5.1 Questions

Easy

Medium

Hard

1. (Medium) An 87-year-old man presents after slipping on his grandson’s firetruck and falling. Upon presentation, he is noted to have significant periocular edema and ecchymosis. A CT of the orbits is ordered as part of his work-up. Which of the following were most likely impacted by his injury?

1. 
   

   Frontal and sphenoid bones

   
   
2. 
   

   Zygomatic and sphenoid bones

   
   
3. 
   

   Ethmoid, lacrimal, maxillary, and sphenoid bones

   
   
4. 
   

   Zygomatic, maxillary, and palatine bones

2. (Easy) A 64-year-old woman presents with chronic, constant epiphora OS for the past year. Irrigation of the nasolacrimal system reveals a complete nasolacrimal duct obstruction, and the patient is consented for a dacryocystorhinostomy with nasolacrimal intubation. As you explain the procedure to her, you demonstrate the anatomic location of nasolacrimal duct outflow, as well as the location in which a new bony ostium is created. Where was the original, and where will the new one most likely be?

1. 
   

   Inferior meatus (beneath the inferior turbinate), and in the region anterior to the middle turbinate

   
   
2. 
   

   Middle meatus (beneath the middle turbinate), and in the middle turbinate

   
   
3. 
   

   Inferior meatus (beneath the inferior turbinate), and between the middle turbinate and the superior turbinate

   
   
4. 
   

   Middle meatus (beneath the middle turbinate), and in the region underneath or anterior to the superior turbinate

3. (Hard) Which of the following complications could occur secondary to surgical disruption of the medial orbital wall above the frontoethmoidal suture?

1. 
   

   Optic neuropathy

   
   
2. 
   

   Disruption of the cribriform plate

   
   
3. 
   

   Orbital tissue necrosis

   
   
4. 
   

   Disruption of innervation to the inferior oblique muscle

4. (Easy) A patient needs an incisional lacrimal gland biopsy to rule out lymphoma. Which of the following techniques would be preferred?

1. 
   

   Lid crease approach with palpebral lobe biopsy

   
   
2. 
   

   Conjunctival approach with palpebral lobe biopsy

   
   
3. 
   

   Lid crease approach with orbital lobe biopsy

   
   
4. 
   

   Conjunctival approach with orbital lobe biopsy

5. (Hard) A patient presents with unilateral contractions of her eyelids, cheek, and mouth. Imaging shows no pathology. You discuss treatment, and your patient asks you to “give her a little extra” along her forehead and laugh lines on the uninvolved side—“after all, you have a deal going on, my insurance is paying for it!” What should you do?

1. 
   

   Inject botulinum toxin type A along regions impacted by the seventh nerve unilaterally, and then perform the cosmetic injection; submit the insurance claim for the total quantity injected and wasted.

   
   
2. 
   

   Inject botulinum toxin type A along regions impacted by the third nerve unilaterally, and perform the cosmetic injection; submit the insurance claim for the quantity injected and wasted for the functional purposes alone, and bill the patient separately for the cosmetic injection.

   
   
3. 
   

   Inject botulinum toxin type A along regions impacted by the seventh nerve unilaterally, and then perform the cosmetic injection; submit the insurance claim for the quantity injected and wasted for the functional purposes alone, and bill the patient separately for the cosmetic injection.

   
   
4. 
   

   Inject botulinum toxin type A along regions impacted by the third nerve unilaterally, and then perform the cosmetic injection; submit the insurance claim for the total quantity injected and wasted.

6. (Hard) Interventional radiology wants your help accessing a carotid-cavernous sinus fistula by exposing a large vein. Which of the following is your vein of choice?

1. 
   

   Superior ophthalmic vein

   
   
2. 
   

   Inferior ophthalmic vein

   
   
3. 
   

   Angular vein

   
   
4. 
   

   Facial vein

7. (Medium) A mother brings in her toddler, as she has noticed a swelling of the right brow area. It doesn’t appear to bother her toddler, and isn’t tender, but it has been slowly increasing in size since birth. You discuss options and decide to perform a lesion excision. What is the pathology most likely to show?

1. 
   

   Endothelium-lined capillary channels in a lobular configuration

   
   
2. 
   

   Keratinized epithelial lining, hair follicles, and sebaceous glands

   
   
3. 
   

   Keratin-filled cyst

   
   
4. 
   

   Spindle cells with occasional cross-striations

8. (Medium) A pediatrician urgently refers a male infant for evaluation of an orbital mass. The child was the product of a normal pregnancy and delivery. He looks comfortable. After seeing the following on examination, what do you advise the parents to do?

1. 
   

   Perform an excisional biopsy.

   
   
2. 
   

   Perform a partial excision if irritating.

   
   
3. 
   

   Perform an incisional biopsy.

   
   
4. 
   

   Never biopsy or excise.

9. (Easy) A 6-month-old male infant with known Crouzon’s syndrome presents for ophthalmic examination. Which of the following is incorrect?

1. 
   

   He will never be able to interact meaningfully with his environment.

   
   
2. 
   

   He should be managed in a multidisciplinary manner with services including neurosurgery, ENT, and ophthalmology.

   
   
3. 
   

   He will need routine, chronic monitoring for evidence of exposure keratopathy, and elevated intracranial pressure.

   
   
4. 
   

   He should be carefully refracted to help prevent refractive amblyopia.

10. (Medium) You receive a call from the Newborn Nursery regarding a 1-day-old who appears to be missing an eye. After examining the newborn, you diagnose microphthalmia of the left eye; the right eye is normal. What is the next best step?

1. 
   

   Patch therapy OD.

   
   
2. 
   

   Enucleation OS with placement of gradually larger conformers.

   
   
3. 
   

   Retain microphthalmic eye OS and use gradually increasing conformers with possible dermis-fat graft in the future.

   
   
4. 
   

   Perform an immediate dermis-fat graft.

11. (Easy) A 61-year-old woman presents with diplopia of 2 month’s duration. She has no past medical history. Examination shows limited supraduction OS and retraction of the left upper eyelid. Which of the following studies would be most helpful in diagnosing the underlying etiology of her diplopia?

1. 
   

   Complete blood count with differential

   
   
2. 
   

   Thyroid-stimulating immunoglobulin

   
   
3. 
   

   Acetylcholine receptor binding, blocking, and modulating antibodies

   
   
4. 
   

