediately B. Juvenile rheumatoid arthritis B. At 2 months of age C. Psoriatic arthritis C. At 1 year of age when globe becomes D. Reiter’s syndrome normal sized 5. A two-week old child presents with D. After 4 years when entire ocular and unilateral cataract, which of the orbital growth become normal following statement represent the 8. Dislocation of lens is seen in all the best management advice? following conditions except:  16 Review of Ophthalmology A. Congenital rubella 15. The crystalline lens derives its B. Weil-Marchesani syndrome nutrition from: C. Marfan’s syndrome A. Blood vessels B. Connective tissue D. Homocystinuria C. Aqueous D. Zonules 9. After cataract surgery, glasses are 16. Which laser is used in the management prescribed after: of after cataracts? A. 2 weeks B. 6 weeks A. Argon B. Krypton C. 12 weeks D. 20 weeks C. Nd-YAG D. Excimer 10. Sunflower cataract is caused by: 17. A 55 years old patient complains of decreased distance vision. However A. Siderosis now he does not require his near B. Chalcosis glasses for near work. The most C. Lead intoxication likely cause is: D. Silicosis A. Posterior subcapsular cataract 11. Anterior lenticonus is found in: B. Nuclear sclerosis A. Lowe’s syndrome C. Zonular cataract B. Willium syndrome D. Anterior subcapsular cataract C. Alport’s syndrome 18. A 56 years old patient presents after D. Down’s syndrome 3 days of cataract surgery with a history of increasing pain and 12. Vossius ring is seen on: diminution of vision after an initial A. Cornea improvement. The most likely cause B. Anterior capsule of lens would be: C. Posterior capsule of lens A. Endophthalmitis D. Iris B. After cataract 13. Steroid-induced cataract is: C. Central retinal vein occlusion A. Posterior subcapsular D. Retinal detachment B. Anterior subcapsular 19. Which morphological type of cataract C. Nuclear cataract is most visually handicapping? D. Cupulliform cataract A. Cortical 14. Which of the following is the most B. Nuclear important factor for prevention of C. Posterior subcapsular endophthalmitis in cataract surgery? D. Zonular A. Preoperative preparation with povidone 20. The standard sutureless cataract iodine surgery done with phacoemulsifi- B. One week antibiotic therapy prior to cation and foldable IOL has an surgery incision of: C. Trimming of the eyelashes A. 1 mm–1.5 mm D. Use of intravitreal antibiotics B. 2–2.5 mm Diseases of Lens 17 C. 3–3.5 mm A. Glucokinase D. 3.5–4.5 mm B. NADPH+ dependent aldolase 21. Oldest component of lens of the eye C. Phosphofructoisomerase is: D. Hexokinase A. Anterior capsule 27. In Finchams test–there is breakup of B. Posterior capsule halo and rejoining (patient present C. Nucleocortical junction with coloured halo and giddiness). Diagnosis is: D. Nucleus A. Open angle glaucoma 22. Ideal fluid for irrigation during ECCE is: B. Cataract C. Mucopurulent conjunctivitis A. Normal saline to dextrose D. Acute angle closure glaucoma B. Normal saline 28. All are methods of intracapsular C. Balanced salt solution extraction of lens, except: D. Balanced salt solution + glutathione A. Phacoemulsification 23. The most common complication of B. Cryosurgery hypermature sclerotic cataract is: C. Forceps delivery A. Dislocation of the lens D. Erisophake B. Phacomorphic glaucoma 29. Snow flake cataract is a pathognomic C. Uveitis feature of: D. Neovascularization of retina A. Chalcosis 24. A 60 years old male patient operated B. Diabetes mellitus for cataract 6 months back now complains of floaters and sudden C. Wilson’s disease loss of vision. The diagnosis is: D. Trauma A. Vitreous haemorrhage 30. Chalcosis is associated with: B. Retinal detachment A. Copper B. Zinc C. Central retinal artery occlusion C. Lead D. Gold D. Cystoid macular edema 31. Polychromatic lusture is seen in: 25. Most common senile cataract A. Zonular cataract