Chapter 9 Uveitis
9.1 Questions
Easy | Medium | Hard |
Consider the following case for questions 1 and 2:
1. (Easy) A 32-year-old male patient presents with a 3-day history of pain, photophobia, and decreased vision in the left eye. The patient denies any prior medical history. On slit lamp examination, there is evidence of nongranulomatous keratic precipitates, 3+ cell in the anterior chamber, and moderate-to-severe vitritis in the left eye. Work-up shows a positive rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption test (FTA-ABS). What other test would be imperative to order based on this diagnosis?
Human immunodeficiency virus (HIV) testing
Angiotensin-converting enzyme (ACE) and lysozyme
Human leukocyte antigen B27 (HLA-B27)
Herpes simplex virus (HSV) 1 and 2 and varicella-zoster virus (VZV) titers
2. (Medium) What is the best treatment recommended for a patient with syphilitic uveitis?
Intramuscular ceftriaxone for 10 days followed by oral prednisone
Aqueous crystalline penicillin G IV for 10 to 14 days with topical corticosteroids
Benzathine penicillin G single dose and topical corticosteroids
Benzathine penicillin G daily with probenecid for 10 to 14 days
3. (Medium) A 27-year-old female patient with history of multiple sclerosis presents to you as a consult for the management of her uveitis. She was diagnosed with intermediate uveitis in both eyes 9 months ago and has been unable to taper oral prednisone below 20 mg without having recurrence of inflammation. When considering immunosuppression therapy, which of the following drugs should be avoided?
Mycophenolate mofetil
Adalimumab
Methotrexate
Azathioprine
4. (Hard) Which of the following has the strongest human leukocyte antigen (HLA) association with ocular disease?
HLA-B27 and psoriatic arthritis
HLA-B7 and ocular histoplasmosis
HLA-B51 and Behcet’s disease
HLA-A29 and birdshot chorioretinopathy
5. (Medium) A 26-year-old woman presents for evaluation after coming back from a cruise and reporting vision changes in her right eye for the past 3 days. She describes her vision as blurry with a central area where she sees many dots. Her left eye is asymptomatic. Two weeks prior to the trip, she experienced cold symptoms, including a runny nose. On examination, her vision is 20/50 OD and 20/20 OS. There is no anterior chamber or vitreous cell. On followup 2 weeks after the initial examination, the vision improves to 20/30 OD, and fundus examination only shows perifoveal granularity. Optical coherence tomography (OCT) is shown. Given the most likely diagnosis, what would you tell this young patient about the prognosis?
Aggressive treatment with steroids and immunomodulatory therapy is mandatory to avoid blindness.
The disease is known to cause multiple relapses.
The disease course is typically self-limiting, and prognosis is excellent.
She should have regular examinations to check for involvement of the other eye, which is common.
6. (Easy) A 36-year-old myopic woman with a prescription of –3.00 OU presents due to acute vision loss of her left eye and metamorphopsia. On examination, her best corrected visual acuity is 20/200 OD and 20/20 OS. Slit lamp examination is unremarkable OU. Posterior examination shows clear vitreous and multiple deep yellow-white lesions of about 100 to 200 µm in size in both eyes. The right eye also has a grayish perifoveal elevation, confirmed to be a choroidal neovascular membrane on optical coherence tomography (OCT). What is the most common presumed diagnosis?
Presumed ocular histoplasmosis syndrome
Multifocal choroiditis with panuveitis
Punctate inner choroidopathy (PIC)
Birdshot chorioretinopathy
7. (Easy) A 16-year-old adolescent girl with a history of juvenile idiopathic arthritis (JIA) comes to have her regular eye examination. She is currently asymptomatic. On slit lamp examination, she has 5 cells/high-power field (hpf) in the anterior chamber of her right eye with faint haze and 26 cells/hpf in her left eye with a hazy view of the iris and lens details. The rest of the anterior and posterior examination is within normal limits. How would you grade the patient’s degree of anterior-chamber cell and flare using the Standardization of Uveitis Nomenclature (SUN) criteria?
0.5+ cell and 1+ flare OD/3+ cell and 3+ flare OS
0.5+ cell and 0.5+ flare OD/3+ cell and 3+ flare OS
1+ cell and 1+ flare OD/2+ cell and 2+ flare OS
1+ cell and 1+ flare OD/3+ cell and 2+ flare OS
8. (Hard) A 25-year-old woman is diagnosed with chronic anterior uveitis OU and has been unable to taper off topical steroids, so immunosuppression therapy is recommended to control her disease. After discussing risks versus benefits of the possible therapies, methotrexate (MTX) is decided to be adequate as a first-line treatment. When she is about to leave the room, the patient asks you if she is going to be able to have kids in the future. Which of the following is the best way to approach this question?
Tell the patient she needs to avoid sexual intercourse for the duration of the treatment since there’s always a risk of pregnancy.
Educate the patient about the risk of pregnancy while on immunomodulatory therapy (IMT) and consult your OB/GYN colleague to further discuss contraception options.
Start the treatment and tell the patient that her concerns will be discussed at the next visit.
Tell the patient that IMT needs to be started to avoid vision loss and complications associated with topical steroids and that it may permanently affect her ability to conceive in the future.
9. (Medium) A 76-year-old male patient, who had uncomplicated cataract surgery 1 year ago in his right eye and 3 months ago in his left eye, presents due to chronic inflammation in his left eye that worsened after a YAG capsulotomy done 1 month postoperatively. Inflammation improves with topical steroids but recurs every time he tries to discontinue them. On examination, his best-corrected visual acuity is 20/20 OD and 20/40 OS; he has granulomatous inflammation OS with anterior chamber and vitreous cell. No hypopyon is identified. Posterior examination shows a slightly hazy view of the retina but no focal areas of retinitis. Examination of the right eye is within normal limits. What is the next best step in the management of this patient?
Increase the dose of topical steroids to every 1 hour, and follow up in 1 week.
Pars plana vitrectomy (PPV) with injection of intravitreal antibiotics.
Intraocular lens (IOL) explantation with complete capsulectomy and intravitreal vancomycin.
Obtain aerobic, anaerobic, and fungal cultures, Gram and Giemsa stain, and inject intravitreal antibiotics.
10. (Hard) A 71-year-old female pseudophakic patient with a past medical history of hypertension reports floaters in both eyes for the past 6 months. An initial infectious work-up that included syphilis, tuberculosis (TB), and Lyme testing was negative. She was treated with topical steroids and later periocular steroids, but her inflammation returned once the effect of the injection was gone. She was scheduled for a vitrectomy in her left eye; the vitreous specimen is shown. Based on the findings, which of the following tests would you order next?