   Erythrocyte sedimentation rate

12. (Medium) A 24-year-old patient with recent diagnosis of hyperthyroidism presents with acute proptosis OD. History is also notable for a deep ache OD. Further examination reveals chemosis OD, mild bilateral upper eyelid retraction, and left upper lid lateral flare. A CT scan of the orbits is performed. What is the most likely finding?

1. 
   

   Tendon-sparing enlargement of the superior oblique muscle

   
   
2. 
   

   Diffuse enlargement of the medial rectus muscle

   
   
3. 
   

   Cavernous hemangioma

   
   
4. 
   

   Fatty proliferation

13. (Hard) A 68-year-old woman with thyroid eye disease (TED) is very distressed by her right upper eyelid retraction. She would like you to “make things right” as quickly as possible. Her examination is otherwise notable mild chemosis OD, rare punctate keratopathy OU, and new resolution of a mild supraduction deficit. What is your treatment plan for this patient?

1. 
   

   IV methylprednisolone infusions for the next 12 weeks

   
   
2. 
   

   Surgical right upper eyelid recession

   
   
3. 
   

   Artificial tears four times a day OU

   
   
4. 
   

   Orbital radiotherapy

14. (Hard) A 44-year-old woman presents with an enlarged lacrimal gland. After serum laboratory work shows elevated immunoglobulin G4 (IgG4) levels, you maintain a high suspicion for IgG4-related orbital disease and decide to biopsy the lacrimal gland. Which of the following is unlikely to be present upon histopathologic review of the biopsy specimen?

1. 
   

   Cribriform appearance

   
   
2. 
   

   Storiform fibrosis

   
   
3. 
   

   Obliterative phlebitis

   
   
4. 
   

   Elevated IgG4/IgG ratio

15. A 49-year-old man presents with scleritis and swelling of the superomedial eyelid. He reports a history of glomerulonephritis. Imaging is consistent with a bone-destructive process of the sinuses. Which of the following is incorrect?

1. 
   

   Histopathologic examination of the affected tissue would show vasculitis, granulomatous inflammation, and necrosis.

   
   
2. 
   

   Treatment with cyclophosphamide should be initiated.

   
   
3. 
   

   This disease process can be fatal.

   
   
4. 
   

   Serum cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) is specific for this disease process; if it is negative, this process can be ruled out.

16. (Hard) A previously healthy 7-year-old patient presents with bilateral dacryoadenitis, abdominal pain, and vomiting. Which of the following is true?

1. 
   

   There is no need to rule out systemic infection.

   
   
2. 
   

   Treatment with steroids should begin immediately.

   
   
3. 
   

   In adults, this condition is typically unilateral and without systemic symptoms.

   
   
4. 
   

   Imaging is likely to show tendon-sparing enlargement of the extraocular muscles.

17. (Medium) A 5-year-old, otherwise healthy girl presents with acute periocular edema and proptosis OD in the setting of sinus congestion. She has no relative afferent pupillary defect and her vision remains intact, though her adduction and abduction are painful and restricted. You obtain her CT scan. Which of the following is the best next step?

1. 
   

   Anterior orbitotomy with drainage

   
   
2. 
   

   Initiation of IV antibiotic therapy

   
   
3. 
   

   Initiation of oral antibiotic therapy

   
   
4. 
   

   Functional endoscopic sinus surgery

18. (Easy) A 29-year-old woman presents with acute-onset, progressive periocular edema and erythema OS. Her history is notable for a recent scratch near her left eye. Which of the following is the most important bacteria to cover for when treating?

1. 
   

   Haemophilus influenzae

   
   
2. 
   

   Staphylococcus aureus

   
   
3. 
   

   Klebsiella pneumoniae

   
   
4. 
   

   Actinomyces israelii

19. (Hard) A 39-year-old poorly controlled diabetic presents with rapidly progressive discoloration of his right periocular tissue after recently hitting a cabinet corner; the eyelid is swollen and painful, and the color has turned from rose to blue-gray. The emergency room attending sends him home with oral antibiotics. Which of the following is most likely to be accurate?

1. 
   

   He must be monitored for shock and has a high mortality risk.

   
   
2. 
   

   Histopathologic review would show a thrombosing vasculitis involving nonseptate hyphae.

   
   
3. 
   

   Amphotericin B should be administered systemically.

   
   
4. 
   

   Surgical debridement will not be necessary.

20. (Medium) A 45-year-old Black woman presents with dacryoadenitis and skin nodules. A skin biopsy reveals the following. Which of the following is helpful in the diagnosis of cases such as this?

1. 
   

   Conjunctival biopsy

   
   
2. 
   

   PPD testing

   
   
3. 
   

   Chest X-ray

   
   
4. 
   

   Bone marrow biopsy

21. (Easy) A 74-year-old man presents with at least 4 months of foreign body sensation in both eyes. The most common type of this eyelid malposition in the lower lid is ________, while the most common type of this eyelid malposition in the upper lid is _________.

1. 
   

   cicatricial, spastic

   
   
2. 
   

   involutional, cicatricial

   
   
3. 
   

   involutional, congenital

   
   
4. 
   

   spastic, congenital

22. (Medium) A 60-year-old woman with a history of pernicious anemia and Graves’ disease complains of droopy upper lids, left worse than right. She notes that it seems to be worse when she is tired, when she has had a few glasses of wine, and at the end of each day. The medical student and the resident get into an argument over the margin to reflex distance 1 (MRD1) measurement only to be disappointed when neither of their measurements match the attending’s. What is the next best step?

1. 
   

   Ptosis repair at the ambulatory surgical center after cardiac clearance

   
   
2. 
   

   Laboratory work-up of acetylcholine receptor antibodies

   
   
3. 
   

   MRI of the brain or spine with aquaporin-4 antibodies

   
   
4. 
   

   MRI or MRA of the internal auditory canal

23. (Easy) A patient presents complaining of droopy upper lids. Examination reveals a high upper eyelid crease and normal levator function. What is the most likely type of ptosis?

1. 
   

   Aponeurotic

   
   
2. 
   

   Neurogenic

   
   
3. 
   

   Myogenic

   
   
4. 
   

   Mechanical

24. (Medium) A 4-month-old male infant is referred for evaluation of tearing in both eyes. His mom reports that he hates direct sunlight and constantly has tears rolling down his cheeks. What is the most likely etiology?

1. 
   