causing glaucoma is: B. Posterior subcapsular cataract A. Incipient type C. Nuclear cataract B. Nuclear type D. Anterior subcapsular cataract C. Morgagnian hypermature 32. Cataract is seen in all, except: D. Sclerotic hypermature A. Rheumatoid arthritis 26. A diabetic patient gets cataract B. Glucocorticoid administration because of accumulation of sorbitol in lens. The enzyme responsible for C. Galactosemia this is: D. Hypoparathyroidism  18 Review of Ophthalmology 33. Sunflower cataract is seen in: A. Prevents cystoid macular edema A. Injury B. Decrease endothelial damage B. Laurence-Moon-Biedl syndrome C. Progressively improves vision C. Wilson’s disease D. Decrease chance of retinal detachment D. Galactosemia E. Decrease chance of endophthalmitis 34. Before IOL implantation the following 40. Infective complication in cataract are done for the estimation of operation can be decreased by: refractory power of IOL: A. Antibiotic eye drops A. Keratometry B. Intracameral instillation of antibiotic B. Axial length at the end of the operation C. Lens thickness C. Intraoperative antibiotics D. Corneal thickness D. Preoperative antibiotics E. Corneal diameter E. Postoperative oral antibiotics 35. Most common cause of cataract is: 41. Cataract is caused by all except: A. Age related changes A. Ultraviolet radiation B. Hereditary B. MRI C. Diabetes mellitus C. Infrared radiation D. Trauma induced D. Microwave radiation E. Myxoedema E. Ionizing radiation 36. Treatment of cataract in infant is: 42. Best site for IOL implantation: A. Lensectomy A. Iris B. ICCE B. Capsular bag C. Discission C. Anterior chamber D. ECCE D. Sulcus E. Phacoemulsification 43. Common complication of IOLs are all except: 37. Cataract is evaluated by: A. Corneal dystrophy A. Gonioscopy B. Tonometry B. Glaucomas C. Stereoacuity D. Contrast C. Anisocoria E. Colour vision D. Macular edema 38. Modern IOL is made up of: 44. Rosette shape cataract is seen in: A. Acrylic acid B. PMMA A. Trauma B. Radiation C. PML D. Glass C. DM D. Iridocyclitis E. Silicon 45. Christmas tree cataract is seen in: 39. Leaving the capsule behind in cataract surgery is advantageous A. Down’s syndrome because it: B. Rubella Diseases of Lens 19 C. Myotonic dystrophy 52. Congenital cataract is seen in: D. Diabetes A. Lowe’s syndrome 46. Good vision in dim light and clumsy B. Tyrosinemia in day lights, seen in: C. Maple syrup urine disease A. Cortical cataract D. Beckwith-Wiedemann’s syndrome B. Morgagnian cataract 53. Cataract can be caused by prolonged C. Nuclear cataract ingestion of which drug? D. Steroid induced cataract A. Phenothiazines 47. Most common type of cataract is: B. Methotrexate A. Blue dot B. Zonular C. Ethambutol C. Cupulliform D. Cuneiform D. Chloroquine 48. The complication of extracapsular 54. Statement not true about rubella extraction of lens is: cataract is: A. Cystoid macular oedema A. Pearly white B. Opacification of capsule B. Bilateral C. Iritis C. Stationary D. Glaucoma D. Associated with subluxation E. None of the above 55. Cataract is caused by all except: 49. Factor leading to raised intraocular A. Systemic corticosteroids pressure after cataract extraction: B. Busulphan A. Vitreous touch syndrome C. Thioridazine B. Use of alpha chymotrypsin D. Metronidazole C. Choroidal detachment 56. Organism most commonly isolated D. Epithelial ingrowths from the vitreous following endoph- E. Residual lens cortex thalmitis developing 4 days after 50. Lens develops from: cataract surgery is: A. Surface ectoderm A. Staph epidermidis B. Neuroectoderm B. Bacillus subtilis C. Visceral mesoderm C. Pseudopyocyanea D. Paraxial mesoderm D. Propionobacterium 51. Downward and nasal subluxation of 57. All are risk factors for cataract lens is typically seen in: except: A. Homocystinuria A. Diabetes mellitus B. Marfan’s syndrome B. Hypertension