Chapter 1 Cornea, External Disease, and Anterior Segment



10.1055/b-0039-173407

Chapter 1 Cornea, External Disease, and Anterior Segment

Carolina Adams, Danielle Trief


1.1 Questions













Easy


Medium


Hard


1. (Medium) A 67-year-old female presents to the outpatient clinic with a history of recurrent nodules of the right upper eyelid for the past 5 years that were treated with multiple intralesional injections of triamcinolone. On exam, you notice two right upper lid nodules associated with madarosis and lid margin thickening. The left eyelids are unremarkable. What condition are you concerned about?




  1. Recurrent chalazion



  2. Sebaceous gland carcinoma



  3. Basal cell carcinoma



  4. Squamous cell carcinoma


2. (Easy) A 47-year-old female presents with a history of chronic foreign body sensation and tearing associated with inferior punctate epithelial erosions. You decide to evaluate tear production without topical anesthetic. What is the name of this test?




  1. Basic secretion test



  2. Schirmer I test



  3. Schirmer II test



  4. Schirmer IV test


3. (Medium) Which of the following is a quantitative test of tear production?




  1. Lactoferrin



  2. Immunoglobulin G



  3. Schirmer testing



  4. Meibography


4. (Easy) A 45-year-old female with a history of seborrheic dermatitis complains of foreign body sensation and tearing. On exam, there is a rapid tear breakup time and foam in the tear meniscus. What would be the most likely cause of this patient’s dry eye?




  1. Sjogren’s syndrome



  2. Age-related dry eye



  3. Trachoma



  4. Meibomian gland dysfunction


5. (Easy) A 19-year-old Caucasian female presents with a history of meibomian gland dysfunction for the past 2 years. On slit lamp exam, she has lid margin telangiectasias and anterior blepharitis in both eyes and corneal neovascularization of the right eye as shown in figure. What is the most likely underlying etiology of this patient’s findings?




  1. Rosacea



  2. Staphylococcal blepharitis



  3. Keratoconjunctivitis sicca



  4. Chalazion


6. (Medium) A 45-year-old female presents to your office due to persistent left eye foreign body sensation and pain. She visited the emergency room 5 months ago due to sudden left facial weakness including the forehead. On exam, she is noted to have interpalpebral fluorescein uptake. Which of the following findings on clinical exam would you expect to find?




  1. Reduced sensation of the cornea on the affected side



  2. History of ptosis surgery on the affected side



  3. Failure to close the eye completely on the affected side



  4. Uncontrolled high blood pressure


7. (Medium) Which one of the following is not a cause of neurotrophic keratopathy?




  1. Herpes simplex virus (HSV)



  2. Riley–Day syndrome



  3. Hansen’s disease



  4. Human immunodeficiency virus (HIV)


8. (Medium) A 34-year-old obese male with obstructive sleep apnea presents to the cornea clinic due to progressive decline in visual acuity in the right eye. He visited a community optical shop and was told he had irregular astigmatism in the right eye. Clinical findings revealed laxity of the bilateral upper eyelid with severe tarsal papillary reaction. What is the most likely diagnosis?




  1. Floppy eyelid syndrome



  2. Superior limbic keratoconjunctivitis



  3. Dermatochalasis



  4. Ocular rosacea


9. (Medium) A 57-year-old woman presents with a history of chronic ocular surface disease since a bilateral upper lid blepharoplasty 3 years ago. Clinical findings include a fine papillary reaction on the superior tarsal conjunctiva associated with hypertrophy of the superior limbus and fine punctate epithelial erosions in the superior one-third of the cornea. What would be the most likely diagnosis?




  1. Floppy eyelid syndrome



  2. Exposure keratopathy



  3. Foreign body under superior eyelid



  4. Superior limbic keratoconjunctivitis


10. (Hard) A 25-year-old healthy female presents with a history of multiple episodes of sudden left eye pain upon awakening associated with photophobia and tearing. She has a remote history of a left eye corneal abrasion due to a fingernail trauma 3 years ago. Which of the following is not a potential therapy for this patient?




  1. Lubricating ointment at night



  2. Sodium chloride hypertonic ointment



  3. Phototherapeutic keratectomy (PTK)



  4. Laser-assisted in situ keratomileusis (LASIK)


11. (Hard) A 29-year-old medical resident presents with a worsening corneal infiltrate and edema despite topical antibiotics. The resident had a corneal abrasion and was treated initially in the emergency department. Clinical exam findings include keratic precipitates, a necrotic ring opacity, and ciliary flush. The patient reports compliance and denies the use of contact lenses or history of trauma. Which of the following diagnoses should be considered?




  1. Topical anesthetic abuse



  2. Acanthamoeba keratitis



  3. Fungal keratitis



  4. Herpetic keratitis


12. (Medium) A 12-year-old female with a history of a bone marrow transplant 2 months ago presents with dry eye not responding to standard lubrication management. On exam, she is noted to have a loss of the palisades of Vogt in two-thirds of the limbus and early corneal neovascularization. What would be the most likely diagnosis?




  1. Toxic keratoconjunctivitis



  2. Stem cell deficiency



  3. Keratoconjunctivitis sicca



  4. Rosacea


13. (Hard) A 3-year-old boy is referred by his pediatrician due to progressive right eye corneal clouding since birth. On exam, he is noted to have opacification resembling sclera limited to the corneal periphery and 10 D of hyperopia in each eye. Which of the following corneal anomalies is most likely to be present?




  1. Microcornea



  2. Megalocornea



  3. Cornea plana



  4. Posterior embryotoxon


14. (Easy) An 8-year-old boy with multiple craniofacial and dental abnormalities presents for follow-up. On anterior slit lamp examination, as shown in the figure, you notice one of the following. What is the most likely diagnosis?




  1. Peters anomaly



  2. Keratoconus



  3. Axenfeld–Rieger syndrome (ARS)



  4. Sclerocornea


15. (Medium) A 1-day-old premature male born at 30 weeks of gestation presents with multiple cardiac malformations, cleft lip, and skeletal abnormalities. On exam, bilateral corneal opacities are noted. You suspect a condition characterized by the findings on the provided figure. What is the most likely diagnosis?




  1. Corneal ulcer



  2. Peters anomaly



  3. Trauma



  4. Dermoid


16. (Hard) An 8-year-old male presents to clinic due to bilateral eye pain and redness. He has a history of premature delivery overseas. While interviewing the patient you note that the patient has a hearing deficit and dental abnormalities. On examination, as seen in the given figure, he is noted to have microcystic edema, intense stromal vascularization, and ghost vessels. Which of the following treatment would have prevented this corneal pathology?




  1. IV penicillin



  2. IV ceftazidime



  3. IV acyclovir



  4. IV voriconazole


17. (Easy) A 5-day-old female with no systemic abnormalities presents with left eye corneal opacities as shown in the given figure. What would the most likely cause of the findings?




  1. Forceps trauma



  2. Congenital glaucoma



  3. Cortical cataract



  4. Corneal ulcer


18. (Easy) A 35-year-old female complains of chronic progressive foreign body sensation in the left eye for the past 5 years. On exam, she is noted to have a nasal conjunctivalization with elastotic changes on pathology review. Which of the following is most likely to be present?




  1. Stocker’s line



  2. Hudson–Stahli line



  3. Fleischer’s ring



  4. Ferry’s line


19. (Hard) A 78-year-old woman with no past ocular history presents with progressive bilateral corneal opacity for the past 7 years associated with foreign body sensation and decreased visual acuity. She has a history of sun exposure and on examination she was found to have translucent, golden brown deposits in the superficial peripheral cornea. All of the following are potential therapies, except?




  1. Lubricating ointment



  2. Superficial keratectomy



  3. Phototherapeutic keratectomy



  4. Photorefractive keratectomy


20. (Hard) A 45-year-old female with a history of diabetes mellitus type 2 and end-stage renal disease presents with recurrent episodes of eye pain and photophobia in the left eye. On examination, she is noted to have a horizontal white plaque at 3 and 9 o’clock on the right eye and a large one across the inferior visual axis in the left eye (see the figure provided). Which of the following is not advised as primary treatment of this condition?