Erythrocyte sedimentation rate (ESR) and temporal artery biopsy
Complete blood count (CBC) and lymph node biopsy
MRI brain/lumbar puncture
CT head and orbits
11. (Medium) A 14-year-old adolescent boy with no prior medical history presents due to decreased vision in his left eye. He denies pain, redness OS, or any symptoms in the right eye. On examination, his vision is 20/25 OD and 20/400 OS. Slit lamp examination is unremarkable OU. There is evidence of an afferent pupillary defect (APD) in the left eye, and fundus examination shows arteriolar narrowing with diffuse retinal pigment epithelium (RPE) degeneration and optic nerve atrophy OS. The right eye is within normal limits. What is the next step in establishing a diagnosis?
Fluorescein angiography and indocyanine green (ICG) angiography
Electroretinogram (ERG)
Examine the fundus of his siblings and/or parents
Genetic testing
12. (Easy) A 25-year-old male patient with no prior medical or ocular history presented to an ophthalmologist complaining of blurry vision, floaters, pain, and light sensitivity in the left eye. His vision was 20/20 OD and 20/50 OS. He had a normal anterior examination OD, but 3+ cell OS with 2+ flare OS. The patient deferred dilation at the time; he was started on topical steroids every 1-hour OS with an appointment to return in 1 week. When he returns to his follow-up, he reports that his vision has decreased significantly and is now CF OS. On examination, the patient has 2+ cell with 2+ flare OS, and on dilation, there is evidence of dense vitritis with 3+ haze and large areas of retinal necrosis coalescing in the periphery. The patient sees you for a second opinion and asks how it is possible that his vision deteriorated so much if he was evaluated only a week before. How would you best approach this possible diagnostic error with your patient?
“Tell the patient that he should sue the previous doctor for failing to diagnose acute retinal necrosis on his first visit.”
“Start treatment with intravitreal foscarnet, do an a/c tap for viral polymerase chain reaction (PCR), and tell the patient that he needs to forget about the past.”
“Send him to the prior ophthalmologist to start treatment for possible acute retinal necrosis.”
“Start treatment right away and explain to the patient that infections in the eye tend to progress quickly and it is possible that the retinal findings were not present on the first visit, although dilation should always be performed in new cases of uveitis.”
13. (Medium) A 43-year-old Hispanic patient with no past medical history presents to the urgent care due to sudden-onset pain, redness, and light sensitivity in the left eye for 2 days. He also reports blurry vision and floaters. He denies any symptoms in the right eye. Fundus examination and fluorescein angiography OS is demonstrated. Which of the following is false based on the most likely diagnosis?
It is the most common cause of infectious posterior uveitis.
Neuroimaging is warranted for all patients with bilateral disease.
It usually reactivates adjacent to a previous scar, but there could be multiple lesions or bilateral involvement.
Segmental arterial plaques, known as Kyrieleis’ arteriolitis, could be seen.
14. (Easy) What is the mechanism of action of nonsteroidal anti-inflammatory drugs (NSAIDs)?
Inhibition of phospholipase A2
Inhibition of inosine monophosphate dehydrogenase
Inhibition of cyclooxygenase (COX-1 and -2) resulting in reduced synthesis of prostaglandins
Inhibition of neutrophil migration and T-lymphocyte activation
15. (Easy) Juvenile idiopathic arthritis (JIA)-associated uveitis is most common in which of the following?
Early-onset pauciarticular disease
Late-onset pauciarticular disease
Still’s disease
Early-onset polyarticular disease
16. (Easy) Which medication has been associated with a sterile hypopyon anterior uveitis?
Indinavir
Cidofovir
Pentamidine
Entecavir
17. (Easy) A 48-year-old male patient presents for evaluation due to pain, tenderness, and marked redness in both eyes for the past 2 weeks. He also has had recent breathing problems and has been diagnosed with an atypical reactive airway disease. On examination, there are signs of scleritis in both eyes. Laboratory evaluation shows negative antinuclear antibody (ANA), anti–double-stranded DNA (antidsDNA) and perinuclear antineutrophil cytoplasmic antibody (p-ANCA) studies but positive cytoplasmic ANCA (c-ANCA). What is the pathophysiology of the suspected diagnosis?
Necrotizing granulomatous vasculitis of the upper and lower respiratory tract and of small arteries and veins
Arterial occlusive disease with no venous involvement
Formation of noncaseating granulomas with Langerhans’ multinucleated cells
Immune complex deposition in the basement membrane
18. (Easy) A 32-year-old male patient with history of recurrent anterior uveitis OS presents for evaluation due to a possible new flare-up. His past medical history is positive for ankylosing spondylitis. On examination, his vision is 20/20 and 20/50 with normal intraocular pressure. Slit lamp examination is unremarkable OD but demonstrates 4+ cell with 4+ flare OS with early posterior synechiae. With regard to the most likely diagnosis, what other area may be inflamed apart from the eye and lumbosacral spine?
Heart
Brain
Kidneys
Liver
19. (Easy) A 35-year-old man with no prior medical history developed a diarrheal illness 2 weeks ago. He went to urgent care because he is also having pain in his knees and is having discomfort with urination. From urgent care he was referred to you because his eyes are red and irritated. Which one of the following concerning the most likely diagnosis is false?
Almost 90% of cases are in men.
It may follow a bout of urethritis.
Skin lesions may be present.
The most common finding is anterior uveitis.
20. (Medium) A 45-year-old woman from Mississippi presents for her initial evaluation after noticing that her vision is not as good in her left eye. She has never been diagnosed with any medical or ocular conditions. On examination, her vision is 20/20 and 20/80 and on Amsler’s grid, she notices a central distortion in her left eye. Slit lamp examination shows a quiet anterior-chamber OU with clear vitreous. Fundus examination shows bilateral peripapillary atrophy and multiple small, white, atrophic chorioretinal scars in both eyes. Her left eye also has a macular scar with an adjacent area of subretinal discoloration. Which of the following concerning the presumed diagnosis is true?
Maculopathy generally precedes the formation of punched-out lesions.
The vitritis associated with the condition may decrease vision.
Fundus lesions in their acute phase represent a retinitis with a secondary choroidal reaction.
A patient with a macular histoplasmosis spot has about one-in-four chance of active maculopathy over the next 3 years.
21. (Medium) Potential adverse effects of the pharmacologic management of toxoplasmosis include all of the following except which one?
Pseudomembranous colitis
Stevens–Johnson syndrome
Microcystic anemia
Aggravation of diabetes mellitus
22. (Hard) A 38-year-old male patient presents due to pain, redness, and decreased vision in the right eye for 2 days. He denies any prior medical history. Review of systems is remarkable for occasional oral ulcers in the gums and tongue. He also had a genital ulcer once. His vision is 20/400 OD and 20/20 OS. On slit lamp examination, there is a 1.5-mm hypopyon with 4+ anterior-chamber cell and posterior synechiae. The fluorescein angiography OD is shown. Based on the most likely diagnosis, which of the following is true?
Ocular disease is bilateral in only 30% of cases.
Steroids are always required and are generally used as long-term therapy.