   Epiblepharon

   
   
2. 
   

   Euryblepharon

   
   
3. 
   

   Entropion

   
   
4. 
   

   Congenital glaucoma

25. (Hard) What are the three anatomic issues that must be addressed in the surgical treatment of involutional entropion?

1. 
   

   Scarring of the posterior lamella, horizontal laxity, and trichiasis

   
   
2. 
   

   Horizontal laxity, capsulopalpebral fascia dehiscence, and trichiasis

   
   
3. 
   

   Capsulopalpebral fascia dehiscence, overriding orbicularis, and horizontal laxity

   
   
4. 
   

   Overriding orbicularis, scarring of the posterior lamella, and capsulopalpebral fascia dehiscence

26. (Medium) A patient presents complaining of droopy upper lids. Examination is significant for decreased levator function, eyelid lag on downgaze, and lagophthalmos. What is the most likely type of ptosis?

1. 
   

   Aponeurotic

   
   
2. 
   

   Neurogenic

   
   
3. 
   

   Myogenic

   
   
4. 
   

   Mechanical

27. (Hard) A 67-year-old patient with a history of diabetes type 2, hypertension, and hyperlipidemia comes in complaining of binocular diplopia, worse in left gaze, starting after a lower lid blepharoplasty by an outside surgeon. What is the most likely cause?

1. 
   

   Iatrogenic left cranial nerve VI palsy

   
   
2. 
   

   Damage to the left lateral rectus muscle

   
   
3. 
   

   Damage to the left inferior oblique muscle

   
   
4. 
   

   Damage to the right inferior oblique muscle

28. (Easy) A 23-year-old female model presents with left upper lid ptosis (margin to reflex distance 1 [MRD1]: right 4.5 and left 3) and a levator function of 14. Her ptosis resolves with instillation of phenylephrine. What is the best option for surgical repair?

1. 
   

   Levator advancement

   
   
2. 
   

   Conjunctivomullerectomy

   
   
3. 
   

   Frontalis sling

   
   
4. 
   

   Bick’s procedure

29. (Easy) A patient presents with stable eyelid changes. He is tired of getting funny looks and is requesting treatment. Examination is normal except for the following appearance. What is the next step?

1. 
   

   Ptosis repair of the right upper lid

   
   
2. 
   

   Retraction repair of the left upper lid

   
   
3. 
   

   Radioactive iodine

   
   
4. 
   

   Check free T₄, TSH, and thyroid antibodies

30. (Hard) A 50-year-old woman presents with droopy upper lids. She complains that they are getting in her way, worsening over the last few years, and she has to lift her lids with her hands to see. She says this runs in her family (her dad and her paternal grandmother have the same problems). Her examination is significant for margin to reflex distance 1 (MRD1) of 1 OU and a levator function of 12 OU. Her examination is otherwise normal. Which of the following would be most consistent with this presentation?

1. 
   

   Red ragged fibers on muscle biopsy.

   
   
2. 
   

   Delayed swallow study and genetic mutations of PABPN1.

   
   
3. 
   

   Ptosis improves with opening of the jaw.

   
   
4. 
   

   After looking down and then back in primary gaze, the upper eyelid will overshoot and appear to open briefly before returning to its normal position.

31. (Hard) A 58-year-old woman complains of spasms that have worsened to the point where she has difficulty opening her eyes. She reports that it has gotten so bad that she is scared of leaving the house. Which of the following is true?

1. 
   

   The medication she should receive takes about 2 to 3 days to work, peaks in effect 7 to 10 days later, and lasts about 3 to 4 months.

   
   
2. 
   

   The medication she should receive inhibits acetylcholine binding in the postsynaptic neuron.

   
   
3. 
   

   She should get an MRI to rule out pathology of the pons.

   
   
4. 
   

   The most common cause of this disorder is vascular compression of the facial nerve at the brainstem.

32. (Hard) A 58-year-old woman complains of spasms around her right eye. On examination, you note that her lower face on the right also twitches. Which of the following is true?

1. 
   

   Neurosurgical decompression of the facial nerve should be recommended.

   
   
2. 
   

   The spasms likely occur at nighttime, when she is asleep.

   
   
3. 
   

   She may have a history of ipsilateral facial nerve palsy, and this represents unilateral aberrant synkinetic facial movements.

   
   
4. 
   

   B and C.

33. (Medium) A 67-year-old man complains of droopy upper lids. Examination reveals heaviness in the upper eyelid area, especially temporally. The amount of skin between the eyelid margin and the inferior aspect of the brow measures 20 mm. Palpation reveals the brow position to be below the superior orbital rim. The margin to reflex distance 1 (MRD1) is 4 in both eyes. What is the best surgical option?

1. 
   

   Upper eyelid blepharoplasty

   
   
2. 
   

   Upper eyelid fractional CO₂ laser

   
   
3. 
   

   Levator advancement

   
   
4. 
   

   Brow lift

34. (Medium) A 67-year-old man complains of redness and copious tearing in both eyes. He reports he recently went on long trip abroad and got a great deal on a surgery to make him look younger. Which of the following are possible solutions?

1. 
   

   Artificial tears and ointment

   
   
2. 
   

   Full-thickness skin graft

   
   
3. 
   

   Midface lifting

   
   
4. 
   

   All of the above

35. (Medium) A budding oculoplastic surgeon approaches you for advice on how to surgically approach an ectropion. There is no cicatricial component. Which of the following is your recommendation?

1. 
   

   Lateral tarsal strip

   
   
2. 
   

   Lateral tarsal strip with medial spindle procedure

   
   
3. 
   

   Weiss procedure

   
   
4. 
   

   Quickert suture

36. (Easy) A 44-year-old man with a past medical history of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HL), and morbid obesity complains of red eyes associated with discharge. Which of the following disorders are associated with this entity?

1. 
   

   Keratoconus

   
   
2. 
   

   Obstructive sleep apnea

   
   
3. 
   

   Obesity

   
   
4. 
   

   All of the above

37. (Medium) In addition to an ectropion of the right lower lid, which other right-sided eyelid malpositions are associated with the etiology of this right lower lid ectropion?

1. 
   

   Dermatochalasis

   
   
2. 
   

   Blepharoptosis

   
   
3. 
   

   Blepharochalasis

   
   
4. 
   

   Lagophthalmos

38. (Easy) The following examination finding is discovered on a work-up for ptosis of the right upper lid. What is the best explanation for the changes that occur in this figure?