C. Weil-Marchesani syndrome C. Smoking D. Ehlers-Danlos syndrome D. Recurrent diarrhoea  20 Review of Ophthalmology 58. After phacoemulsification, sutures 65. Lens capsule is thinnest at: applied are: A. Anterior pole B. Posterior pole A. Continuous C. Equator D. Pupillary margin B. Interrupted 66. Spontaneous absorption of the C. No sutures needed lenticular material is seen in: D. None of the above A. Myotonic dystrophy 59. Increased lactic acid in aqueous B. Hallerman Streif syndrome humour is found in: C. Aniridia A. Aphakia D. Persistent hyperplastic primary B. Ectopia lentis vitreous C. Traumatic dislocation of lens 67. Anterior cortical cataract is caused by: D. Senile cataract A. Perforating injury to eye 60. Earliest visual rehabilitation occurs with: B. Radiation A. ICCE + IOL C. Steroid B. ECCE + IOL D. Senile C. ICCE alone or laser 68. Traumatic dislocation of lens is diagnosed by: D. Phacoemulsification A. Direct ophthalmoscopy 61. Lens has a respiratory quotient of: B. Indirect ophthalmoscopy A. 1 B. 0.6 C. Distant direct ophthalmoscopy C. 0.7 D. 0.9 D. Slit lamp examination 62. True about complicated cataract is all except: 69. Constantly changing refractory error is seen in: A. Axial involvement A. Traumatic cataract B. Sutural involvement B. Diabetic cataract C. Polychromatic luster C. Morgagnian cataract D. Posterior subcapsular involvement D. Intumescent cataract 63. Hypermature cataract leads to: 70. What is the most important A. Phacomorphic glaucoma complication of anterior chamber B. Phacotoxic glaucoma lenses? C. Phacolytic glaucomas A. Glaucoma D. None of the above B. Hyphema 64. Scan used to calculate power of C. Subluxation intraocular lens is: D. Retinal detachment A. A scan B. C scan 71. The biochemistry of cataract C. S scan D. None formation is: Diseases of Lens 21 A. Hydration intumescence D. Associated with hypocalcemia B. Denaturation of lens proteins E. None of the above C. Slow sclerosis 78. The most common type of cataract D. All of the above in adults: A. Nuclear cataract 72. Which is not associated with zonular cataract? B. Cortical cataract A. Diabetes C. Morgagnian cataract B. IUGR D. Hypermature nuclear sclerotic cataract C. Rickets 79. Cataract is associated with: D. Dental abnormalities A. Pseudomuscular hypertrophy 73. Uniocular diplopia is seen in which B. Myotonic dystrophy stage of cataract? C. SLE A. Incipient B. Intumescent D. Rheumatoid arthritis C. Mature D. Hypermature E. All of the above 74. Modern criteria for cataract operation 80. Which of the following is not correct is: about the cataract in cases of A. Maturation of cataract galactosemia? B. Loss of vision A. It is most often central C. Complications B. It is zonular or lamellar D. All of the above C. Involve the embryonal and foetal nuclei 75. Vossius ring is seen in: D. Is polar A. Chalcosis 81. Equatorial diameter of the lens is: B. Siderosis A. 7 mm B. 9 mm C. Lens concussion C. 8 mm D. 10 mm D. Pseudomonas infection 82. Which continues to grow in a 76. Most common complication of lifetime? extracapsular cataract surgery is: A. Cornea B. Lens A. Retinal detachment C. Iris D. Retina B. Opacification of posterior capsule 83. All of the following lead to the C. Vitreous haemorrhage formation of complicated cataract, D. None except: 77. Zonular cataract is: A. Pigmentary retinal dystrophy A. Bilateral B. Progressive hypermetropia B. Stationary C. Progressive myopia C. Autosomal dominant D. Iridocyclitis  22 Review of Ophthalmology 84. Maximum refractive index in eye is 90. Christmas-Tree cataract is seen in: of: A. Myotonic dystrophy A. Cornea B. Irradiation cataract B. Anterior capsule of lens C. Diabetes C. Posterior capsule of lens D. Traumatic cataract D. Centroid of lens 91. An elderly male on eye examination 85. Dislocation of the lens is seen in: shows limbal scar, deep anterior