The pathophysiology is a nongranulomatous necrotizing obliterative vasculitis.
There are no cardiovascular risks associated with the presumed diagnosis.
23. (Hard) A 23-year-old African American male patient presents to urgent care complaining of pain, redness, light sensitivity, and blurry vision in both eyes. He has no prior medical history or history of trauma. Review of systems is positive for tinnitus and headaches. His vision was 20/40 OU but distorted. Slit lamp examination shows 3+ cell and 2+ flare in the anterior chamber with early posterior synechiae formation. Fundus examination shows vitritis and multiple areas of retinal elevation with serous retinal detachments. What is the typical fluorescein angiography pattern seen in the most likely diagnosis?
A smoke stack of leakage into subretinal space
Multiple pinpoint areas of fluorescein into the subretinal space
Diffuse retinal venous staining and leakage
Well-defined lacy hyperfluorescence with late leakage
24. (Easy) Early findings in Vogt-Koyanagi-Harada (VKH) syndrome include all the following except which one?
Serous retinal detachments
Tinnitus
Granulomatous anterior segment inflammation
Vitiligo
25. (Easy) A 55-year-old female patient with sympathetic ophthalmia was treated with high-dose oral prednisone and had resolution of her serous retinal detachments. The dose has been gradually decreased, and 4 months into therapy, she is on prednisone 20 mg daily without major side effects. She is on topical prednisolone acetate 1% four times a day and her visual acuity is 20/30 OD and HM OS. There are 2+ cells in the anterior chamber of both eyes with no vitritis, cystoid macular edema, or subretinal fluid. What is the most appropriate next step?
Start steroid-sparing immunotherapy.
Increase prednisone to 40 mg followed by slower taper.
Periocular injections of triamcinolone.
Increase topical steroids to every 2 hours and continue to taper oral prednisone.
26. (Medium) A 22-year-old man from New York presents with redness, pain, and photophobia in both eyes. He also notices floaters and blurry vision. On review of systems (ROS), he denies any previous illness, sick contacts, tick bites, or travel abroad. He did go on a hiking trip a few weeks ago. He mentioned that he had a rash in his thigh but it disappeared. On examination, he has evidence of anterior and intermediate uveitis with no retinal involvement. Which of the following is true regarding the most likely diagnosis and uveitis?
The recommended treatment for this type of uveitis with severe posterior segment manifestations requires intravenous antibiotic therapy.
Laboratory criteria for the diagnosis of the underlying pathology only consists of the isolation of borrelia Burgdorferi.
Ocular involvement has not been reported in stage 1 manifestations.
It is transmitted to humans through the bite of infected Ixodes burgdorferi.
27. (Hard) A 36-year-old female patient is referred from optometry due to her fundus findings. Patient reports minimal pain and redness in the right eye for the last 2 weeks. On initial evaluation, her vision is 20/20 OU and her fundus examination is seen in the figure. What would you expect to see in this patient’s fluorescein angiography?
Early hyperfluorescence with late leakage of the lesions
Early hypofluorescence due to blockage of choroidal staining and late staining of the active edge
Early hypofluorescence with late staining of acute active lesions
Early hyperfluorescence that fades in the late phases
28. (Easy) A 48-year-old female patient presents for a second opinion due to lack of improvement of her eye redness and severe tenderness that has been present for the past 3 weeks. She has no prior medical history and no known drug allergies. Patient was prescribed loteprednol drops four times a day OU, which the patient admits is using regularly but has not seen any improvement. Which of the following is false regarding the treatment of scleritis?
If initial nonsteroidal anti-inflammatory drug (NSAID) fails, a second should be tried before switching to corticosteroids.
Systemic corticosteroids remain the mainstay of noninfectious scleritis.
Subconjunctival injection of corticosteroids is indicated on severe cases concerning for necrosis.
Scleral reinforcement surgery may be needed to avoid globe rupture.
29. (Easy) A 37-year-old male patient arrives to your office with 1-day history of pain, redness, and photophobia in the left eye. He admits he had a previous episode of “eye inflammation” 10 years ago in the same eye. He denies any past medical history, and review of systems (ROS) is positive for chronic low back pain, but he admits he does a lot of heavy lifting. On examination, there are 4+ cell in the anterior-chamber OS with fibrin and multiple posterior synechiae. What would be the most appropriate test to determine the possible diagnosis based on this patient’s history?
Spine CT Scan
Anterior-chamber paracentesis
Fluorescein angiography and OCT macula
Sacroiliac plain X-ray
30. (Medium) A 21-year-old female patient with no prior medical history goes to the university medical center with history of arthralgia, fever, fatigue, and loss of appetite. Upon questioning, she also admits her eyes have been red and blurry. Upon evaluation by ophthalmology, she has KPs, 2+ anterior chamber cells OU, and posterior synechiae OU. Fundus examination is within normal limits. Laboratory results ordered in the walk-in clinic showed elevated erythrocyte sedimentation rate (ESR), proteinuria, and white cell casts. Which of the following is not part of the criteria for a clinical diagnosis of this syndrome?
Associated systemic illness with possible elevated ESR and eosinophilia
Abnormal urinalysis with increased B2 microglobulin, proteinuria, and presence of eosinophils, pyuria or hematuria, white cell casts, and glucosuria
Abnormal serum creatinine level or decreased creatinine clearance
Renal biopsy
31. (Medium) A 35-year-old woman from the Midwest region of the United States experienced loss of vision in the left eye to a level of 20/400. Examination revealed multiple discrete choroidal scars. The vision subsequently improved to 20/30, but a relapse occurred, and the visual acuity OS declined to count fingers. The funduscopic findings in the left eye are illustrated in the figure. Cells were present in the posterior vitreous. Fluorescein angiography revealed staining of the retinal pigment epithelial (RPE) lesions in the right eye. Which of the following clinical entities is most consistent with this clinical presentation?
Multifocal choroiditis with panuveitis (MCP)
Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)
Birdshot chorioretinopathy
Presumed ocular histoplasmosis (POHS)
32. (Medium) Which of the following is the most appropriate instruction to a patient beginning oral cyclophosphamide therapy?
The patient should take 1 mg of folic acid daily.
The patient should get the live influenza vaccine every year.
The patient should maintain adequate hydration.
The medication should be taken on an empty stomach and should avoid dairy products.
33. (Medium) Which of the following findings is least likely manifestation of systemic lupus erythematosus (SLE)?
Cotton wool spots with intraretinal hemorrhages
Scleritis
Chronic anterior uveitis
Serous retinal detachment
34. (Hard) A 57-year-old female patient presented to the emergency room with acute vision loss of her right eye with pain and photophobia for the past 3 days. She has past medical history of coronary artery disease (CAD) and hypertension (HTN). No prior ocular history. On examination, she has nongranulomatous keratic precipitates, 3+ anterior chamber cell, and moderate vitritis with retinal examination OD seen in the figure. Right eye examination is unremarkable. Intraocular pressure is 32 mm Hg OD and 16 mm Hg OS. Which of the following is true regarding the most likely diagnosis?