1. 
   

   Hering’s law

   
   
2. 
   

   Sherrington’s law

   
   
3. 
   

   Cogan’s lid twitch

   
   
4. 
   

   Harada–Ito sign

39. (Medium) A 48-year-old eye makeup model presents with foreign body sensation of the right eye for several years. On examination, she is noted to have trichiasis. For which of the following situations would radiofrequency epilation be the best solution?

1. 
   

   She is White and not Black.

   
   
2. 
   

   She has just three trichiatic lashes scattered throughout both upper and lower eyelids.

   
   
3. 
   

   She has a 4-mm segment on the right lower lid that is completely trichiatic.

   
   
4. 
   

   She has many trichiatic lashes on the lower lid, they are scattered diffusely, and the eyelid margin appears rounded.

40. (Medium) A 37-year-old Irish woman comes in complaining of aging changes in her lower face. She notices fine lines throughout, especially around her lips. She admits to being a heavy smoker until last year, when she quit to pursue a vegan/yoga lifestyle. What are some possible nonsurgical options for her?

1. 
   

   Hyaluronic acid fillers to the fine perioral lines

   
   
2. 
   

   Fractionated CO₂ laser throughout the lower face (with option for adding upper face)

   
   
3. 
   

   Botox injection to the fine perioral lines

   
   
4. 
   

   A and B

41. (Easy) A 9-month-old female infant has group E retinoblastoma of the left eye. What is the best surgical option for this eye?

1. 
   

   Exenteration

   
   
2. 
   

   Evisceration with 18-mm silicone implant

   
   
3. 
   

   Enucleation with dermis-fat graft

   
   
4. 
   

   Enucleation with 18-mm silicone implant

42. (Medium) A patient presents with a remote history of left eye enucleation with implant placement. What can be done to correct her secondary eyelid problem?

1. 
   

   Subperiosteal orbital floor implant OS

   
   
2. 
   

   Brow lift OD

   
   
3. 
   

   External levator advancement OS

   
   
4. 
   

   Blepharoplasty OD

43. (Medium) One week after an enucleation for a blind, painful right eye, the tarsorrhaphy is removed. One week later, the conformer falls out while the patient was showering and is lost down the drain. The patient calls to let you know, and also states that there is no pain, discharge, or bleeding. He is very happy with the results so far. What should you do?

1. 
   

   Confirm his follow-up with the ocularist at postoperative week 6.

   
   
2. 
   

   Ask him to come urgently to clinic.

   
   
3. 
   

   Schedule surgery to replace the conformer.

   
   
4. 
   

   Recommend lubrication with antibiotic ointment and see him as scheduled in 2 weeks.

44. (Medium) A 59-year-old man comes for routine eye examination. He has a prosthesis in the left eye related to an enucleation for a severe chemical eye injury many years ago with “some tissue taken from his mouth.” What complication might he have suffered from his injury?

1. 
   

   Anophthalmic ptosis

   
   
2. 
   

   Fornix contracture

   
   
3. 
   

   Deep superior fornix

   
   
4. 
   

   Implant exposure

45. (Medium) A 65-year-old patient has a blind painful eye from neovascular glaucoma. You recommend removing the eye, but she is concerned about motility postoperatively. What is the best option for this patient?

1. 
   

   Enucleation with acrylic sphere

   
   
2. 
   

   Evisceration with acrylic sphere

   
   
3. 
   

   Enucleation with acrylic sphere wrapped in sclera with muscles attached to it

   
   
4. 
   

   Enucleation with dermis-fat graft

46. (Medium) A 79-year-old woman walks in to see you 6 months after enucleation for a blind, painful eye. She had removed her prosthesis to clean it, and a translucent sphere “popped out.” On examination, you notice a deflation of her anophthalmic socket and disruption of her conjunctiva. Which of the following factors is least likely to contribute to this scenario?

1. 
   

   Oversized implant

   
   
2. 
   

   Suturing the extraocular muscles to each other over the anterior surface of the implant

   
   
3. 
   

   Improper Tenon’s closure

   
   
4. 
   

   Improper conjunctival closure

47. (Easy) A 45-year-old patient is referred to you for removal of his blind, painful eye. You present the options of enucleation and evisceration to him. What do you describe as an advantage of enucleation over evisceration?

1. 
   

   Better motility

   
   
2. 
   

   Treatment of endophthalmitis

   
   
3. 
   

   Less disruption of orbital anatomy

   
   
4. 
   

   Reduced risk of sympathetic ophthalmia

48. (Hard) Which of the following is true regarding the lacrimal drainage system?

1. 
   

   By the 10th week of gestation, the nasolacrimal groove forms as a furrow lying between the nasal and maxillary prominence.

   
   
2. 
   

   The canalicular system is an outgrowth of the lacrimal gland.

   
   
3. 
   

   Caudally, the developing nasolacrimal duct exits in the middle meatus.

   
   
4. 
   

   Canalization of the nasolacrimal duct is usually complete around the time of birth.

49. (Medium) Referring to the four images below, examining from images a to d in sequence, which description is the most accurate?

1. 
   

   Normal lacrimal sac, scrolling anterior to posterior

   
   
2. 
   

   Post dacryocystorhinostomy surgery, scrolling anterior to posterior

   
   
3. 
   

   Normal lacrimal sac, scrolling posterior to anterior

   
   
4. 
   

   Post dacryocystorhinostomy surgery, scrolling posterior to anterior

50. (Hard) The parents of a 3-month-old male infant note that he has been tearing excessively since birth, with occasional crusting of his eyelashes. There is no evidence of erythema, edema, or purulent discharge on examination. Which statement is true?

1. 
   

   The obstruction is presumed to be an imperforate valve of Rosenmuller.

   
   
2. 
   

   A dacryocystorhinostomy is the initial procedure of choice.

   
   
3. 
   

   This condition can rarely be associated with life-threatening respiratory compromise.

   
   
4. 
   

   Approximately 50% of symptomatic congenital nasolacrimal duct obstructions resolve in the first year of life.

51. (Hard) A 66-year-old woman comes in complaining of tearing bilaterally. You decide to perform testing in order to better understand the nature of her tearing. Which of the following tests are considered “physiologic?”

1. 
   

   Jones I

   
   
2. 
   

   Jones II

   
   
3. 
   