A. Retinoblastoma chamber, iridodonesis, dark B. Medulloblastoma pupillary reflex, visual acuity 6/6 with 11D lens. Diagnose: C. Neuroblastoma A. Aphakia D. None of these B. Pseudophakia 86. Which is the most important complication of anterior chamber C. Hypermetropia IOLs? D. Posterior dislocation of lens A. Glaucoma 92. A patient presents with diplopia in B. Hyphema one eye. On examination with oblique illumination– golden crescent and on C. Subluxation axial illumination black/dark D. Retinal detachment crescent is seen. Likely diagnosis 87. A 55 years old patient complains of would be: decreased distant vision. However, A. Ectopia lentis now he does not require his near B. Lenticonus glasses for near work. The most likely cause is: C. Coloboma A. Posterior subcapsular cataract D. Microspherophakia B. Zonular cataract 93. A child presents bilateral white C. Nuclear sclerosis pupillary reflex, on slit lamp examination there is zone of opacity D. Anterior subcapsular cataract around fetal nucleus with some 88. Complicated cataract is seen in: spoke of wheel like arrangement A. Blunt trauma towards centre. Probable diagnosis would be: B. Diabetes mellitus A. Cataracta purvulenta C. Neovascular glaucoma D. Myopic chorioretinitis B. Lamellar cataract C. Posterior pole cataract 89. Ectopia lentis is not seen in: D. Coronary cataract A. Homocystinuria 94. Following 2 days of successful phaco- B. Down’s syndrome emulsification and IOL placement, a C. Pseudoexfoliation diabetic patient presents with redness, D. Marfan’s syndrome pain and grey white pupillary reflex. Diseases of Lens 23 Patient also shows hypopyon, retro- 100. Causes of ectopia lentis are all lental flare and posterior synechiae. except: Likely diagnosis is: A. Homocystinuria A. Post operative endophthalmitis B. Marfan’s syndrome B. Post operative glaucoma C. Cogan-Reese syndrome C. Post operative keratitis D. Sulphite oxidase deficiency D. Post operative cyclitis 101. Lens contains which antigen? 95. Congenital cataract occurs due to A. Sequestered antigens abnormalities in protein formation in which of the following genes? B. Cross antigens A. PAX6 B. SIX5 C. Heterophile antigens C. CryG D. PITX3 D. Isoantigens 96. In a case of senile cataract, which of 102. Which type of lenticonus is more the following occurs? common in males? A. Soluble protein increases, insoluble A. Posterior protein decreases B. Anterior B. Soluble protein decreases, insoluble C. Both are equally common protein increases D. Inferior C. Soluble protein increases, insoluble 103. Marfan’s syndrome associated with protein increases all except: D. Soluble protein equal to insoluble protein A. Retinal detachment 97. Ascorbate and -tocopherol are maintained in a reduced state in the B. Vitreous hemorrhage lens by: C. Ectopia lentis A. Glucose B. Glycoprotein D. Roth spots C. Glutathione D. Fatty acid 104. Thinnest part of lens is: 98. Chronic systemic steroid use causes: A. Anterior pole A. Open angle glaucoma B. Posterior pole B. Conjunctival and lid papillomatis C. Posterior capsule C. Uveitis D. Apex D. Cataract 105. In a district hospital in India, an 99. What is to be done of congenital ophthalmologist is expected to cataract involving visual axis? perform which of the following surgeries most commonly? A. Wait and watch B. Operated when the baby reaches an A. Phacoemulsification appropriate age B. Dacryocystectomy C. Mydriatics are given C. Bilamellar tarsal rotation D. Immediately operate D. Trabeculectomy  24 Review of Ophthalmology 106. Congenital cataract occurs due to A. HM 1 and 2 B. HM 2 and 4 abnormalities in protein formation C. HM 3 and 4 D. HM 2 and 3 in which of the following genes? A. PAX6 B. SIX5 108. The frequency of pulse in laser assisted cataract surgery is: C. CRYGS3 D. PITX3 A. 10–12 B. 10–15 107. High molecular weight proteins in cataractous lens seen only in humans: C. 10–20 D. 10–10 ANSWER AND EXPLANATION 1. a Lens has a special carrier system for 8. a Congenital Rubella is characterized the ascorbic acid which is a major by nuclear pearly cataract, but there antioxidant in the lens. This carrier is no dislocation of the lens. system is mediated by myoinositol. 