The posterior pole is typically involved early in the disease.
Polymerase chain reaction (PCR) is the most sensitive, specific, and rapid diagnostic method for detecting the causative organism.
Pathophysiology is occlusive vasculopathy of venous system only.
The most common causative organism is herpes simplex virus 2 (HSV-2).
35. (Hard) A 23-year-old college student presents for evaluation due to decreased vision in the right eye with mild redness. She denies any trauma or previous medical conditions, and has not traveled recently, though she did move in with a new roommate and her cat. A review of systems (ROS) is positive for malaise but no fever, joint pain, skin rash, cough, or any other symptoms. On examination, her vision is 20/70 OD and 20/20 OS. Intraocular pressure is 19 mm Hg OD and 17 mm Hg OS. Anterior segment is unremarkable, but a slight afferent pupillary defect (APD) is noticed in the right eye. Fundus examination shows optic nerve head edema OD extending to the macula with a few exudates. Left eye is normal. What is the most common uveitic manifestation of this disease process?
Neuroretinitis
Focal retinochoroiditis
Intermediate uveitis
Optic nerve infiltration
36. (Medium) A 40-year-old Black male patient is referred for evaluation due to possible uveitis. The patient has had fever for the past week, with droopiness of the left side of the face, incomplete blink, and associated redness, pain, and photophobia of both eyes. On review of systems (ROS), he admits having bilateral facial swelling but no cough or breathing problems and no skin rashes. His vision is 20/50 and 20/70 with evidence of mutton-fat keratic precipitates (KP), iris nodules, and 3+ anterior chamber cell. Fundus examination is normal OU. A chest X-ray done showed hilar adenopathy. What is the most likely diagnosis based on this patient’s findings?
Taches de bougie syndrome
Neurosarcoidosis
Lofgren’s syndrome
Heerfordt’s syndrome
37. (Medium) A 53-year-old male patient presents as a consult due to history of multiple episodes of inflammation in his right eye. He tells you that every time he develops pain and redness in his eye, he goes to the local ophthalmologist, and they find anterior-chamber cell and a very high intraocular pressure (IOP). Previous treatment has consisted of topical steroids and IOP-lowering drops. He is always able to taper off the drops and remains quiet without inflammation and normal IOP for months and sometimes years before the next episode develops. What viral organism has been linked to the most likely diagnosis?
Cytomegalovirus (CMV)
Herpes simplex virus (HSV) 1 and 2
Rubella
Varicella-zoster virus (VZV)
38. (Hard) A 28-year-old male patient with no prior medical history was referred for ophthalmology evaluation due to changes in his vision. He describes his vision as “not normal” with “central areas that are distorted.” Mild redness and photophobia are noted. On review of systems (ROS) he explains that he is having headaches and feels “like I’m not myself” for 3 weeks. He also had malaise and myalgia. On examination, his vision was 20/60 OU with trace cell in the anterior-chamber OU and 1+ cell vitreous cell. Amsler’s grid shows paracentral scotomas. Fundus examination and fluorescein angiography (FA) are seen in the images. Work-up including rapid plasma reagin (RPR), fluorescent treponemal antibody absorption (FTA-ABS), chest X-ray (CXR), and Lyme titers was negative. Which of the patient’s symptoms would need further work-up and possibly treatment for this condition?
Paracentral scotomas
History of malaise and myalgia
Headaches and “not feeling like myself”
Eye redness and photophobia
39. (Easy) A 38-year-old male patient with history of HIV, CD4 100, and unknown viral load is sent for a screening evaluation. The patient is asymptomatic, though he admits he also has history of Kaposi’s sarcoma treated with chemotherapy. No prior ocular history. What is the most common fundus finding expected in this patient?
Cytomegalovirus (CMV) retinopathy
HIV retinopathy
Progressive outer retinal necrosis (PORN)
Cryptococcus choroiditis
40. (Easy) Which of the following is not true regarding glaucoma management in uveitis?
Most cases of uveitic glaucoma, especially if pseudophakic or aphakic, require aqueous drainage devices.
Cyclodestructive procedures may worsen ocular inflammation and could lead to hypotony and phthisis.
When medical management with drops is not enough to achieve good intraocular pressure (IOP), a laser trabeculoplasty is a good option before proceeding to surgery.
Meticulous control of inflammation using immunomodulatory therapy (IMT) and steroids improves visual acuity outcomes and overall success of glaucoma surgery.
Consider the following case for questions 41 and 42:
41. (Hard) A 65-year-old female patient with prior medical history of diabetes mellitus (DM) and hypertension (HTN) presents for evaluation due to 3 days history of a painful rash in the right side of her forehead with associated vesicles that extend into the tip of the nose. She also has conjunctival injection and reports her vision is slightly blurry. On examination, her vision is 20/50 OD and 20/20 OS; intraocular pressure (IOP) is 30 and 21 mm Hg. Slit lamp examination shows multiple vesicles in the upper and lower lid, and fluorescein delineates a dendritiform lesion with negative staining. There are fine keratic precipitates (KP) and 1+ cell in the anterior-chamber OD. Left eye is unremarkable. Dilated fundus examination OU shows few microaneurysms and dot blot hemorrhages but no signs of retinitis, neovascularization of the disc (NVD) or neovascularization elsewhere (NVE). Which of the following best explains the pathogenesis of this condition?
Cell-mediated immunity and not direct viral infection.
The virus remains latent in B lymphocytes and mucosal epithelial cells throughout life spreading through saliva.
Live virus spreading from the skin via sensory nerve axons.
Endogenous reactivation of latent virus.
42. (Easy) What is the recommended treatment for this patient?
Oral valacyclovir 1 g three times a day × 7 to 10 days
Oral acyclovir 400 mg five times a day for 7 to 10 days
Oral famciclovir 250 mg three times a day for 7 to 10 days
Topical trifluridine every 3 hours for 14 days
43. (Easy) A 75-year-old female patient with history of cataracts OU presents due to redness, pain, and light sensitivity in her left eye that started after trauma 3 days prior to presentation under unclear circumstances. Her vision is 20/100 OD and counting fingers (CF) OS. On slit lamp examination, right eye was only remarkable for a 3+ nuclear sclerotic (NS) cataract. Left eye has evidence of ciliary flush, corneal edema, with a self-sealed 1-mm corneal laceration, multiple keratic precipitates (KP), 3+ cell and flare, posterior synechiae, and an intumescent cataract with a small violation of the anterior capsule. No posterior view but B scan showed an attached retina with clear vitreous. What histologic finding would you expect to see in this patient?