   Dacryoscintigraphy

   
   
4. 
   

   Dacryocystogram

   
   
5. 
   

   1 and 2

   
   
6. 
   

   3 and 4

   
   
7. 
   

   2 and 4

   
   
8. 
   

   1 and 3

52. (Easy) What are the correct locations and names of the valves in the tear drainage system?

1. 
   

   Middle meatus Hasner, upper canaliculus Rosenmuller

   
   
2. 
   

   Superior meatus Rosenmuller, lower canaliculus Hasner

   
   
3. 
   

   Inferior meatus Hasner, common canaliculus Rosenmuller

   
   
4. 
   

   Middle meatus Hasner, lower lacrimal sac Rosenmuller

53. (Easy) A medical student scrubs in on your dacryocystorhinostomy case. In an attempt to explain the procedure, which bones do you tell her you are planning to remove?

1. 
   

   Lacrimal and ethmoid

   
   
2. 
   

   Ethmoid and maxillary

   
   
3. 
   

   Maxillary and lacrimal

   
   
4. 
   

   Maxillary, lacrimal, and ethmoid

54. (Medium) What is the least urgent step in management of this patient?

1. 
   

   Incision and drainage

   
   
2. 
   

   Full eye examination

   
   
3. 
   

   Oral antibiotics

   
   
4. 
   

   Complete blood count

55. (Medium) A 34-year-old man presents with epiphora. Irrigation testing reveals a left nasolacrimal duct obstruction. Which is the best next step in management?

1. 
   

   CT orbits with contrast

   
   
2. 
   

   External dacryocystorhinostomy (DCR)

   
   
3. 
   

   Endoscopic DCR

   
   
4. 
   

   Contrast dacryocystography

56. (Hard) A 50-year-old man presents with painful and progressive proptosis and hypoglobus of the left eye for the last 6 months. Visual acuity is normal. Imaging reveals a well-circumscribed tumor in the left lacrimal gland. What is the best management for this condition?

1. 
   

   Tumor excision without biopsy

   
   
2. 
   

   Biopsy, tumor excision, and adjuvant proton therapy

   
   
3. 
   

   Neoadjuvant radiation, tumor excision, and chemotherapy without biopsy

   
   
4. 
   

   Biopsy, exenteration, and chemotherapy

57. (Hard) You perform probing and irrigation on a 57-year-old woman due to epiphora in the right eye. The puncta appear normal in size. She has prolonged dye disappearance test in the right eye. You encounter a “hard stop” when probing the upper and lower canaliculi. On irrigation testing of both canaliculi, there is no reflux and the patient senses fluid in the nasopharynx. What procedure would you recommend?

1. 
   

   None

   
   
2. 
   

   Balloon dacryoplasty

   
   
3. 
   

   Dacryocystorhinostomy

   
   
4. 
   

   Conjunctivodacryocystorhinostomy

58. (Medium) An otherwise normal 2-year-old child presents with epiphora. What is the best additional information to confirm the location of the blockage in this patient?

1. 
   

   None

   
   
2. 
   

   Duration of symptoms

   
   
3. 
   

   Results of canalicular probing

   
   
4. 
   

   MRI maxillofacial

59. (Medium) A 63-year-old man presents with an erythematous, hot medial lower lid. When placing pressure over the medial lid, purulent discharge is expressed from the punctum. You decide to perform a curative procedure in the office, and note several concretions are able to be removed. What is the most common cause of this finding?

1. 
   

   Trauma

   
   
2. 
   

   Actinomyces israelii

   
   
3. 
   

   Candida

   
   
4. 
   

   Idiopathic

60. (Medium) A 15-year-old adolescent boy presents with acute right upper lid swelling and pain. You notice an S shape to the lid, and he is tender to palpation superolaterally. Upon lifting his lid, you note purulent discharge from the lacrimal gland. What is the most common infectious cause of this condition?

1. 
   

   Gram-positive bacteria

   
   
2. 
   

   Epstein–Barr virus

   
   
3. 
   

   Tuberculosis

   
   
4. 
   

   Adenovirus

61. (Hard) An 87-year-old man presents for consultation for a right optic nerve lesion. On examination, his vision is 20/50 in the right eye; there is an afferent pupillary defect; there is inferior depression on his visual field; and he has 5 mm of proptosis. Below is his MRI scan (T1-weighted pre-gadolinium and post-gadolinium, respectively). Based on this appearance, which is the most likely diagnosis?

1. 
   

   Optic nerve glioma

   
   
2. 
   

   Optic nerve meningioma

   
   
3. 
   

   Cavernous hemangioma

   
   
4. 
   

   Solitary fibrous tumor

62. (Medium) A 6-year-old boy presents with no light perception vision and an optic nerve lesion as seen in the MRI and corresponding pathology. What genetic disorder is most often associated with this abnormality?

1. 
   

   Neurofibromatosis 1 (NF1)

   
   
2. 
   

   von Hippel–Lindau disease

   
   
3. 
   

   Neurofibromatosis 2 (NF2)

   
   
4. 
   

   Sturge–Weber syndrome

63. (Medium) A 72-year-old man presents with proptosis and downward displacement of the left eye with a scan showing a well-circumscribed, expansile sinus mass with bony erosion extending into the orbit. Which of the following is true of this lesion?

1. 
   

   Most commonly results from chronic noninvasive fungal sinusitis from the ethmoid sinus.

   
   
2. 
   

   Usually presents in children.

   
   
3. 
   

   MRI is the best imaging modality.

   
   
4. 
   

   The frontal sinus is the most common place for mucocele development to occur.

64. (Easy) A 6-year-old girl falls and hits her head while playing with her brother. On examination, her vision is intact, intraocular pressure (IOP) is within normal limits, and the motility in the right eye is severely limited in upgaze with associated double vision. Coronal and sagittal cut of her CT is shown below. What is the best next step in her management?

1. 
   

   Proceed to the OR immediately for exploration and management of the entrapped fracture.

   
   
2. 
   

   Reassure the parents that this will resolve over time on its own.

   
   
3. 
   

   Perform an emergent lateral canthotomy and cantholysis.

   
   
4. 
   

   Send the patient home and advise her to return to the clinic in a week for reevaluation.

65. (Easy) A 37-year-old man presents with an eyelid laceration after a neighbor’s pit bull bit him. Which of the following is not necessary when planning and performing a repair of a canalicular laceration?

1. 
   