  1. Ethylenediaminetetraacetic acid (EDTA) chelation



  2. Phototherapeutic keratectomy (PTK)



  3. Artificial tears



  4. Bandage contact lens


21. (Easy) A 65-year-old male presents to the clinic for an annual exam. He has no complaints and requests a new glasses prescription. On exam, he is noted to have unilateral arcus senilis. Which of the following test you should order next?




  1. Renal function test



  2. Hemoglobin A1C



  3. Carotid doppler



  4. Echocardiogram


22. (Hard) A 45-year-old male with no systemic diseases presents complaining of decreased visual acuity. Two years ago, you had noted a mild superonasal pannus in the left eye. Today, the patient has high astigmatism in both eyes and bilateral painless superior deposits (see the figure provided) thinning with neovascularization. The rest of his exam appears within normal limits. Which is the most likely diagnosis?




  1. Peripheral ulcerative keratitis (PUK)



  2. Mooren’s ulcer



  3. Staphylococcal marginal degeneration



  4. Terrien’s marginal degeneration


23. (Hard) A 47-year-old healthy female with progressive bilateral superior corneal thinning, an intact epithelium, and neovascularization presents for refraction. On exam, there is marked thinning on the top one-third of cornea with a leading edge of lipid. Her conjunctiva is white and there are no signs of infection. Which of the following diagnostic procedures will help you make the diagnosis?




  1. Corneal topography



  2. Confocal microscopy



  3. Anterior segment ocular coherence tomography



  4. Corneal scraping


24. (Medium) A 40-year-old Caucasian female presents to your office due to foreign body sensation of the right eye over several years. Slit lamp exam reveals the findings as shown in the figure. What is the most likely diagnosis?




  1. Phlyctenulosis



  2. Band keratopathy



  3. Salzmann’s nodular degeneration



  4. Corneal ulcer


25. (Hard) A 56-year-old male presents with a bluish gray lesion in his paracentral cornea, foreign body sensation, and the following findings on anterior segment optical coherence tomography (OCT) (see the figure provided). The lesion is well demarcated and measures 2 mm. It is slightly raised. He is wondering if anything can be done about this lesion and what you recommend. You advise should be:




  1. Penetrating keratoplasty



  2. Deep anterior lamellar keratoplasty



  3. Superficial keratectomy



  4. Corneal biopsy with cryotherapy and adjuvant chemotherapy


26. (Medium) A 35-year-old female presents with progressive loss of vision in the left eye over the past 7 years. On exam, she is noted to have a superonasally displaced pupil, intraocular pressure of 34 mm Hg, and mild corneal edema. Gonioscopy reveals posterior anterior synechiae to Schwalbe’s line. Posterior exam reveals a cup-to-disc ratio of 0.8. Before referring the patient to a glaucoma specialist, you should perform which of the following definite diagnostic procedure?




  1. Corneal topography



  2. Specular microscopy



  3. Anterior segment optical coherence tomography (OCT)



  4. Ultrasound biomicroscopy


27. (Easy) A 65-year-old male with atrial fibrillation presents for a routine eye exam. Slit lamp exam reveals a whorled pattern haze in the central cornea. Which of the following is the most likely inciting agent?




  1. Metoprolol



  2. Amiodarone



  3. Diltiazem



  4. Apixaban


28. (Easy) A 4-year-old female is referred by her pediatrician for an eye exam. On anterior slit lamp exam, she is noted to have bilateral whorl-like corneal pattern. Which of the following conditions is associated with your exam findings?




  1. Fabry disease



  2. Hunter syndrome



  3. Scheie syndrome



  4. Hurler syndrome


29. (Easy) A neonatology intensive care attending decides to request a consult for a patient who has persistent tearing without crying. At arrival you note obvious corneal enlargement. Which of the following is the normal corneal diameter in infants?




  1. 9.5–10.5 mm



  2. 13–15 mm



  3. 8–9 mm



  4. 14–15 mm


30. (Easy) You have been following an 18-year-old male with keratoconus for the past 8 months. After multiple visits, you decide the patient is an excellent candidate for collagen cross-linking. Which of the following collagen types is the main target for collagen cross-linking?




  1. Collagen type I



  2. Collagen type II



  3. Collagen type III



  4. Collagen type IV


31. (Easy) A 66-year-old male comes to your clinic for a second opinion. He underwent left eye cataract surgery 1 year ago and since then has experienced progressive decline in visual acuity. On exam, he is noted to have minimal corneal edema and an irregular appearance to his corneal endothelium on direct illumination. Which of the following would give you an endothelial cell count?




  1. Specular microscopy



  2. Pachymetry



  3. Corneal topography



  4. Anterior exam optical coherence tomography


32. (Medium) A 34-year-old high myope man presents with a history of 3 days of progressive pain, light sensitivity, and tearing in the right eye. He has a history of chronic use of contact lenses and has recently been swimming in his lenses. On exam, he is noted to have a paracentral large infiltrate. Which of the following imaging modalities would help most with making this diagnosis?




  1. Specular microscopy



  2. Confocal microscopy



  3. Anterior exam optical coherence tomography



  4. Ultrasound biomicroscopy


33. (Easy) A penetrating keratoplasty is planned for a 1-year-old patient with bilateral corneal opacities and iridocorneal adhesions. From which of the following embryological structures does the absent corneal layer in this patient originate?




  1. Surface ectoderm



  2. Neural crest



  3. Mesoderm



  4. Endoderm


34. (Hard) A 55-year-old with history of recurrent bilateral eye pain upon awakening presents with following bilateral findings on slit lamp exam (see the figures provided). What is the most likely diagnosis?




  1. Reis–Bucklers corneal dystrophy (RBCD)



  2. Thiel–Behnke corneal dystrophy (TBCD)



  3. Epithelial basement membrane dystrophy (EBMD)



  4. Meesmann epithelial corneal dystrophy


35. (Hard) Recurrent corneal erosions present in all of the following corneal dystrophies, except?




  1. Epithelial basement membrane dystrophy (EBMD)



  2. Meesmann epithelial corneal dystrophy (MECD)



  3. Lisch epithelial corneal dystrophy (LECD)



  4. Reis–Bucklers corneal dystrophy (RBCD)


36. (Medium) A 20-year-old female presents with progressive glare and light sensitivity. Histology review reveals the following (see the figures provided). What is the patient’s most likely underlying diagnosis?




  1. Epithelial basement membrane dystrophy (EBMD)



  2. Meesmann epithelial corneal dystrophy (MECD)



  3. Lisch epithelial corneal dystrophy (LECD)



  4. Reis–Bucklers corneal dystrophy (RBCD)


37. (Hard) A 50-year-old landscaper reports monocular diplopia in the left eye for the past 5 months. Exam findings revealed visual acuity 20/20 in the right eye and 20/40 in the left eye; you suspect a corneal dystrophy with Ki-67 positive staining. What is the most likely diagnosis?




  1. Meesmann epithelial corneal dystrophy (MECD)



  2. Epithelial basement membrane dystrophy (EBMD)



  3. Lisch epithelial corneal dystrophy (LECD)



  4. Thiel–Behnke corneal dystrophy (TBCD)


38. (Hard) A 55-year-old man presents with chronic recurrent erosions and reports that he has suffered from this since the age of 5. Slit lamp exam reveals the findings as shown in the figure provided. Histopathology demonstrates granular deposits that stain with Masson trichrome stain. What is the most likely underlying diagnosis?




  1. Epithelial basement membrane dystrophy (EBMD)



  2. Granular corneal dystrophy type 1 (GCD1)



  3. Reis–Bucklers corneal dystrophy (RBCD)



  4. Thiel–Behnke corneal dystrophy (TBCD)


39. (Medium) A 25-year-old photographer presents with bilateral decreased visual acuity. Electron microscopy reveals “curly fibers.” What is his correct diagnosis?




  1. Thiel–Behnke corneal dystrophy (TBCD)



  2. Granular corneal dystrophy type 1 (GCD1)



  3. Macular corneal dystrophy (MCD)



  4. Reis–Bucklers corneal dystrophy (RBCD)


40. (Hard) A patient presents for a second opinion. He visited his local ophthalmologist due to progressive blurry vision and was found to have bilateral corneal opacifications. He has had recurrent bilateral pain upon awakening since childhood. Slit lamp examination reveals a honeycomb pattern and curly fibers on electron microscopy. All of the following may be appropriate management options, except:




  1. Superficial keratectomy



  2. Phototherapeutic keratectomy (PTK)



  3. Lamellar keratectomy



  4. Descemet’s membrane endothelial keratoplasty (DMEK)


41. (Medium) A 15-year-old female has the following corneal findings (see the figure provided). Which of the following stains will help you make a diagnosis?