Engorged macrophages and lens protein clogging the trabecular meshwork
Neutrophils around the lens material with surrounding lymphocytes, plasma cells, epithelioid cells, and occasional giant cells forming a zonal granuloma
Presence of immunoglobulin E (IgE), mast cells, and basophils in the anterior chamber
Refractile bodies in the aqueous representing lipid-laden macrophages
44. (Easy) A 50-year-old male patient with long-standing blindness in his right eye due to trauma presents with vision loss in his left eye. Patient’s last eye examination was a year ago with visual acuity of no light perception OD and 20/30 OS. On current presentation, his vision decreased to 20/100 OS and slit lamp examination of the left eye shows 2+ cell with 1+ flare, keratic precipitates (KP), 2+ vitreous cell with 1+ haze, and a serous retinal detachment OS. Which of the following is true regarding the histopathologic features of the suspected diagnosis?
Diffuse necrotizing infiltration of the choroid with predominance of neutrophils.
Nodular clusters of epithelioid cells containing pigment, located in the retina.
Dalen–Fuchs nodules are pathognomonic of sympathetic ophthalmia (SO).
Absence of inflammatory involvement of the choriocapillaris and retina.
45. (Hard) A 30-year-old male from India presents for evaluation of vision loss and floaters in the left eye for 3 days. He has no prior medical history but recalls having previous episodes of vision loss and floaters in the same eye. On examination, there is evidence of a vitreous hemorrhage with no evidence of retinal breaks. When you obtain previous records, there is evidence of multiple episodes of retinal and vitreous hemorrhage with a fluorescein angiography that shows periphlebitis in the periphery and vasculitis with neovascularization. What should be included in this patient’s work-up of vasculitis with recurrent hemorrhages?
Herpes simplex virus (HSV) 1 and 2 titers
Toxoplasma gondii IgM titers
Interferon gamma release assay
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
46. (Medium) A 51-year-old female patient presents for evaluation as a second opinion due to blurry vision in her right eye for the past 3 years. She also mentions that people tell her that the color of her eyes is different. She denies any prior ocular history including any trauma. On examination, best-corrected vision is 20/50 OD and 20/25 OS, and there is evidence of diffuse stellate keratic precipitates (KP) over the entire endothelium with 2+ anterior chamber cell and few cells in the anterior vitreous. No synechiae but there is diffuse stromal atrophy. She also has evidence of a visually significant cataract OD. Posterior examination is unremarkable. The patient is interested in cataract surgery. What would you tell this patient in this regard?
Cataract surgery can be performed, but there is an increased risk of postoperative hyphema.
Aggressive treatment with topical corticosteroids is necessary to control inflammation before cataract surgery.
Cataract surgery is indicated but an intraocular lens cannot be implanted at the time of surgery.
Prophylaxis with oral valganciclovir is recommended prior to surgery.
47. (Easy) A 17-year-old adolescent girl complains of blurred vision and floaters which have increased over several months. Her visual acuity last year was 20/20 OU, but now is 20/60 OD, 20/50 OS. Examination shows bilateral anterior-chamber cells, a mild peripheral cortical cataract, 1+ vitreous cells and 1+ haze, a few snowball vitreous opacities, and small snowbanks at the ora serrata OU. What is the most likely cause of her decreased vision?
Vitritis
Cystoid macular edema (CME)
Cortical cataracts
Peripheral retinal vasculitis
48. (Medium) An 8-year-old girl with history of juvenile idiopathic arthritis (JIA) presents for evaluation of a corneal scar. The mother reports her daughter has a white mark in her right eye that has been noticed on previous examinations but never addressed. On examination, her best-corrected visual acuity (BCVA) is 20/100 and 20/25. Corneal examination shows a band-shaped, horizontal, gray-white subepithelial corneal opacity, more evident in the interpalpebral fissure involving the visual axis OD. In the left eye, there are similar findings at 3 and 9 o’clock not involving the visual axis. She has trace cell OU, and there is also evidence of cataracts. What is the recommended treatment for her corneal pathology?
Bandage contact lenses
Alcohol epithelial debridement
Phototherapeutic keratectomy (PTK)
Manual superficial keratectomy with sodium ethylenediaminetetraacetic acid (EDTA)
49. (Hard) A 59-year-old female patient presents for evaluation due to recent onset of floaters, blurry vision, and problems with nighttime vision. Past ocular history is significant for cataracts in both eyes. On examination, her vision is 20/50 OD and 20/80 OS and normal intraocular pressure. Slit lamp examination shows intraocular lenses in both eyes. In the posterior examination, there is evidence of trace vitreous cell and very subtle hypopigmented ovoid choroidal lesions in both eyes, more prominent nasally. What test could help you establish the most likely diagnosis?
Optical coherence tomography (OCT) macula
Fluorescein angiography (FA)
Indocyanine green angiography (ICG)
Vitreous biopsy
50. (Medium) A 7-year-old boy with no prior medical history is brought for evaluation because his mother notices that his left eye drifts outward. She also noticed that the patient’s left eye looks white when flash pictures are taken. On examination, his vision is 20/20 OD and 20/400 OS. Anterior segment is quiet OU and posterior examination of the left eye shows a peripheral solitary white elevated lesion with dense membranes in the vitreous that extend to the posterior pole. Right eye fundus is unremarkable. Which of the following is the next best step in the evaluation of this young patient?
B-scan ultrasonography
Serum titers for Toxocara canis and Toxocara cati
Examination under anesthesia with vitreous biopsy
Laser photocoagulation of the lesion
51. (Medium) A 4-year-old girl with history of juvenile idiopathic arthritis (JIA) (diagnosed 6 months ago) +ANA, −RF presents to the ophthalmologist for a regular eye examination. The mother reports that she only had arthritis in her right knee and left ankle but has never had eye symptoms. On examination, her vision is 20/20 OU and slit lamp examination is unremarkable. Dilated examination is also normal in both eyes. At the end of the visit, the mother asks when the next follow-up is due. How often should you evaluate this patient?
Every 12 months
Every 6 months
Every 3 months
As needed when symptoms develop
52. (Hard) A 39-year-old male patient with history of HIV (CD4 45) presents for evaluation due to vision loss in the right eye. Patient denies pain or redness. On examination, best-corrected vision acuity is 20/200 OD and 20/25 OS. Slit lamp examination shows no cell in the anterior chamber and trace cell in the vitreous. Dilated examination is seen in the figure. Based on this image and the most likely diagnosis, what is the mechanism of spread to the eye?
Congenital
Hematogenous
Direct invasion
Iatrogenic
53. (Hard) A 62-year-old Hispanic male patient presents due to recent onset of pain, severe tenderness, and discharge in his right eye. He denies prior medical history but had recent pterygium excision in his right eye. Best-corrected vision acuity is 20/60 and 20/30. On external examination, there is mucopurulent discharge and the nasal sclera looks necrotic and thin surrounded by marked inflammation with severe tenderness to palpation. What is the most likely organism in this patient?
Fusarium spp.
Nocardia spp.