   A complete ophthalmic examination, including a dilated examination, is recommended.

   
   
2. 
   

   Repair should be performed under general anesthesia.

   
   
3. 
   

   A stent should be left in place temporarily.

   
   
4. 
   

   The repair can be done within 24 to 72 hours after the injury.

66. (Medium) A 70-year old man presents to the emergency room after sustaining a fall while at home with a bicanalicular laceration and medial canthal tendon avulsion. Reattachment of the medial canthal tendon to which of the following structures is necessary for reconstruction of the normal eyelid anatomy?

1. 
   

   Anterior process of the maxilla

   
   
2. 
   

   Anterior lacrimal crest

   
   
3. 
   

   Lacrimal sac fossa

   
   
4. 
   

   Posterior lacrimal crest

67. (Easy) A 32-year-old man presents to the emergency room after getting punched in the right eye during a bar fight. Which of the following are indications for an emergent lateral canthotomy and cantholysis?

1. 
   

   Elevated IOP, limitation in upgaze

   
   
2. 
   

   Elevated IOP, decreased vision

   
   
3. 
   

   Limitation in upgaze, diplopia

   
   
4. 
   

   Diplopia, decreased vision

68. (Medium) A 65-year-old man trips on the sidewalk while walking his dog and falls onto his face sustaining an orbital floor fracture. What is not an indication to repair the fracture?

1. 
   

   Enophthalmos that exceeds 2 mm

   
   
2. 
   

   Diplopia in primary gaze with limitation in upgaze that persists for 2 weeks

   
   
3. 
   

   Hypoesthesia in the V2 distribution

   
   
4. 
   

   Fractures involving approximately 50% of the orbital floor

69. (Easy) A 25-year-old woman presents after getting assaulted with a large orbital floor fracture of the right eye, −1 limitation in upgaze, and 3 mm of enophthalmos. Which of the following is considered to be the optimal timing for repair of this fracture?

1. 
   

   Within 6 weeks following the injury

   
   
2. 
   

   Within 2 weeks following the injury

   
   
3. 
   

   Within 1 to 3 days following the injury

   
   
4. 
   

   Within 24 hours of injury

70. (Hard) A patient presents concerned after an MRI performed for headaches reveals the following (see figure). Which of the following is true regarding lesions such as this?

1. 
   

   Pathology is characterized by “staghorn” vascular sinusoids.

   
   
2. 
   

   Usually presents with significant pain that improves with steroids.

   
   
3. 
   

   May be treated with propranolol.

   
   
4. 
   

   Represents the most common benign orbital tumor in adults.

71. (Easy) This is an 8-year-old girl who presented with significant proptosis and hypoglobus in the right eye. Which of the following subtype is associated with the worst prognosis?

1. 
   

   Botryoid

   
   
2. 
   

   Embryonal

   
   
3. 
   

   Alveolar

   
   
4. 
   

   Pleomorphic

72. (Hard) Which of the following statements is true about the most likely entity shown in the figure below?

1. 
   

   Most commonly B-cell-associated.

   
   
2. 
   

   Most commonly T-cell-associated.

   
   
3. 
   

   About 90% is associated with systemic disease.

   
   
4. 
   

   About 80% presents in the lacrimal fossa.

73. (Easy) If planning a biopsy of the above lesion, what is the most appropriate way to submit the tissue to pathology?

1. 
   

   Formalin-fixed

   
   
2. 
   

   Fresh

   
   
3. 
   

   Frozen

   
   
4. 
   

   Alcohol-fixed

74. (Hard) An 8-month-old female infant presented with a bruise around her eye, abnormal eye movements, and a mass in her adrenal gland. Her scan is shown below. Which of the following statements about her condition is true?

1. 
   

   Almost 90% survival when present in patients younger than 1 year.

   
   
2. 
   

   Debulking of the orbital mass should be performed.

   
   
3. 
   

   Associated with ocular apraxia.

   
   
4. 
   

   Should obtain serum catecholamine levels.

75. (Hard) A 60-year-old woman presents with sudden proptosis of the left eye and periorbital ecchymosis around the eye. She recently recovered from an upper respiratory infection. Imaging shows lesions with fluid levels. Which of the following is not an appropriate treatment option?

1. 
   

   Refer to interventional radiology for sclerotherapy.

   
   
2. 
   

   Observe with or without steroidal therapy.

   
   
3. 
   

   Perform an orbitotomy with debulking of the lesion.

   
   
4. 
   

   Refer for orbital radiotherapy.

76. (Medium) A 35-year-old woman presents with 3 months of boring pain around the right eye. CT imaging demonstrates a poorly circumscribed lesion in the lacrimal fossa with bone destruction. Which is the most likely diagnosis?

1. 
   

   Pleomorphic adenoma

   
   
2. 
   

   Adenoid cystic carcinoma of the lacrimal gland

   
   
3. 
   

   Adenocarcinoma of the lacrimal gland

   
   
4. 
   

   Nonspecific orbital inflammation

77. (Medium) A 23-year-old man gets hit in the face with a softball while playing second base during a recreational game. Imaging demonstrates a right-sided small orbital floor fracture extending to the orbital rim and ipsilateral disruption of the zygoma. All of the following except which one can be associated with this type of fracture?

1. 
   

   Trismus

   
   
2. 
   

   V2 hypoesthesia

   
   
3. 
   

   Epiphora

   
   
4. 
   

   Lateral canthal dystopia

78. (Easy) A 65-year-old woman presents with a metastatic mass of the left orbit. What is the most likely site of origin?

1. 
   

   Lung

   
   
2. 
   

   Colon

   
   
3. 
   

   Breast

   
   
4. 
   

   Melanoma

79. (Hard) A 44-year-old woman presents with a slowly progressive distortion of the globe such that it appears to be pushed inferomedially. You palpate a firm mass in the superolateral quadrant of the orbit. Which of the following is most likely false about this mass?

1. 
   

   Most common benign epithelial neoplasm of the lacrimal gland.

   
   
2. 
   

   Excision should be performed to avoid rupture of tumor’s pseudocapsule.

   
   
3. 
   

   Characterized by gradual progressive proptosis with no associated pain.

   
   
4. 
   

   Has the potential of transforming into adenoid cystic carcinoma.

80. (Medium) Which of the following scenarios involving an orbital foreign body requires urgent exploration?

1. 
   