  1. Masson trichrome stain



  2. Congo red stain



  3. Alcian blue



  4. Oil red O


42. (Hard) A 20-year-old male with history of myopic LASIK presents with progressive corneal opacities (see the figure provided). Histology reveals hyaline granular material accumulation that stains with Masson trichrome. What is the most likely diagnosis?




  1. Granular corneal dystrophy type 1 (GCD1)



  2. Reis–Bucklers corneal dystrophy (RBCD)



  3. Macular corneal dystrophy (MCD)



  4. Granular corneal dystrophy type 2 (GCD2)


43. (Hard) A 25-year-old with history of bilateral epidemic keratoconjunctivitis, 10 years ago, is referred to the cornea clinic due to bilateral superficial stromal opacities (see the figure provided) that did not resolve with topical steroids. Which of the following is the most likely genetic inheritance?




  1. Autosomal dominant



  2. X-linked dominant



  3. Autosomal recessive



  4. Sporadic


44. (Hard) A 35-year-old male presents to your practice for evaluation of progressive blurry vision in both eyes for the past 8 years. This is his first time visiting an eye doctor. Slit lamp examination reveals diffuse haze with no clear intervening spaces. You suspect a pathology with the following histology (see the figures provided):




  1. Cholesterol



  2. Amyloid deposits



  3. Glycosaminoglycan deposits



  4. Hyaline deposits


45. (Hard) A 23-year-old male presents with progressive blurry vision and glare associated with central corneal opacification since early childhood. The patient states vision in dim light is better than bright light. Which of the following blood test you should order?




  1. Hemoglobin A1C



  2. Liver function test



  3. Fasting lipid profile



  4. Serum electrolytes


46. (Medium) All of the following are possible management options for a patient with the following corneal finding on specular microscopy (see the figure provided), except?




  1. Sodium chloride drops



  2. Descemet’s membrane endothelial keratoplasty



  3. Penetrating keratoplasty



  4. Deep anterior lamellar keratoplasty


47. (Easy) How might you advise this 16-year-old female with the following corneal topography (see the figure provided)?




  1. Limit your contact lens wear



  2. Start antibiotic drops



  3. Obtain autoimmune blood work-up



  4. Stop rubbing your eyes


48. (Medium) A 10-year-old male with a history of an ascending aorta aneurysm repair presents with generalized corneal thinning on topography. What is the most likely diagnosis?




  1. Keratoconus



  2. Keratoglobus



  3. Pellucid margin degeneration



  4. Ectasia post refractive surgery


49. (Easy) A 2-year-old patient diagnosed with an autosomal recessive syndrome presents with bilateral corneal clouding. What is the most likely diagnosis?




  1. Hurler syndrome



  2. Hunter syndrome



  3. Fabry disease



  4. Tay–Sachs disease


50. (Easy) A 5-year-old with renal failure, peripheral neuropathy, and psychomotor retardation is found to have the findings as shown in the given figure. What is the most likely diagnosis?




  1. Hunter syndrome



  2. Tay–Sachs disease



  3. Scheie syndrome



  4. Fabry disease


51. (Easy) A 15-year-old with history of dwarfism and progressive renal dysfunction presents with the corneal crystals. The patient has noticed improvement of visual acuity after initiating which one of the following?




  1. Moxifloxacin drops



  2. Prednisolone acetate drops



  3. Cysteamine eye drops



  4. Ketotifen drops


52. (Easy) A patient diagnosed with tyrosinemia during newborn screening will have which of the following corneal findings?




  1. Interstitial keratitis



  2. Corneal clouding



  3. Pseudodendrites



  4. Corneal verticillata


53. (Medium) An 8-year-old male presents to clinic accompanied by his parents. They have noticed bilateral black deposits in both eyes along medial rectus. The mother comments that he has noticed his urine has had a very dark color. All of the following is true, except?




  1. Ocular manifestations are usually symmetric.



  2. Pigmentation is usually localized to the endothelium.



  3. Scleral pigmentation occurs in over 80% of cases.



  4. It has an autosomal recessive inheritance.


54. (Hard) A 38-year-old male with a history of left peripheral facial palsy and corneal transplant presents to the emergency room due to left eye foreign body and photophobia for the past 3 days. Clinical findings reveal left lagophthalmos, bilateral dermatochalasis, and corneal opacities (see the figure provided). Which of the following histological stains is most likely to be positive?




  1. Alcian blue



  2. Masson trichrome



  3. Oil red O



  4. Crystal violet dye


55. (Medium) A 45-year-old male presents to the emergency room due to progressive yellow discoloration on the skin and conjunctiva along with involuntary tremor. Which of the following would be the most likely ocular finding?




  1. Fleischer ring



  2. Sunflower cataract



  3. Polychromatic cataract



  4. Coats white ring


56. (Medium) A 15-year-old male with hyperextensibility of his joints presents with worsening visual acuity and high irregular astigmatism. Corneal topography reveals an asymmetric bowtie pattern. Which of the following patterns is most likely to be present?




  1. Protrusion below the area of maximal thinning



  2. Protrusion above the area of thinning



  3. Steepening 90 degrees away from the area of thinning



  4. Thinning nasal and temporally


57. (Easy) A 25-year-old male with Marfan syndrome present with sudden monocular double vision. In which of the following quadrants you would classically expect the findings to be present?




  1. Inferotemporal



  2. Superonasal



  3. Superotemporal



  4. Inferonasal


58. (Medium) A 5-year-old is referred from his pediatrician due to a failed vision screening. At arrival you note preauricular skin tags and this corneal finding (see the figure provided). Which of the following may also be present?




  1. Iris coloboma



  2. Optic nerve staphyloma



  3. Eyelid coloboma



  4. Conjunctival nevi


59. (Medium) All of the following are associated with enlarged corneal nerves except:




  1. Multiple endocrine neoplasia type 2B



  2. Refsum syndrome



  3. Hansen’s disease



  4. Meretoja syndrome


60. (Hard) A 20-year-old male with xeroderma pigmentosum presents with multiple small nodules coalescing between 3 and 9 o’clock positions. He has experienced photophobia and irritation for the past 5 years. All of the following are appropriate therapies, except:




  1. Ethylenediaminetetraacetic acid (EDTA) chelation



  2. Superficial keratectomy



  3. Lamellar keratoplasty



  4. Penetrating keratoplasty


61. (Medium) A corneal scraping from a 23-year-old male who presented to the emergency room was obtained. The patient presented with right eye pain, photo-phobia, and tearing. On initial examination, visual acuity was 20/70 in the affected eye with a central 3 × 3 mm epithelial infiltrate with feathery edges. Cultures revealed a microorganism that can invade an intact epithelium. Which of the following is the most likely pathogen?




  1. Fusarium species



  2. Candida albicans



  3. Acanthamoeba



  4. Pseudomonas aeruginosa


62. (Medium) A 24-year-old male photography student presents for a second opinion. He returned from overseas recently, where he was treated with tobramycin and vancomycin fortified antibiotics every hour with no improvement. The patient has a history of contact lens wear. On examination, the patient has a visual acuity of 20/80 and the following corneal finding on slit lamp examination (see the figure provided). After careful examination, you notice prominent corneal nerves. Which of the following culture methods should you use?




  1. Non-nutrient agar with Escherichia coli (E. Coli) overlay



  2. Sabouraud dextrose agar



  3. Blood agar



  4. Gomori methenamine silver (GMS)


63. (Medium) A 5-year-old presents with a history of bilateral corneal dendritic lesions. Which of the following conditions is most like to be present?




  1. Diabetes mellitus



  2. Atopic dermatitis



  3. Human immunodeficiency virus (HIV)



  4. Seborrheic dermatitis


64. (Medium) A 45-year-old male presents with photophobia and left eye pain for past 3 days. On exam, he is noted to have ptosis, ciliary flush, stromal edema, and inferior keratic precipitates. At the time of examination, visual acuity was 20/25 OU. Intraocular pressure was 26 in the affected eye and 1+ cell was found in the anterior chamber. The rest of the exam was within normal limits. Which of the following is proven to shorten the duration of his keratitis?