Actinomyces
Pseudomonas aeruginosa
54. (Hard) A 50-year-old man with no known prior medical history is referred to the Uveitis clinic by your cornea colleague due to new diagnosis of peripheral ulcerative keratitis (PUK) with associated scleritis in the right eye. On ROS, patient reports weight loss, myalgia, and weakness and was told to have high blood pressure (160/100). Which of the following tests should be part of your work-up?
Hepatitis panel, antineutrophil cytoplasmic antibodies (ANCA)
Rapid plasma reagin (RPR), antinuclear antibody (ANA), Toxoplasma titers
Complete blood count (CBC), chest X-ray, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)
Lupus anticoagulans, anti-dsDNA
55. (Medium) A 4-year-old girl is brought for evaluation due to right eye redness for 1 week. She was treated by pediatrician for conjunctivitis, but no improvement was seen. Parents deny any prior medical history. On examination, patient has moderate chemosis in her right eye. Intraocular pressure (IOP) is 34- and 14 mm Hg. In the anterior segment, there is evidence of 4+cell with a white shifting hypopyon and vitritis but no good view to the posterior pole. Left eye is unremarkable. B scan does not show a mass but significant vitreous inflammation. What is the most important diagnostic consideration in this case?
Toxocara
Retinoblastoma
Herpes simplex
Sarcoidosis
56. (Easy) A 48-year-old African American female patient is referred for a consult due to her history of bilateral chronic anterior uveitis. Treatment with topical steroids has been unable to control inflammation completely. She is currently on prednisolone acetate twice daily OU. On examination, her vision is 20/40 OD and 20/60 OS with mutton-fat keratic precipitates (KPs), 3+ cell and 2+ flare in both eyes, and three iris nodules in the pupillary border OS. Fundus examination is unremarkable. What is the name given to this type of iris nodule?
Busacca nodule
Koeppe nodule
Berlin nodule
Lisch nodule
57. (Medium) A 25-year-old male patient from China presented to the clinic due to vision loss in his left eye with mild pain and redness. He denies any prior medical history but reports having multiple episodes of vision loss that eventually resolve. On ROS, patient admits having recurrent oral ulcers but no genital ulcers. He also has a painful rash in his legs that is elevated and tender. Left eye examination is normal. Right eye retinal examination is seen in the figure. Based on the most likely diagnosis, what is the recommended treatment?
Corticosteroids and colchicine
Topical corticosteroids and oral corticosteroids with a taper
Oral corticosteroids along with immunomodulatory therapy (IMT)
Cyclosporine
58. (Hard) A 46-year-old female patient, with no past medical history, allergic to sulfa with long-standing chronic anterior uveitis and uveitic glaucoma, on methotrexate and prednisolone twice daily OU presents for follow-up due to elevated intraocular pressure (IOP) on maximum tolerated topical therapy (brimonidine, timolol, and latanoprost). Previous attempts to decrease prednisolone result in a flareup. On examination, her vision is 20/20 OU and her IOP is 24 mm Hg OD and 26 mm Hg with a quiet anterior chamber. Visual fields show an inferior arcuate defect in the right eye and a nasal step in the left eye. What is the next recommended step in the management of this patient?
Glaucoma filtration surgery
Laser trabeculoplasty
Add acetazolamide
Discontinue latanoprost
59. (Medium) A 37-year-old male patient with history of HIV, noncompliant with highly active antiretroviral therapy (HAART) with a CD4 count of 65 presents for evaluation due to blurry vision is his left eye. He denies pain or light sensitivity. He has no prior ocular history. On examination, his vision is 20/20 OD and 20/30 OS. In slit lamp examination, anterior segment is unremarkable. Fundus examination shows a clear view of the retina with evidence of multiple patches of retinal whitening in the posterior pole and few in the periphery OS. No significant hemorrhages. Optic disc OS is hyperemic. What clinical finding is typically associated with the suspected diagnosis?
Low rate of retinal detachment
Severe vasculitis
Significant vitritis
Posterior pole may be involved early
60. (Hard) What is the typical profile of a patient diagnosed with acute zonal occult outer retinopathy (AZOOR)?
A 24-year-old myopic woman with bilateral vision loss and occult choroidal neovascular membrane (CNVM)
A 26-year-old myopic woman with photopsias in the right eye, mild vitritis, and abnormal ERG (delayed 30-Hz flicker)
A 50-year-old hyperopic woman with photopsias, no vitritis, and loss of inner/outer segment line on OCT
A 43-year-old myopic man with photopsias and multiple hypopigmented ovoid lesions in the posterior pole
61. (Easy) A 31-year-old female patient is diagnosed with anterior uveitis of the right eye. On examination her vision is 20/60 and 20/20, intracranial pressure (IOP) is 35- and 14 mm Hg. She has fine stellate keratic precipitates (KPs), 2+ cell, 2+ flare, and sectorial iris atrophy. Left eye is normal. Fundus examination is unremarkable OU. What is the most likely etiology?
Cytomegalovirus (CMV)
Human leukocyte antigen B27 (HLA-B27)
Herpes simplex virus 1 (HSV-1)
Varicella-zoster virus (VZV)
62. (Medium) A 23-year-old male patient presents for evaluation due to pain, redness, and light sensitivity in his right eye for the past 2 days. He recalls a prior episode with similar symptoms in the same eye. On examination he has 3+ anterior-chamber cell and 2+ flare with early posterior synechiae formation in the right eye. Left eye examination is unremarkable. What is the recommended treatment?
Prednisolone acetate 1% every 1-hour OD
Prednisolone acetate 1% four times a day OD
Periocular injection of triamcinolone OD
Oral prednisone 60 mg daily
63. (Medium) An 80-year-old male patient is diagnosed with anterior uveitis of the left eye. On examination, his vision is 20/30 and 20/60, intraocular pressure (IOP) is 12- and 29 mm Hg. On examination, he has fine keratic precipitates (KPs), 3+ cell, 2+ flare, and sectorial iris atrophy OS. Right eye is normal. Fundus examination is unremarkable OU. What is the most likely etiology?
Cytomegalovirus (CMV)
Human leukocyte antigen B27 (HLA-B27)
Herpes simplex virus 1 (HSV-1)
Varicella-zoster virus (VZV)
64. (Easy) An 18-year-old female patient presents to the office with sudden onset of redness in both eyes, blurry vision, and light sensitivity. She also reports general malaise and myalgia. On examination, she has 2+ cell, 2+ flare OU, and no evidence of synechiae. Dilated examination is unremarkable. Laboratory work-up for this patient must include which of the following based on presentation and most likely diagnosis?