   History of tripping over a bush and falling on eye while running from police with evidence of air pockets in the orbit on CT scan

   
   
2. 
   

   BB pellet in the posterior orbit with otherwise normal examination

   
   
3. 
   

   Shards of shrapnel in the orbit with associated sclopetaria after a bomb explosion

   
   
4. 
   

   History of being ejected from the windshield after a car accident

81. (Medium) A 90-year-old woman comes to you with tearing, worse in the wind and cold. She notes that her tears well up laterally and run down her face. Her lower lids are well opposed to the globe with no signs of trichiasis or in-turning of the eyelid. You note a snap test of 10 seconds and a distraction test of 10 mm. A trial of taping the lower lid laterally results in complete resolution of her symptoms. What condition does this woman likely suffer from?

1. 
   

   Functional nasolacrimal duct obstruction

   
   
2. 
   

   Cicatricial ectropion

   
   
3. 
   

   Involutional ectropion

   
   
4. 
   

   Involutional entropion

82. (Hard) You are asked to see a 97-year-old woman patient whose “lower lids are hanging.” On examination, you note bilateral outward-turning lids with significant horizontal eyelid laxity. There are no associated cicatricial changes or skin lesions. Which of the following conditions can be corrected by horizontal eyelid shortening alone?

1. 
   

   Cicatricial ectropion

   
   
2. 
   

   Involutional ectropion

   
   
3. 
   

   Spastic entropion

   
   
4. 
   

   Mechanical ectropion

83. (Medium) Which of the following is not a feature of this condition?

1. 
   

   Horizontal eyelid laxity

   
   
2. 
   

   Posterior lamellar scaring

   
   
3. 
   

   Overriding by the preseptal orbicularis

   
   
4. 
   

   Disinsertion of the lower eyelid retractors

84. (Easy) A 70-year-old man comes to you with pain, photophobia, and tearing of the right eye. On examination, you note in-turning of the right lower eyelid. You also note significant horizontal eyelid laxity and inferior corneal staining. Which of the following procedures could not temporarily improve his signs and symptoms?

1. 
   

   chemodenervation of the lower lid orbicularis

   
   
2. 
   

   Quickert’s sutures

   
   
3. 
   

   Eyelid taping

   
   
4. 
   

   Medial spindle procedure

85. (Hard) A young child presents to you for a routine eye examination after his pediatrician noticed atypical-appearing eyelids. His parents are nonplussed (see figure). Which type of epicanthus is correctly paired with its description?

1. 
   

   Epicanthus tarsalis—the fold is most prominent in the lower eyelid.

   
   
2. 
   

   Epicanthus tarsalis—the fold is most prominent in the upper eyelid.

   
   
3. 
   

   Epicanthus palpebralis—the fold is most prominent in the lower eyelid.

   
   
4. 
   

   Epicanthus palpebralis—the fold is most prominent in the upper eyelid.

86. (Hard) A 3-year-old child presents with vertically positioned lower eyelashes. The lower eyelid lashes are noted to be touching the inferior cornea when the child looks down. There is no staining of the cornea, and the parents have not noted any eye redness or apparent discomfort. Which of the following is the most appropriate treatment option?

1. 
   

   A skin and muscle flap should be excised in the area of the misdirected lashes in order to prevent corneal decompensation.

   
   
2. 
   

   The child should be observed and followed carefully for any signs of corneal decompensation.

   
   
3. 
   

   The lashes should be epilated to prevent corneal decompensation.

   
   
4. 
   

   A lateral tarsal strip with reinsertion of the lower eyelid retractors should be performed.

87. (Medium) A 56-year-old man with a history of obesity presents to clinic complaining of mucous discharge and eye irritation. You note easy eversion of the upper eyelids and a chronic papillary conjunctivitis of the upper eyelid. Which of the following conditions is not associated with his ocular problem?

1. 
   

   Obstructive sleep apnea

   
   
2. 
   

   Christmas tree cataract

   
   
3. 
   

   Keratoconus

   
   
4. 
   

   Obesity

88. (Easy) A 14-year-old adolescent girl comes to you for routine eye examination. Her mother mentions that she is an honor roll student and currently applying college. On examination, you note areas of madarosis and lashes in different stages of regrowth. Her eyelid skin appears normal and she has no past medical history. What is the most likely diagnosis?

1. 
   

   Sebaceous cell carcinoma

   
   
2. 
   

   Thyroid eye disease

   
   
3. 
   

   Trichotillomania

   
   
4. 
   

   Merkel cell carcinoma

89. (Medium) You see a 9-year-old boy demonstrated in the figure below. His father has similar eyelid features. What is the inheritance pattern of this condition?

1. 
   

   Autosomal recessive

   
   
2. 
   

   Autosomal dominant

   
   
3. 
   

   X-linked

   
   
4. 
   

   X-linked recessive

90. (Easy) A 35-year-old woman with rosy cheeks complains of a “bump” of her right upper eyelid for approximately 6 months. On examination, you note meibomian gland inspissation in both eyelids and a red firm elevated lesion that appears to be internal to the tarsus. She has been using warm compresses with a warming facial mask and lid massage for the past 3 months without improvement. Which of the following would you recommend?

1. 
   

   Oral trimethoprim–sulfamethoxazole

   
   
2. 
   

   Incision and curettage

   
   
3. 
   

   Ofloxacin eyedrops

   
   
4. 
   

   Artificial tears

91. (Easy) A 93-year-old woman with no history of skin cancer presents to you for routine eye examination. You note a 1 × 1 mm pigmented lesion of her left lower lid. The lesion is uniform in color, non-ulcerating, and does not distort the eyelid margin. You note multiple lashes growing through the lesion. Which of the following is not a clinical sign suggesting eyelid malignancy?

1. 
   

   Swelling

   
   
2. 
   

   Ulceration

   
   
3. 
   

   Madarosis

   
   
4. 
   

   Distorted margin architecture

92. (Medium) A 67-year-old Irish runner presents with the eyelid lesion depicted. She notes the lesion occurred gradually over the past several months. What is the most appropriate treatment?

1. 
   

   External photographs and observation

   
   
2. 
   

   Warm compresses and lid massage

   
   
3. 
   

   Incisional biopsy for diagnosis

   
   
4. 
   