  1. Oral acyclovir



  2. Oral valacyclovir



  3. Topical corticosteroids



  4. Topical trifluridine


65. (Easy) A 7-year-old male presents with painful swelling of the left lateral upper eyelid and a follicular conjunctivitis. The mother reports a maculopapular rash after a dose of amoxicillin. Which of the following is the most likely diagnosis?




  1. Herpes simplex virus



  2. Epstein–Barr virus (EBV)



  3. Herpes zoster virus



  4. Adenovirus


66. (Easy) A 42-year-old male presents for a third opinion. The patient has experienced four episodes of right eye follicular conjunctivitis. He has been treated with topical corticosteroid eye drops, however the episodes recur shortly after tapering the drops. Which of the following would be the best treatment for this patient?




  1. Valacyclovir



  2. Doxycycline



  3. Systemic steroids



  4. Topical antibiotics


67. (Medium) A 65-year-old female visits your clinic for a third opinion. The patient had been experiencing left eye redness, tearing, and photophobia for 3 weeks. She was diagnosed with iritis after YAG capsulotomy at an outside hospital and managed with topical steroids with recurrent bouts after tapering attempts. At examination, visual acuity is 20/40 in the affected eye, intraocular pressure is 21, and keratic precipitates are observed. There is no retained lens material on gonioscopy. Which of the following pathogens are you most concerned for?




  1. Gram-positive cocci in clusters



  2. Gram-positive cocci in pairs



  3. Gram-positive rods



  4. Gram-negative diplococci


68. (Medium) A 35-year-old male presents to your clinic to establish care. The patient was diagnosed with a corneal ulcer 1 week ago. He states corneal cultures were obtained at the time of initial diagnosis. The microbiology lab reports a septate filamentous fungus. Which of the following is the most likely pathogen?




  1. Mucor



  2. Rhizopus



  3. Fusarium



  4. Candida


69. (Medium) A 45-year-old male is referred to your office with concern for possible corneal ulcer of the left eye. He presented 1 week prior to the emergency room with tearing, irritation, and redness. Moxifloxacin was initiated. However, his symptoms worsened. On examination, visual acuity is 20/20 in the right eye, 20/40 in the left eye, the lashes have collaretes OU and there is bulbar injection. The cornea has a perilimbal opacity superotemporally with overlying epithelial defect (see the figure provided). What is the most likely diagnosis?




  1. Mooren’s ulcer



  2. Peripheral ulcerative keratitis



  3. Staphylococcal marginal keratitis



  4. Exposure keratopathy


70. (Easy) A 25-year-old male is referred from urgent care with right eye redness and hyperpurulent discharge for the past 3 days. The patient denies any significant ocular history. On examination, there is periauricular lymphadenopathy, 3+ bulbar injection, and 3 × 3 mm peripheral corneal ulcer associated with corneal edema. Which of the following is the most appropriate management?




  1. Topical vancomycin and tobramycin



  2. Doxycycline 100 mg every 12 hours



  3. Ceftriaxone 1 g IV every 12 hours for 3 days plus topical vancomycin and tobramycin



  4. Moxifloxacin drops, every hour


71. (Easy) A 4-day-old male born at 38 weeks of gestation presents with acute left eye purulent discharge for the past 24 hours. What is the most likely diagnosis?




  1. Chlamydia trachomatis



  2. Neisseria gonorrhoeae



  3. Herpes simplex virus



  4. Pseudomonas aeruginosa


72. (Medium) A 47-year-old Egyptian male presents with a history of foreign body sensation, redness, and tearing for more than 1 year. The patient was diagnosed with dry eyes and managed with topical cyclosporine without improvement of symptoms. Slit lamp examination reveals bilateral conjunctival follicular reaction, eyelid margin erythema, and a superior pannus of the cornea with interdigitated round pigmented scars. Which of the following is the most appropriate management?




  1. Azithromycin



  2. Ceftriaxone



  3. Acyclovir



  4. Vancomycin


73. (Medium) A 55-year-old female with a past ocular history of bilateral penetrating keratoplasty 10 years ago due to advanced keratoconus presents with a history of mild discomfort in the right eye, redness, and photophobia. On examination, her visual acuity is 20/50 in the right eye and 20/30 in the left eye. Slit lamp examination reveals chemosis and conjunctival injection and an anterior stromal needle-like white infiltrate. Histological slides exhibit interlamellar aggregates of gram-positive cocci. Which of the following is the most likely pathogen?




  1. Streptococcus pneumoniae



  2. Staphylococcus aureus



  3. Streptococcus viridans



  4. Staphylococcus epidermidis


74. (Medium) A 23-year-old male presents with eye redness and tearing 6 weeks after a myopic LASIK procedure. On exam, he has a stromal infiltrate along the flap. Scrapings are obtained from the stromal bed after lifting the flap and placed the specimen on Lowenstein–Jensen medium. All the following are appropriate therapies except:




  1. Clarithromycin



  2. Amikacin



  3. Linezolid



  4. Vancomycin


75. (Medium) An 88-year-old female with a history of Crohn’s disease presents due to progressive visual loss over the past 10 years. Her past ocular history includes an uneventful bilateral cataract surgery. On examination, her initial visual acuity is 20/40 OU, with intraocular pressure of 12 mm Hg on the right and 10 mm Hg on the left. Ishihara color plates are within normal limits. Slit lamp exam reveals the finding in the photograph below (see the figure provided). Automated perimetry shows central constriction bilaterally. Electroretinography reveals reduced scotopic and photopic responses. Which of the following pathogens have been associated with this condition?




  1. Gram-positive rods



  2. Gram-negative cocci



  3. Gram-positive cocci



  4. Gram-positive filaments


76. (Easy) A 25-year-old male patient with history of uneventful LASIK surgery 2 months ago presents with right eye pain, photophobia, and blurry vision for the past 2 weeks. On examination, his visual acuity is 20/50 on the right and 20/20 on the left. Slit lamp examination revealed a corneal epithelial defect 2 × 2 mm at 3 to 5 o’clock, originating from the flap and intrastromal infiltration. Corneal scraping revealed gram-positive aerobic filaments. Which of the following growth media was most likely to be used?




  1. Blood agar



  2. MacConkey agar



  3. Lowenstein–Jensen medium



  4. Thayer Martin agar


77. (Medium) A 45-year-old female with no significant past medical history presents with chronic left eye redness for the past 2 years. She has visited multiple eye care providers and has been prescribed low-potency steroids without resolution of her symptoms. She presents to your office another opinion. On examination, her visual acuity is 20/20 on the right and 20/30 on the left. Slit lamp examination reveals right eye palpebral injection with two raised hyperemic granulomas in the inferior tarsal conjunctiva. Head and neck exam is noted for submandibular and preauricular lymph nodes. Which of the following is not part of the differential?




  1. Tuberculosis



  2. Sarcoidosis



  3. Tularemia



  4. Trachoma


78. (Easy) A 46-year-old female contact lens wearer presents with 3 days of left eye photophobia and redness. She has no past medical or ocular history. On examination, visual acuity is 20/20 on the right and hand motion on the left. Slit lamp examination reveals the findings as shown in the given figure. Fundus exam was difficult to assess due to haze. Which of the following is the most likely pathogen?




  1. Acanthamoeba



  2. Staphylococcus aureus



  3. Streptococcus viridans



  4. Pseudomonas aeruginosa


79. (Easy) A 49-year-old female contact lens wearer presents with redness and photophobia for 2 weeks. Initial examination reveals a central corneal ulcer with a dense underlying infiltrate, purulent discharge, and 1 mm hypopyon. She was started on fortified antibiotics, including tobramycin and vancomycin every hour. One week later, the corneal infiltrate and thinning have worsened and the hypopyon size has increased. Which of the following is the next step in management?




  1. Stop all drops and add prednisolone acetate.



  2. Stop all drops and perform penetrating keratoplasty.



  3. Obtain confocal microscopy.



  4. Change antibiotics to fluoroquinolones every hour.


80. (Medium) A 51-year-old male presents with a history of left eye injection and severe pain for the past 7 days. The patient states symptoms started after trauma with a tree branch during gardening. On examination, visual acuity is 20/20 on the right and light perception on the left. Slit lamp examination reveals severe bulbar injection and a 4 × 4 mm central infiltrate in the left eye. Gomori methenamine silver staining is positive. Which of the following is the best next step in management?