Angiotensin-converting enzyme (ACE) levels
B 2 microglobulin
Antinuclear antibody (ANA)
Human leucocyte antigen B27 (HLA-B27)
65. (Medium) A 53-year-old female patient is referred to you by optometry due to a recent diagnosis of uveitis. She developed pain, redness, and light sensitivity in both eyes about 2 weeks ago and is not improving. Her visual acuity is 20/60 OD and 20/80 OS. On examination, there is evidence of large mutton-fat keratic precipitates (KP), 3+ cell, and 3+ flare in both eyes with iris nodules along the pupillary margin of the left eye. Dilated examination shows mild anterior vitritis and no posterior involvement. Work-up ordered by previous provider shows a positive chest X-ray with bilateral hilar adenopathy and positive human leukocyte antigen B27 (HLA-B27). Based on this patient presentation and test results, what is the most likely diagnosis?
Sarcoid and HLA-B27-related uveitis
Ankylosing spondylitis–related uveitis
Sarcoid-related uveitis
Tuberculosis (TB)-related uveitis
66. (Medium) A 36-year-old Hispanic male patient presented to the urgent care clinic due to bilateral eye redness, pain, light sensitivity, and blurry vision of 3 days of evolution. On examination, his vision was OD 20/60 and OD 20/30. Normal intraocular pressure (IOP). Slit lamp examination showed a corneal scar OD with keratic precipitate (KP), 2+ cell, 2+ flare. OS with 3+ cell, 2+flare. Dilated fundus examination (DFE) showed moderate vitritis with serous retinal detachments in both eyes. Which of the following should be asked as part of this patient history?
Previous history of trauma or intraocular surgery
Family history of uveitis or autoimmune disease
History of chronic cough or shortness of breath
Sexual activity and high-risk behavior
67. (Medium) A 45-year-old female patient from Indiana with no prior known medical history presents for evaluation after noticing vision loss in the right eye. She covered her left eye by accident and noticed her central vision in the right eye was decreased. Visual acuity is 20/400 OD and 20/25 OS. Dilated examination had no signs of vitritis OU. Right eye showed a central macular scar with suspected active choroidal neovascular membrane (CNVM). Left eye is shown in the figure. What is the most likely diagnosis?
Multifocal choroiditis with panuveitis (MCP)
Ocular histoplasmosis syndrome
Toxoplasma chorioretinitis
Tuberculosis (TB)-related uveitis
68. (Hard) A 62-year-old female patient presents for a second opinion due to blurry vision and floaters. She was seen by a previous ophthalmologist and diagnosed with posterior vitreous detachment in both eyes, but her symptoms are persistent. On examination, her vision is 20/40 and 20/30 with 2+ nuclear cataracts OU. Dilated fundus examination (DFE) shows trace vitreous cell in both eyes but not distinct lesions in the retina. Fluorescein angiography (FA) and indocyanine green angiography (ICG) were performed and the right eye can be seen in the figure. Left eye has similar findings. What is the most likely diagnosis?
Multiple evanescent white dots syndrome (MEWDS)
Birdshot chorioretinopathy
Sarcoidosis
Multifocal choroiditis
69. (Hard) A 22-year-old female patient presents for follow-up of pars planitis. She is currently on methotrexate 15 mg weekly, folic acid 1 mg daily, and prednisone 15 mg daily (tapering from 40 mg). On examination, her vision decreased in the right eye to 20/80 and 20/25 OS, and slit lamp examination shows 1+ vitreous cell with trace vitreous haze OU. OCT macula is seen in the figure. What is the most appropriate next step in treatment?
Continue prednisone taper and add prednisolone drops.
Sub-Tenon’s triamcinolone injection in the right eye and stopping methotrexate due to failure.
Increase oral prednisone dose and continue methotrexate 15 mg.
Increase methotrexate dose since patient had recurrence of cystoid macular edema (CME) on prednisone 15 mg.
70. (Hard) A 55-year-old male patient was diagnosed with peripheral ulcerative keratitis associated with rheumatoid arthritis 4 years ago and was stable after completing treatment with 2 years of methotrexate. He now presents for evaluation due to pain, redness, and significant light sensitivity in the left eye. On examination, there is evidence of significant corneal thinning inferonasally with 30% of corneal thickness left. He was started on prednisone 60 mg and on follow-up, there was further thinning (10% corneal thickness) and progression with no evidence of perforation. What is the most adequate next step in the management of this patient?
Pulse with IV methylprednisolone daily for 3 days.
Start prednisolone drops every 1-hour OS.
Continue prednisone at the current dose and restart methotrexate.
Schedule for emergent corneal graft in case he perforates.
71. (Easy) One of your patients with uveitis is complaining of significant light sensitivity. She works in a computer all day and feels that she is not able to perform her duties because of eye discomfort. On examination, she is 20/20 OU and no signs of active inflammation. She brings to her appointment disability forms and is asking for you to fill them out, so that she doesn’t have to work anymore. You explain to her that her vision is perfect, and her disease is controlled, but she starts crying that if you don’t fill out those papers in a way she can get disability, she will not be able to provide for her family. How would you proceed in this situation?
Tell the patient you will not fill out any disability papers since she is not disabled from her ophthalmic condition.
Fill out the papers stating that she currently has decreased vision and active inflammation and is unable to return to work.
Fill out the papers with her current examination, visual acuity, and assessment.
Refer to the social security administration for further evaluation.
72. (Easy) A 46-year-old female patient was referred as a consult due to persistent redness in the left eye. She denies any past medical history and reports this is the first time she has problems with her eye. She denies pain or light sensitivity. No sick contacts. No crustiness or discharge. On examination, her vision is 20/20 OU and slit lamp examination shows a focal area of redness on the temporal side of her left eye with no tenderness. Right eye is unremarkable. No A/C cell OU. What is the most likely etiology for this condition?
Herpes simplex
Systemic lupus erythematosus (SLE)
Idiopathic
Rheumatoid arthritis
73. (Hard) You are treating this 35-year-old female patient for acute anterior uveitis in the right eye with prednisolone drops and on her last examination inflammation had resolved, so you order a taper of the drop with follow-up in 1 month. On followup, she tells you that she is still using the drop once daily because for the past 3 days she has had some discomfort, light sensitivity, and blurry vision in her right eye. On examination, her vision is 20/30 OD and 20/20 OS with normal intraocular pressure (IOP). Slit lamp examination showed the following corneal finding OD. The rest of the examination was unremarkable. What is the best next step?
Start patient on IV acyclovir.
Increase steroid drop.
Discontinue steroid drop and start trifluridine every 2 hours.
Place a bandage contact lens for relief of symptoms.
74. (Medium) A 65-year-old female patient with birdshot chorioretinitis presents to you for a second opinion because of persistent inflammation despite a maximum dose of mycophenolate mofetil. She has tried multiple intravitreal injections of corticosteroids but her intraocular pressure (IOP) has significantly increased. After discussing options of additional immunosuppressive therapy, you decide on adding tacrolimus but the patient is concerned about which of the main side effects?