9. b After ECCE, we prescribe the glasses 2. a Lens has two major antioxidants, i.e., after 6 weeks whereas after SICS we Vitamin C and Vitamin E. Also it can prescribe after 2 weeks. has two detoxifying enzymes, i.e., 10. b Chalcosis is copper alloy in the eye. catalase and superoxide dismutase. 11. c Alport’s syn drome is Familial 3. b In homocystinuria, the subluxation Haemorrhagic Nephritis. is inferonasal whereas in Marfan’s it is superotemporal. Hyperinsulinemia 12. b Vossius ring is the iris pigments does not present with subluxation imprinted on the anterior capsule of whereas in ocular trauma there is no the lens, in shape of pupil–due to specific direction. blunt trauma. 4. b Inflammatory reaction in children is 13. a Steroid induced cataract are posterior always severe, and if the child is subcapsular cataracts. already suffering from uveitis, IOL 14. a Part preparation is the most critical implantations can deteriorate the factor to prevent infection during any condition. surgery. 5. a Ideally the child has to be operated 15. c Lens is avascular and hence derives as soon as feasible, this is to prevent its nutrition from aqueous humour. amblyopia (visual reflex formation occurs by 5–6 months). As no ideal 16. c NdYAG is a photodisruptive laser age has been recommended, we will and is used for both posterior capsulo- mark the answer with the shortest tomy and peripheral iridotomy. duration. 17. b Nuc lear sclerosis causes mild 6. c Most prominent feature is Mega- increase in the refractive index of the loc ornea and most c ommon is lens and hence the refractive power Ectopia Lentis. of the lens increases, leading to 7. a We have to opt for the minimum improvement in the near vision. duration mentioned hence we will 18. a Pain which is increasing alongwith mark the answer immediately. D/V, particulary after only 3 days of Diseases of Lens 25 cataract surgery strongly suggests 32. a Rheumatoid arthritis causes thinning endophthalmitis. and melting of the peripheral cornea 19. c PSC is near the nodal point of the eye and scleritis called Scleromalacia and hence diminishes the vision perforans. most. 33. c Wilson’s disease is characterized by 20. c The incision size in phacoemulsi- copper deposition, it is characterized fication is 2.75 mm–3.2 mm. by sunflower cataract and KF ring. 21. d Nucleus is the oldest part of the lens. 34. a,b The process of calculating the refractive power of the IOL is called 22. d BSS with glutathione resembles the Biometry. It is calculated by applying aqueous most and hence the most the SRK formula. ideal. 35. a Most common cause of acquired 23. a Subluxation of the lens is the most cataract is senile cataract. common complication of Nuclear Sclerotic Hypermature cataract. 36. a,d, ICCE is contraindicated in children, e because there is a strong adhesion 24. b Retinal detachment can be the most between the posterior capsule of the probable cause of floaters occurring lens and the vitreous called hyaloido- after 6 months of surgery. capsular ligament (ICCE will cause 25. c Morgagnian cataract complicates into traction on the vitreous due to this phacolytic glaucoma. adhesion leading to retinal detachment). 26. b The enzyme responsible for sorbitol Dissicision is an obsolete procedure. pathway is Aldose Reductase. 37. a,b, A patient of cataract is evaluated under 27. b If the halos break it is due to cataract c,e all the above headings before being and if not it is due to angle closure treated. glaucoma. 