  1. Tobramycin



  2. Vancomycin



  3. Moxifloxacin



  4. Natamycin


81. (Medium) A 43-year-old male was diagnosed with herpes simplex virus (HSV) keratitis. The patient has been on topical trifluridine for 3 days and develops periorbital redness and foreign body sensation. On examination, he is noted to have periorbital skin thickening, conjunctival papillary reaction, and corneal punctate epithelial erosions. Which of the following is the most likely hypersensitivity reaction?




  1. Hypersensitivity type I



  2. Hypersensitivity type II



  3. Hypersensitivity type III



  4. Hypersensitivity type IV


82. (Medium) A 10-year-old male with seasonal allergies presents with foreign body sensation and itching. The patient reports recurrences every year during the spring. On examination, his lids and cornea show the following findings (see the figures provided). All of the following are appropriate management options except:




  1. Prednisolone acetate



  2. Azithromycin



  3. Cyclosporine



  4. Tacrolimus


83. (Medium) A 14-year-old male presents with worsening perioral bullous lesions and target like lesions on his limbs for the past 4 days associated with fever and malaise. He recently finished a course of antibiotics for an upper respiratory tract infection. On examination, the patient is noted to have bilateral bulbar conjunctival injection and inferior punctate epithelial erosions. Which of following management options provides significant long-term benefit?




  1. Aggressive lubrication



  2. Topical steroids



  3. Oral steroids



  4. Amniotic membrane graft


84. (Medium) A 42-year-old with history of epilepsy is admitted to the intensive care unit due to status epilepticus. The patient is managed with a variety of antiepileptic drugs, including phenytoin, valproic acid, and carbamazepine. During the second day of admission, he starts having fever spikes and bilateral eyelid erythema progressing rapidly to bilateral eyelid swelling and erythema with epidermal scaling. After examining the patient, you are mostly concerned for a disease associated with which of the following characteristic?




  1. Rapidly progressive skin exfoliation and target-like lesions



  2. Honey-colored crusted lesions with an erythematous base



  3. Exudative pharyngitis and bright red exanthem



  4. Raised target lesions on the extremities


85. (Medium) A 65-year-old male presents to your clinic with a chief complaint of chronic red eye and epiphora. The patient has no past medical or ocular history. On examination, bilateral findings include: visual acuity of 20/40 OU, eyelid margin erythema, misdirected lashes, upper eyelid tarsal fibrosis, inferior coalescent punctate epithelial erosions, and a fornix depth of 4 mm. All of the following are associated with your most likely diagnosis, except:




  1. IgA localized to the epidermis.



  2. Cyclophosphamide is the mainstay of therapy.



  3. Lubrication can be helpful in milder cases.



  4. Fornix reconstruction surgery can be beneficial after immunosuppression.


86. (Easy) A 47-year-old male with a history of bone marrow transplant for acute myelogenous leukemia presents with a history of 1 year of foreign body sensation and photosensitivity. He reports using artificial tear drops and ointment on the regular basis without much improvement. On examination, visual acuity is 20/20 OU; while the lids and lashes are within normal limits, the cornea reveals inferior punctate erosions with mucoid strands. Which of the following is not indicated in the next step of management?




  1. Aggressive ocular lubrication and punctal plugs



  2. Autologous serum tears



  3. Prosthetic replacement of the ocular surface ecosystem (PROSE) lens



  4. Keratoprosthesis


87. (Easy) A 31-year-old with a recent history of diarrhea and vomiting presents to the emergency room with fever, lymphadenopathy, and oligoarticular arthritis. Which of the following would be the most common ocular manifestation in this patient?




  1. Episcleritis



  2. Conjunctivitis



  3. Iridocyclitis



  4. Keratitis


88. (Hard) A 15-year-old presents with a recurrent episode of photophobia, tearing, and foreign body sensation in both eyes. This is the third episode in less than 2 years. Upon examination, visual acuity is 20/30 OU, the lids and lashes are within normal limits, the conjunctiva is white, and the cornea has multiple elevated punctate lesions centrally (see the figure provided). Fluorescein reveals negative staining of these lesions. Which is the most likely associated finding?




  1. Interpalpebral fluorescein staining



  2. Dramatic response to low-dose steroids



  3. Stromal opacities with intervening haze



  4. Inferior corneal fluorescein staining


89. (Medium) A 45-year-old female with a history of vertigo and hearing loss presents with severe periorbital pain and redness. The patient states that her ocular symptoms began 1 week ago. She has severe photophobia and conjunctival injection. Examination reveals a visual acuity of 20/60 OU. The cornea appears hazy and there is 1+ anterior chamber cell. Posterior exam is grossly within normal limits. Infectious and immune blood panel are unremarkable. Which of the following is the most likely diagnosis?




  1. Susac syndrome



  2. Cogan’s syndrome



  3. Vogt–Koyanagi–harada syndrome



  4. Sarcoidosis


90. (Easy) A 65-year-old male with no significant past medical history presents with left eye severe pain, photophobia, and tearing. The patient mentions that he has been experiencing hand pain, swelling, stiff-ness, and mild joint deformities. The patient states that he has had worsening foreign body sensation in the affected eye for the past year. Slit lamp examination reveals the following (see the figure provided). Which of the following is the next step in diagnosis?




  1. Anterior segment fluorescein angiography



  2. Corneal topography



  3. Corneal biopsy



  4. Autoimmune panel


91. (Medium) A 74-year-old female with no significant past medical history presents to your office. She had been followed by an outside ophthalmologist for peripheral ulcerative lesions of the right for the past 5 years. She complains of left eye pain, photo-phobia, and redness. On examination, the right eye appears phthisical and she has hand motion vision. The visual acuity in the left eye is 20/40. Slit lamp exam reveals an oval ulcer with sharp borders in the nasal cornea near the limbus and mild conjunctival injection. Corneal scrapings and autoimmune workup are negative. The diagnosis of Mooren’s ulcer is entertained. Which of the following has been linked to this pathology?




  1. Rheumatoid arthritis



  2. Hepatitis C virus



  3. Syphilis



  4. Tuberculosis


92. (Medium) A 10-year-old male presents for evaluation of a recurrent slow-growing mass in the left eye for the past year despite surgical excision (see the figure provided) The patient has no significant past medical or ocular history. Slit lamp exam reveals a pedunculated and fleshy growth along the plica semilunaris. Biopsy of the mass reveals multiple branching fronds branching from a central vascularized core. All of the following are management options, except:




  1. Topical interferon



  2. Oral cimetidine



  3. Dinitrochlorobenzene



  4. Infliximab


93. (Hard) A 60-year-old female with a history of diabetes mellitus and hypertension presents for her first annual diabetic exam. The patient has no eye related complaints. Slit lamp exam reveals a gelatinous conjunctival mass extending to the nasal limbus and cornea, with multiple feeder vessels. The rest of the anterior and posterior exam are within normal limits. Which of the following statements is correct regarding the most likely diagnosis?




  1. Immunosuppression is not an associated risk factor.



  2. Ninety-five percent occur at the fornix.



  3. Neoplastic cells frequently penetrate Bowman’s layer.



  4. Hyperreflective thickened epithelium with a transition zone can be seen on anterior segment optical coherence tomography (OCT).


94. (Easy) A 26-year-old female presents with the following finding (see the figure provided). What is her lifetime risk of uveal melanoma?




  1. 1 in 10,000



  2. 1 in 1,000



  3. 1 in 400



  4. 1 in 100


95. (Hard) All of the following are factors associated with a poor conjunctival melanoma prognosis, except:




  1. Melanomas arising from primary acquired melanosis (PAM)



  2. Nonlimbal tumor



  3. Pagetoid spread



  4. Thickness > 1.8 mm


96. (Easy) A 37-year-old male presents with a history of 5 days of a fleshy, friable, and pedunculated mass. He had a recent chalazion excision. Biopsy was obtained and revealed exaggerated granulation tissue with proliferating capillaries in a radiating pattern. Which of the following is the most likely diagnosis?