   Intralesional steroid injection

93. (Hard) An 80-year-old woman is referred to you for a second opinion regarding a chalazion of her right upper lid. The referring physician has drained the lesion three times, but the lesion has not resolved and continues to grow. You send an excisional biopsy of the lesion, and the pathology comes back consistent with adenocarcinoma. Which of the following statements regarding adenocarcinoma is incorrect?

1. 
   

   Wide surgical excision with map biopsies of the conjunctiva should be performed.

   
   
2. 
   

   Orbital exenteration may be considered.

   
   
3. 
   

   Sentinel lymph node biopsy may be considered.

   
   
4. 
   

   Excisional biopsy is frequently all that is required.

94. (Hard) You have diagnosed a 70-year-old man with melanoma of the upper eyelid by excisional biopsy. Your wide margins are clear, and there are no signs of vascular or lymphatic invasion on pathology. Your patient is happy with your periocular reconstruction and asks you more about malignant melanoma in the periocular region. Which of the following statements is incorrect?

1. 
   

   Primary cutaneous melanoma of the eyelid is relatively common, accounting for approximately half of eyelid malignancies.

   
   
2. 
   

   Primary cutaneous melanoma of the eyelid is rare, accounting for less than 0.1% of eyelid malignancies.

   
   
3. 
   

   Lentigo maligna melanoma, nodular melanoma, superficial spreading melanoma, and acral lentiginous melanoma are the four types of cutaneous melanoma that may affect the eyelid.

   
   
4. 
   

   Thin lesions (< 0.75 mm) have a high 5-year survival rate (98%).

95. (Medium) You are examining a patient in the emergency room who sustained a penetrating injury to the lower eyelid during a motor vehicle collision. A CT of the orbits reveals no foreign body or orbital fractures. On your examination, you note normal visual acuity, pupils, extraocular motility, slit lamp examination, and dilated fundus examination findings. You note a central lower eyelid laceration 10 mm in length, which does not involve the eyelid margin or canalicular system. A small amount of orbital fat is visible through the wound. Which of the following statements is correct regarding your repair?

1. 
   

   The presence of orbital fat indicates that the orbital septum has been violated, and the patient requires surgical exploration and repair of the lower eyelid focusing on meticulous closure of the orbital septum.

   
   
2. 
   

   The presence of orbital fat in the wound is of no clinical significance, and the orbital septum has not necessarily been violated.

   
   
3. 
   

   The presence of orbital fat in the wound indicates the orbital septum has been violated, and the wound should be carefully explored for signs of foreign bodies and copiously irrigated. The orbital septum should not be sutured, but the overlying orbicularis and skin should be closed.

   
   
4. 
   

   The laceration is relatively small, and therefore, the wound should be left to heal by secondary intension.

96. (Medium) You are examining a 24-year-old man in the emergency room who has sustained a full-thickness eyelid laceration involving the upper lid margin from a dog bite. The laceration is in the center of the eyelid. Which of the following statements is correct regarding your treatment?

1. 
   

   The patient should immediately receive systemic antibiotics and tetanus vaccine; the eyelid lesion should be copiously irrigated and repaired.

   
   
2. 
   

   During the repair, full-thickness tarsal bites should be taken above the eyelid margin to ensure adequate closure.

   
   
3. 
   

   Permanent marginal sutures should always be used to repair the eyelid margin.

   
   
4. 
   

   The patient should immediately receive systemic antibiotics, tetanus vaccine, and copious irrigation. However, repair of the laceration should be delayed several days to ensure that there are no signs of infection.

97. (Hard) A 79-year-old woman presents to you for lower eyelid reconstruction following Mohs’ surgery for a basal cell carcinoma. The canalicular system and canthal tissues are uninvolved. Which of the following is unlikely to be a viable surgical option for this patient?

1. 
   

   A tarsoconjunctival flap from the upper eyelid is used to reconstruct the posterior lamella of the lower eyelid, and a skin graft is used to reconstruct the anterior lamella of the upper eyelid.

   
   
2. 
   

   A tarsoconjunctival flap from the upper eyelid is used to reconstruct the posterior lamella of the lower eyelid, and a skin advancement flap is used to reconstruct the anterior lamella of the upper eyelid.

   
   
3. 
   

   A free tarsoconjunctival graft from the opposite upper eyelid is used to reconstruct the posterior lamella of the lower eyelid, and a skin graft is used to reconstruct the anterior lamella of the upper eyelid.

   
   
4. 
   

   A free tarsoconjunctival graft from the opposite upper eyelid is used to reconstruct the posterior lamella of the lower eyelid and a skin-muscle flap is used to reconstruct the anterior lamella of the upper eyelid.

98. (Medium) A 68-year-old man presents to you for upper eyelid reconstruction following Mohs’ surgery for a squamous cell carcinoma. You note that the upper eyelid defect is small, involving approximately 30% of the upper eyelid. The canalicular system and canthal tissues are uninvolved. Which of the following is likely the best surgical option for this patient?

1. 
   

   Full-thickness lower eyelid advancement flap (Cutler–Beard procedure)

   
   
2. 
   

   Free tarsoconjunctival skin graft from the opposite upper eyelid and free postauricular skin graft

   
   
3. 
   

   Primary closure of the defect with superior crus lateral cantholysis if necessary

   
   
4. 
   

   Tarsoconjunctival flap from the lower lid with a free postauricular skin graft

99. (Hard) A 76-year-old farmer presents to you for reconstruction following excision of an advanced basal cell carcinoma of the medial canthus. The defect is large and extends onto the lateral nasal side wall. There is no involvement of the canalicular system. Which of the following is the most viable surgical option for him?

1. 
   

   Healing by secondary intension

   
   
2. 
   

   Free skin graft

   
   
3. 
   

   Undermining with direct closure

   
   
4. 
   

   Forehead or glabellar flap

100. (Medium) You see a young man in the emergency room after a physical altercation with a friend. The patient believes his friend’s finger pulled offhis lower eyelid. You are suspicious for lower eyelid medial canthal avulsion. His vision, pupils, pressure, extraocular motility, slit lamp examination, and dilated fundus examination are all normal. He has no orbital fractures on CT can. Which of the following is not a critical next step in your examination?

1. 
   

   Dilation and probing of puncta with irrigation

   
   
2. 
   

   Looking for signs of medial canthal rounding

   
   
3. 
   

   Gonioscopy

   
   
4. 
   

   Grasping the lid with toothed forceps and gently tugging away from the injury while palpating the insertion of the tendon