38. a,b, Non foldable IOLs are made up of 28. a Phacoemulsification is method of e PMMA whereas foldable IOLs are SICS. made up of three materials, i.e., Acrylic, Silicon and Hydrogel. 29. b In diabetes we get snowflake or snowstorm cataract. 39. a,d, Posterior segment complications are e least if posterior capsule is retained. 30. a Chalcosis is copper deposition whereas gold deposition is called 40. a,d Intraoperative and intracameral anti- Chrysiasis. Long-term intake of gold biotic injec tions are not g iven of more than 1000 mg (in patients of routinely. Role of oral postoperative RA) leads to corneal deposits and antibiotics is controversial and many anterior subcapsular cataract. surgeons do not prescribe it. 31. b Polychromatic luster is a pathogno- 41. b Radiational cataracts occur due to mic feature of complicated cataract electromagnetic radiations. which is most commonly posterior 42. b In-the-bag implantation is most subcapsular. physiological with least complications.  26 Review of Ophthalmology 43. a Corneal dystrophies are idiopathic 56. a Most common cause of endophthal- spontaneous ch anges with no mitis is staphylococcus epidermidis. inflammatory component. 57. b Hypertension is the least documented 44. a Rossete shaped cataract occurs in risk factor among the other options blunt trauma. mentioned. Recurrent diarrhoea 45. c Myotonic dystrophy presents as causes dehydrational crisis which is ptosis, Christmas tree cataract, said to cause cataract. pupillary changes and pigmentary retinopathy. 58. c Phacoemulsification is a sutureless surgery. 46. c In the day time pupil is constricted and hence nuclear cataract will 59. d Primary metabolism of lens is diminish the vision in the day time. anaerobic and leads to lactic acid 47. a Most common type of congenital formation. In all other three options cataract is blue dot. lens is not present in its place. 48. a,b, All the above mentioned complications 60. d Phacoemulsification—Main advan- c,d can occur after ECCE. CME is parti- tages of this surgery are negligible cularly common if there is posterior post operative astigmatism and early capsular tear. rehabilitation. 49. a,b, Choroidal detachment occurs due to 61. a RQ is the ratio of CO2/O2. In lens it d hypotony. Rest all other can cause is 1 which indicates that carbohy- increased IOP. drates are the main source of energy 50. a Area of the surface ectoderm over- in lens. lying the optic vesicle thickens to form the lens placode which later converts 62. b Sutures of the lens are involved in into lens vesicle which separates from sutural cataract. the surface ectoderm. 63. c Phacomorphic glaucoma occurs in 51. a Inferonasal–Homocystinuria, Supero- intumescent cataract wher eas temporal–Marfan’s syndrome, Inferior Phacotoxic glaucoma occurs in and forward–Weil-Marchesani. trauma and Phacolytic glaucoma 52. a Lowe’s syndrome is inborn error of occurs in Morgagnian cataract. aminoacid metabolism and causes 64. a USG A-scan measures the axial metabolic cataract. length whereas USG–B scan is used 53. a Toxic cataract can occur due to to examine the posterior segment of following drugs—Steroids, Phenothi- the eye. azines, Long acting miotics, Amio- darone, Busulphan and Gold. 65. b Lens capsule is thinnest at the 54. d Rubella does not present with posterior pole with the thickness of subluxation of lens. 0.4 mm. 55. d Metronidazole does not cause 66. b Other features of Hallermann-Strief cataract. syndrome are: microphthalmos, Diseases of Lens 27 macular pigment changes and Coats’ 79. b Myotonic dystrophy and Atopic disease. dermatitis are causes of presenile 67. a Radiational and steroid induced cataract. cataract are most commonly posterior 80. d If Galactosemia occurs due to GPUT subcapsular. Traumatic cataracts are (Galactose phospho uridyl–transferase), most commonly posterior cortical. it causes Oi