  1. Necrobiotic xanthogranuloma



  2. Juvenile xanthogranuloma



  3. Fibrous histiocytoma



  4. Pyogenic granuloma


97. (Easy) A 56-year-old male with HIV presents to the emergency room complaining of blood in his eye. The patient is not compliant with highly active antiretroviral therapy (HAART) therapy and had been experiencing a slow progressive painless inferior conjunctival red growth for the past 8 months. Clinical examination reveals a red and slightly elevated lesion with numerous fine vessels and petechial hemorrhages. Which of the following is the most likely diagnosis?




  1. Kaposi’s sarcoma



  2. Subconjunctival hemorrhage



  3. Episcleritis



  4. Viral conjunctivitis


98. (Medium) A 47-year-old female with no significant ocular history presents with redness, tearing, and foreign body sensation in both eyes for 8 months. She was diagnosed with chronic follicular conjunctivitis at an outside hospital and managed with chronic low-dose steroid drops. Slit lamp examination reveals the following (see the figure provided) and biopsy showed distinct marginal centers and mature lymphocytes. The rest of the examination was within normal limits. What is the best next step in management?




  1. Continue low-potency topical steroids and add erythromycin ointment at bedtime



  2. Conjunctival biopsy



  3. Start higher-potency topical steroids



  4. Viral swab


99. (Easy) A 47-year-old female presents at the emergency room 3 hours after an unknown agent was thrown at her face. Upon arrival, she was noted to have facial burns and left eye injection. Initial pH was 10.0. The emergency room staffstarted irrigation with normal saline until pH of 7.0 was achieved. On exam, the left eye had a visual acuity of count fingers, madarosis, conjunctival sloughing, moderate to severe corneal haze with extensive limbal ischemia, and a difficulty view of the posterior pole. Right eye examination was within normal limits. B-scan revealed that the retina was attached in the left eye. What next step would best maximize her visual prognosis?




  1. Place a contact lens



  2. Perform a tarsorrhaphy



  3. Place amniotic membrane



  4. Hourly artificial tears


100. (Medium) Six months after a severe alkali burn to the right eye, a patient is noted to have worsening conjunctival scarring, keratinization, and corneal haze. Which of the following is the next step in management?




  1. Penetrating keratoplasty



  2. Keratoprosthesis



  3. Lamellar keratoplasty



  4. Limbal epithelial transplantation


101. (Medium) A 25-year-old male presents to the emergency room after a work-related accident with hydrofluoric acid. The patient states that a moderate amount of acid splashed in both of his eyes. On initial examination, visual acuity is 20/40 in both eyes, there are no facial burns or madarosis, there is mild to moderate conjunctival injection, mild to moderate corneal haze, and superonasal area of focal limbal ischemia is noted. After adequate management was instituted, he is noted to have an elevation of intraocular pressure of > 30 mm Hg in the right eye. Which of the following is the most appropriate next step in management?




  1. Brimonidine 0.15%



  2. Timolol 0.5%



  3. Acetazolamide 500 mg bid



  4. Dorzolamide 2%


102. (Medium) A 28-year-old presents with sudden bilateral eye pain, tearing, foreign body sensation, photophobia, and blurred vision 6 hours after skiing. On slit lamp examination, conjunctival injection and interpalpebral corneal punctate epithelial erosions are noted. Which of the following wavelengths penetrates the entire thickness of the cornea?




  1. UV-A



  2. UV-B



  3. UV-C



  4. UV-D


103. (Hard) A 25-year-old Asian male with no significant past medical or ocular history presents to the emergency room after left eye trauma during a baseball game. At his initial presentation, his visual acuity in the affected eye is 20/50, and there is periorbital ecchymosis, chemosis, and 2 mm layering hyphema. The rest of his exam is within normal limits. Which of the following is an indication for surgical intervention?




  1. Intraocular pressure (IOP) average > 60 mm Hg for 2 days



  2. IOP average > 25 mm Hg for 4 days



  3. Total hyphema that persists for 1 day



  4. Any hyphema failing to resolve completely within 8 days


104. (Easy) A 5-year-old African American male presents to the emergency room with a hyphema after being hit in the eye while playing basketball. He is initiated on medium-potency topical steroids and cycloplegia with adequate improvement of symptoms and size of hyphema. Which of the following laboratory tests should be ordered prior to discharge?




  1. 50:50 mixing study



  2. Hemoglobin electrophoresis



  3. Ultrasound biomicroscopy



  4. Viral cultures


105. (Medium) A 34-year-old male with keratoconus and previous penetrating keratoplasty in the right eye returns for a follow-up. Latest topography reveals a K1 49.93 @ 15, K2 at 44.60 @ 100. He has no sutures remaining and has a spherical equivalent of -9.00 in the operated eye and -4.00 in his left eye. The patient is extremely bothered by anisometropia. Which of the following is the next best step in management?




  1. Relaxing incision at the steep meridian



  2. Laser in situ keratomileusis



  3. Photorefractive keratectomy



  4. Contact lens trial


106. (Medium) A 65-year-old female presents status post penetrating keratoplasty in the left eye with progressive blurry vision for the past year. Examination reveals a visual acuity of 20/25 in the right eye and 20/50 in the left eye. Slit lamp reveals a clear graft (see the figure provided) with no signs of rejection and a 1–2+ nuclear sclerosis. The rest of her exam is within normal limits. What is the next best step of management?




  1. Cataract surgery is indicated at this moment.



  2. Remove half of the sutures before cataract surgery.



  3. Cataract surgery should be performed after suture removal is completed.



  4. Penetrating keratoplasty is an absolute contraindication for cataract surgery.


107. (Hard) Which of the following is the most likely disadvantage of Descemet stripping automated endothelial keratoplasty (DSAEK) over penetrating keratoplasty?




  1. Light scattering



  2. Small incision



  3. Preservation of the anterior corneal curvature



  4. More postoperative astigmatism


108. (Medium) A 45-year-old patient presents for Descemet stripping automated endothelial keratoplasty (DSAEK) postoperative day one follow-up. Anterior segment optical coherence tomography reveals the following (see the figure provided). What is the best next step in management?




  1. Observation



  2. Rebubbling in the office



  3. Prednisolone acetate



  4. Take the patient to the operating room for a repeat DSAEK


109. (Medium) A 45-year-old female presents to your clinic due to bilateral foreign body sensation for the past 3 months. Slit lamp examination revealed punctate epithelial erosions limited to the superior cornea. All of the following are associated with the following staining pattern, except?




  1. Vernal keratoconjunctivitis



  2. Superior limbic keratoconjunctivitis



  3. Floppy eyelid syndrome



  4. Eye drop toxicity


110. (Medium) A 15-year-old male with past medical history of asthma presents with right eye pain, redness, and photophobia for the past 3 weeks. Past ocular history is also significant for bilateral allergic conjunctivitis. On examination, visual acuity is 20/60 on the right and 20/20 on the left, there is superior limbal injection and pannus. Corneal examination reveals the following (see the figure provided). Which of the following would you expect to find?




  1. Arlt’s line



  2. Giant papillae



  3. Pseudomembranes



  4. Herbert’s pits


111. (Hard) A 25-year-old presents with 4 days of left eye redness and mucopurulent discharge associated with tender preauricular lymph node. On examination, visual acuity is 20/20 on the right and 20/40 on the left. A follicular reaction is noted in the inferior tarsal conjunctiva, and there are superficial punctate erosions in the inferior cornea. Giemsa stain reveals basophilic intracytoplasmic bodies. Which of the following culture media is indicated?




  1. McCoy cell culture



  2. Sabouraud agar



  3. Non-nutrient agar with Escherichia Coli



  4. Lowenstein–Jensen medium


112. (Hard) A 40-year-old female presents with a history of chronic conjunctival injection, chemosis, and tearing. She has a history of mild to moderate asthma since childhood. On examination, she is noted to have bilateral eyelid erythema, scaliness of the lid skin, and lid thickening. Slit lamp examination reveals bilateral inferior tarsal papillary reaction and punctate epithelial erosions over the inferior third of the cornea. All of the following are associated with this condition except:




  1. Anterior subcapsular cataracts



  2. Higher risk of retinal detachment



  3. Dennie–Morgan folds



  4. Exposed Bowman’s membrane


113. (Medium) A 56-year-old female with no past medical history presents with right eye redness for the past 3 years. She has no other past ocular history. On examination, visual acuity is 20/150 OD and 20/20 OS. Slit lamp examination reveals an intense diffuse papillary conjunctivitis of both eyes, severe forniceal shortening of the right eye, and a large epithelial corneal defect with peripheral neovascularization. Immunofluorescence reveals antibodies binding at the basement membrane. Which of the following statements is false?




  1. Dapsone is the first line of treatment with mild-moderate disease.



  2. Stem cell failure is characterized by keratinization.



  3. Reconstructive surgery is indicated in this patient.



  4. Subconjunctival mitomycin can be used a temporizing treatment.


114. (Easy) A 15-year-old presents with mucosal blistering and lip crusting for the past 10 days. He was admitted to the burn unit and found to have bilateral eye redness. On examination, visual acuity was 20/20 in both eyes, there is mild lid margin crusting and a papillary tarsal reaction, and few punctate epithelial erosions. There is conjunctival staining with fluorescein. All of the following are appropriate next steps except:




  1. Prokera ring



  2. Amniotic membrane graft fixed with sutures



  3. Amniotic membrane graft fixed with glue



  4. Frequent topical lubricants without amniotic membrane


115. (Medium) A 55-year-old female with thyroid eye disease presents with foreign body sensation, burning, and photophobia. Slit lamp examination reveals upper lid papillary hypertrophy, superior redundant conjunctiva, superior punctate corneal epithelial erosions, and mild superior pannus. The rest of her exam is within normal limits. Which of the following statements is incorrect?




  1. The patient has superior bulbar conjunctiva that stains with fluorescein but not with rose Bengal.



  2. Acetylcysteine can be used to break down the filaments.



  3. Retinoic acid can be used to retard keratinization.



  4. This patient should have thyroid labs tested.


116. (Hard) A 5-year-old presents with a gradually enlarging red conjunctival masses bilaterally. On review of systems, she is noted to have similar lesions in vagina and oral mucosa. As per the patient’s parents one of the of the lesions was removed with forceps 1 week ago. After removal a white thickened avascular mass was noticed. All of the following statements are correct except:




  1. Amorphous subepithelial deposits of eosinophilic material can be seen in histopathology.



  2. Complete excisional biopsy is necessary.



  3. Antifibrinolytic drugs are part of the management.



  4. Amniotic membrane graft can be placed after lesion removal.


117. (Hard) A 2-day-old female born with hydrops fetalis was found to have a rapid plasma reagin (RPR) 1:32. Which of the following statements regarding interstitial keratitis secondary to syphilis is correct?




  1. Interstitial keratitis is usually present at birth.



  2. Interstitial keratitis is associated with enlarged corneal nerves.



  3. Interstitial keratitis is bilateral in 20% of cases.



  4. Sectoral superior stromal inflammation is often seen in early disease.


118. (Easy) A 45-year-old male with chronic blepharitis presents with left eye redness and tearing for the past 3 weeks. He has no past medical history. On examination, visual acuity is 20/20 in both eyes. Slit lamp examination reveals several peripheral corneal opacities. All of the following statements are correct, except:




  1. These findings are secondary to a hypersensitivity reaction to staphylococcal exotoxin.



  2. Stromal marginal infiltrates with no clearing space from the limbus.



  3. There is usually no anterior chamber reaction.



  4. Treatment consist of low- to medium-potency topical steroids.


119. (Hard) A 40-year-old male presents complaining of a growth onto the cornea stemming from the nasal conjunctiva, associated with progressive visual decline for the past 2 years. He has no past medical history. On examination, corrected visual acuity is 20/80 on the right and 20/20 on the left. Slit lamp examination reveals a fibrovascular growth associated with moderate corneal thinning in the superonasal aspect of the cornea. Before planning for surgery, Scheimpflug imaging was obtained and revealed steepening of the cornea surface approximately 90 degrees away from the lesion. Which of the following statements is likely to be associated with this condition?




  1. On histopathology, basophilic degeneration of elastotic fibers can be seen.



  2. Tissue excision with bare sclera provides the maximum success rate.



  3. Lamellar or penetrating keratoplasty for severe cases may be necessary.



  4. There is anterior and posterior elevation on corneal topography.


120. (Medium) A 36-year-old female contact lens wearer presents with bilateral chronic foreign body sensation and eye redness. She has been wearing contact lenses for 15 years. She has been using artificial tears without improvement. Examination is remarkable for bilateral multiple mucoid strands attached to corneal epithelium. All the following statements are correct in regard to this condition except:




  1. This condition may be present in patients with thyroid eye disease.



  2. Mucoid strands stain well with fluorescein and to a lesser extend with rose Bengal.



  3. Acetylcysteine is part of the management.



  4. Mechanical removal gives short-term relief.


121. (Hard) Which of the following statements is correct regarding penetrating keratoplasty?




  1. Large diameter grafts cause higher astigmatism.



  2. Donor button is usually about 1 mm larger than the trephination site.



  3. Small-diameter grafts are associated with lower tendency to cause peripheral anterior synechiae.



  4. Host tissue cornea excision precedes preparation of donor cornea.


122. (Medium) A 3-year-old diagnosed with an X-linked lysosomal storage disease presents for annual eye exam. The systemic manifestations of the disease are characterized by acroparesthesias, angiokeratomas, cardiomyopathy, and renal disease. All of the following are eye-related manifestations, except:




  1. Vortex keratopathy



  2. Wedge-shaped posterior cataract



  3. Conjunctival aneurysm



  4. Pseudodendrites


123. (Hard) A 65-year-old with a progressive decline in visual acuity presents for evaluation. He is found to have visually significant cataracts in both eyes with 0.75 D of corneal astigmatism. Which of the following is correct regarding limbal relaxing incisions?




  1. Incisions are placed in the steep meridian.



  2. Incisions are approximately 200 µm in depth.



  3. Hyperopic shift occurs with coupling ratios less than 1.



  4. Cylinder correction depends on the depth of the incision.


124. (Hard) Which of the following statements is correct regarding post radial keratotomy outcomes?




  1. Intraocular lens (IOL) calculation should be done using a regression formula.



  2. Corneal curvature becomes flat in the center and steeper in the periphery.



  3. PERK study revealed a myopic shift in 43% of eyes between 6 months and 10 years postoperatively.



  4. Greater hyperopic shifts occur with larger optical zones.


125. (Easy) An 8-year-old male with no significant past medical history presents with 5 days of left eye redness, tearing, clear discharge, and blurry vision. On examination, visual acuity is 20/20. There is a follicular palpebral reaction and 2+ conjunctival injection. The rest of the anterior and posterior exams are within normal limits. Histology smear reveals multinucleated giant cells. Which of the following is the most likely diagnosis?




  1. Adenovirus conjunctivitis



  2. Herpes simplex virus (HSV) conjunctivitis



  3. Toxic conjunctivitis



  4. Inclusion conjunctivitis


126. (Hard) A 34-year-old contact lens wearer presents to the eye clinic with a history of 6 days of right eye tearing, redness, pain, and discharge. The patient decided to use Polytrim drops prescribed previously for conjunctivitis, without much improvement. On examination, he is noted to have a central dendrite-like lesion. Confocal microscopy reveals the following (see the figure provided). Which of the following would treat the motile and dormant state?




  1. Hexamidine



  2. Polyhexamethylene biguanide



  3. Neomycin



  4. Voriconazole


127. (Hard) A 45-year-old male with HIV/AIDS presents with a history of 1 week of blurry vision, irritation, photophobia, and bilateral conjunctival injection. Slit lamp exam demonstrates multifocal fine punctate fluorescein staining lesions along with follicular conjunctival reaction. Brown and Hopps staining reveal small gram-positive spores. Which of the following is the most appropriate next step in management?




  1. Polyhexamethylene biguanide



  2. Voriconazole



  3. Fumagillin



  4. Vancomycin


128. (Medium) Which of the following indications for PK has the highest rate of nonimmune mediated corneal graft failure?




  1. Pseudophakic bullous keratopathy (PBK)



  2. Fuchs endothelial dystrophy



  3. Keratoconus



  4. Corneal perforation


129. (Easy) You examine a patient with the findings below (see the figure provided). Which of the following is the best step in management?




  1. Prednisolone acetate drops



  2. Moxifloxacin drops



  3. Corneal scraping



  4. Confocal microscopy


130. (Medium) A 38-year-old female presents following a penetrating keratoplasty in the left eye due to progressive keratoconus. The patient complains of blurry vision in the operated eye for the past month. On examination, there are multiple subepithelial infiltrates. Which of the following slit lamp illumination technique would better identify these lesions?




  1. Diffuse illumination



  2. Direct illumination



  3. Tangential illumination



  4. Indirect illumination


131. (Medium) Your patient presents for a postoperative month 1 follow-up with the findings below (see the figure provided). Which of the following is the most likely diagnosis?




  1. Epithelial rejection



  2. Subepithelial rejection



  3. Stromal rejection



  4. Endothelial rejection


132. (Easy) Femtosecond laser works through which type of energy?




  1. Infrared light



  2. Ultraviolet light



  3. Natural light



  4. Microwave


133. (Medium) You performed LASIK 2 days ago in a 28-yearold female. The procedure was uneventful. She returns to your office complaining of slightly hazy vision. On exam, you note a fine granular appearing infiltrate within the flap interface. The eye is otherwise quiet. What would be the best first step?




  1. Start broad-spectrum antibiotics



  2. Lift up her flap and culture



  3. Start topical corticosteroids



  4. Start antifungals


134. (Easy) What is the mechanism of laser action for the excimer laser?




  1. Photoablation



  2. Photodisruption



  3. Photocoagulation



  4. All of the above


135. (Easy) Which of the following factors is associated with haze following photorefractive keratectomy (PRK) treatment?




  1. Patients who tend to develop keloids



  2. High myopic treatment (greater than 6 D)



  3. Postoperative medical noncompliance



  4. All of the above


136. (Medium) A 70-year-old man presents complaining about fluctuations in his vision. He notes that the vision seems different in the morning than at the end of the day. It also seems to vary depending on his location. He is an avid skier and he finds it harder to see when he goes to the mountains. He had refractive surgery in the 1980s and states that a procedure was done “before LASIK to treat my near sightedness.” Overall, his vision is blurry. What do you expect that his prescription will be?




  1. Myopic



  2. Hyperopic



  3. Plano



  4. Irregular astigmatism with a topography that looks like keratoconus


137. (Easy) Which of the following is not a contraindication for refractive surgery for myopia?




  1. History of a bacterial corneal ulcer



  2. Pregnancy



  3. Human immunodeficiency virus (HIV)



  4. Accutane use


138. (Hard) A 40-year-old man presents to you for a second opinion. He had LASIK surgery performed 5 years ago for myopia and has been doing well. On routine follow-up, he was found to have a peripheral corneal opacity (see the figure provided). He asks you what the next steps would be for the management of this finding. Of these, what would you recommend?




  1. Observation



  2. Start empiric antibiotics



  3. Lift the LASIK flap and culture



  4. Lift the LASIK flap and gently irrigate/scrape the stromal bed.


139. (Medium) Which patient would be at highest risk for a button hole during LASIK flap creation?




  1. A patient with a history of cataract surgery



  2. A patient with moderate cylinder



  3. A patient with very flat corneas



  4. A patient with very steep corneas


140. (Easy) A 23-year-old female with a history of herpetic simplex keratitis as well as recurrent corneal erosions presents for an evaluation of phototherapeutic keratectomy (PTK) for the treatment of her erosions. How might you council her?




  1. The recurrent erosions can recur after PTK.



  2. PTK may reactivate herpes simplex virus (HSV).



  3. You may have a change in refraction.



  4. All of the above.


141. (Hard) A 25-year-old patient is interested in refractive surgery. He asks you to briefly explain the difference between LASIK, LASEK, and PRK. You explain:




  1. LASIK involves creation of a stromal flap.



  2. LASEK involves the creation of a stromal flap.



  3. PRK involves the preservation of a sheet of epithelium.



  4. None of the above.


142. (Easy) You have a university-based practice. A 45-year-old woman presents with the following clinical picture (see the figure provided). She also complains of arthralgia, epistaxis, sinusitis, and shortness of breath. Who might you initially consult to help co-manage this patient?




  1. Rheumatology



  2. Pulmonology



  3. Nephrology



  4. Cardiology


143. (Medium) A 25-year-old female presents 2 weeks after conjunctivitis with the following findings (see the figure provided). She had a previous cold, conjunctival injection, and discharge, all of which resolved. She now complains of blurry vision and photophobia. You suspect that she had a previous virus and offer topical corticosteroids. She insists on getting antibiotics and tells you that a previous viral swab was negative. How do you respond?




  1. Agree to a short course of antibiotics.



  2. Repeat viral swab.



  3. Explain that the test may not have been sensitive enough to pick up the underlying virus or that the responsible virus was not tested. Because clinical presentation suggests postviral inflammation, you encourage steroid use.



  4. Have her return in 1 week to monitor progress.


144. (Easy) You are planning to perform a Descemet’s membrane endothelial keratoplasty (DMEK) on a 68-year-old female with Fuchs dystrophy. Your corneal tissue arrives at the beginning of the day, and upon review of the tissue information you learn that you were actually provided with ultrathin Descemet stripping automated endothelial keratoplasty (DSAEK) tissue. The tissue remains unopened and in the proper storage settings. What should be your next step?




  1. Proceed with the surgery as scheduled; ultrathin DSAEK and DMEK have comparable outcomes and the patient will not know the difference.



  2. Cancel the surgery.



  3. Call the eye bank and see if there is available DMEK tissue and if the DSAEK tissue can be exchanged.



  4. Offer the option of ultrathin DSAEK to the patient.


145. (Easy) A 25-year-old contact lens wearer presents asking you for a lens that he does not need to worry about. He would like to be able to swim, shower, and sleep in his lenses, and change them minimally. How would you advise this patient?




  1. Contact lenses are safe to swim in, but they must be removed every night.



  2. Contact lenses are foreign material that you are putting in your eye. They must be regularly cleaned or changed. Swimming and sleeping in lenses increases the risk of infection.



  3. Extended wear lenses are safer than daily lenses.



  4. It is probably safe to occasionally sleep in your lenses.


146. (Medium) A 34-year-old man presents with foreign body sensation, blurry vision, and the following corneal finding (see the figure provided). He wants this to clear immediately and wants to make sure he never experiences an episode like this again. Per the Herpetic Eye Disease Study (HEDS) study, what should you advise:




  1. Starting a topical steroid will clear this faster.



  2. Topical antiviral prophylaxis will reduce chances of recurrence.



  3. Oral antiviral prophylaxis will reduce chances of recurrence.



  4. The HEDS study did not show reduced rates of recurrence with antiviral prophylaxis.


147. (Medium) A 25-year-old contact lens wearer presents with irritation and the following corneal finding (see the figure provided). According to the Steroid for Corneal Ulcer Trial (SCUT), adding topical corticosteroids to his treatment will result in which one of these?




  1. A faster time to reepithelialization



  2. Worse visual outcome at 3 months



  3. No difference in visual outcome at 3 months



  4. A slower time to reepithelialization


148. (Hard) An 84-year-old man with corneal edema in the setting of Fuchs dystrophy presents for consideration of Descemet’s membrane endothelial keratoplasty (DMEK). He wants to optimize his chances of graft survival. According to the collaborative corneal transplant treatment study (CCTS), which factor(s) may be associated with increased risk of rejection?




  1. Patients who are not human leukocyte antigen (HLA) matched



  2. ABO blood type incompatibility



  3. Patients over the age of 65 years



  4. All of the above


149. (Easy) A 54-year-old man presents with irritation and the following corneal lesion (see the figure provided). You predict that his corneal topography will show:




  1. With-the-rule astigmatism



  2. Against-the-rule astigmatism



  3. Steep corneas



  4. Flat corneas


150. (Easy) A 68-year-old renal transplant recipient presents with the following corneal finding in the setting of a forehead rash (see the figure provided). All of the following are true about his condition except:




  1. They stain well with fluorescein and rose Bengal.



  2. The cornea may show decreased sensation.



  3. These findings can recur in the future.



  4. The patient should have a dilated fundus exam.

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Related posts:

  1. Chapter 3 Lens and Cataract
  2. Chapter 4 Neuro-Ophthalmology
  3. Chapter 7 Refractive Management and Optics
  4. Chapter 6 Pediatric Ophthalmology and Strabismus

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May 9, 2020 | Posted by in OPHTHALMOLOGY | Comments Off on Chapter 1 Cornea, External Disease, and Anterior Segment

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