Diarrhea
Hypertension
Hematuria
Nephrotoxicity
75. (Medium) A 68-year-old male patient with past medical history of hyperlipidemia on simvastatin and history of chronic panuveitis OU on mycophenolate mofetil presents to you for a second opinion regarding his immunosuppression. On the last appointment, he was told he needed a second drug to be added to his regimen, due to persistent inflammation. When considering the use of a cyclosporine in this patient, which of the following is a concern?
Rhabdomyolysis
Fatty liver
Transaminitis
Thrombocytopenia
76. (Hard) The differential diagnosis for this patient’s findings in the figure should include all the following except which one?
Serpiginous choroiditis
Syphilitic uveitis
Sarcoidosis
Congenital cytomegalovirus (CMV)
77. (Medium) A 54-year-old male patient with no prior medical history presents as a consult due to new onset of ocular inflammation of unclear etiology. He reports blurry vision in both eyes that has progressed over the past month with associated redness and light sensitivity. ROS is positive for shortness of breath and was recently diagnosed with asthma. On examination, his vision is 20/50 and 20/70. He has normal intraocular pressure. Slit lamp examination shows evidence of granulomatous keratin precipitate (KP), 2+ cell, and flare in both eyes. Fundus examination shows 1+ vitritis and evidence of retinal vasculitis OU as seen in the figure. Which of the following is the most likely diagnosis?
Sarcoidosis
Systemic lupus erythematosus
Behcet’s disease
Susac’s syndrome
78. (Medium) A 24-year-old Hispanic female patient with no past medical history presents for evaluation due to pain, redness, and light sensitivity in her right eye for 2 days. She had two prior episodes in the past in the same eye. ROS is positive for canker sores. Her vision is 20/40 OD and 20/20 OS. Intraocular pressure (IOP) is 6- and 16 mm Hg. On slit lamp examination, she has fine keratin precipitate and 4+ cells and 4+flare OD. Examination in the left eye is unremarkable. Fundus examination is normal OU. Which of the following is the most likely diagnosis?
Posner–Schlossman syndrome
HLA-B27
Toxoplasmosis
Herpes simplex virus (HSV)
79. (Easy) A 55-year-old female patient presents to you for evaluation of cataracts. She has prior medical history of hypertension and prior ocular history of recurrent anterior uveitis. She is currently using prednisolone drops three times a day in the left eye for recent flare-up that started 1 month ago. On examination, her best-corrected visual acuity is 20/30 and 20/60 with cataracts OS greater than OD. Her right eye is quiet and left eye had trace cell. In terms of cataract surgery, what recommendation would you give to this patient?
If patient’s activities are being affected by her vision, cataract surgery can be done as soon as anterior-chamber cell reaction resolves.
Tell the patient you can offer cataract surgery now, but she has poor prognosis due to history of uveitis.
Cataract surgery should be performed when at least 3 consecutive months of quiescence can be documented.
Offer cataract surgery now with periocular treatment with steroids.
80. (Easy) Cystoid macular edema (CME) is a common cause of vision loss in ocular inflammation. In which of the following patients you will not expect to see CME?
A 69-year-old female patient with +HLA-A29 and multiple posterior hypopigmented choroidal lesions, more prominent nasally OU
A 16-year-old adolescent girl with vitritis and snowbanking
A 72-year-old African American male who underwent cataract surgery in the right eye 4 weeks ago
A 53-year old with light blue iris OD, unilateral cataract, diffuse fine KP, and 1+ cell. Normal examination OS.
81. (Easy) A 56-year-old African American patient with chronic anterior uveitis OU. She returned for followup due to pain, redness, and blurry vision after stopping the topical steroids. On examination, she has large greasy KP in both corneas with 2+ cell OU and iris nodules in the left eye. What type of cell is mainly seen histologically in these keratic precipitates?
Neutrophils and lymphocytes
Lymphocytes and macrophages
Macrophages and epithelioid cells
Eosinophils and monocytes
82. (Easy) Ms. Reynolds is a patient with noninfectious uveitis controlled on infliximab every 4 weeks goes to an infusion center to receive her medication. She usually is seen by the same nurse who verifies the name of the patient in the bag with the patient’s wristband. In this occasion, a different nurse comes to administer the medication and tells her “Hi! I will start the usual medication and proceeded to start the IV.” Twenty minutes later, Ms. Reynolds developed itchiness and shortness of breath. Infusion was stopped, and later investigation showed she received the wrong medication. What mechanisms should be in place to enhance patient safety?
Use of a checklist that includes the steps to follow before, during, and after administering a medication including verification of two patient identifiers.
Ask the nurse to resign after this error, so other employees are more careful knowing the consequences.
Change personnel regularly, so they don’t feel they know the patients in the infusion center and are required to verify the information every single time.
Ask the patient to verbalize the name and dose of medication they are supposed to receive before administering the medication.
83. (Hard) Which of the following statements is not true regarding the concept of immune privilege?
The best studied mechanism in the eye is called anterior-chamber–associated immune deviation (ACAID).
ACAID represents an attenuated afferent arc.
Immunization of the anterior chamber results in a robust antibody response and absence of delayed-type hypersensitivity.
Splenectomy eliminates ACAID.
84. (Medium) A 68-year-old female patient with chronic panuveitis OU wants to discuss her options for uveitis treatment. She needs to pick between local therapy with a sustained-release fluocinolone implant versus systemic immunosuppressive therapy. She asks to know how long the implant will work in her eye; what is the answer you will give her based on the median time period of efficacy?
12 months
30 months
50 months
24 months
85. (Hard) A 53-year-old female patient with past medical history of hypertension and lymphoma, now on remission, presents for evaluation due to uncontrolled scleritis in both eyes. She was started by her ophthalmologist on prednisone and methotrexate but has been unable to taper down the oral prednisone below 30 mg. Your assessment is that she needs additional immunosuppression therapy. Of the following treatment options, which one would you avoid in this patient?
Infliximab
Mycophenolate mofetil
Cyclosporine
Rituximab
86. (Hard) A 43-year-old patient with history of HIV and cytomegalovirus (CMV) retinitis presents for evaluation after initiation of highly active antiretroviral therapy (HAART) therapy a few months ago. On evaluation, patient reports worsening of his vision in his left eye with floaters and discomfort. On examination, he has anterior-chamber cell OS and macular edema in the left eye. An old area of retinitis is seen on fundus examination OS, but it looks inactive. Which of the following is true regarding the most likely diagnosis?
May occur in patients with previous history of herpes retinitis whose immune status improves after HAART.
This occurs with an increase in the CD4 count of at least 50 to 100 cells/µL.
Patient with this pathology are less likely to develop macular edema.
Recommended treatment includes the use of intravitreal corticosteroids.
87. (Medium) A 77-year-old male patient presents to your clinic due to decreased vision and mild pain in his right eye. On examination, his vision is 20/200 OD and 20/20 OS and intraocular pressure is 7 mm Hg and 16 mm Hg. On slit lamp examination, there is evidence of trace cell OD with 3+ flare and 3+ nuclear sclerosis (NS) cataracts. Left eye had no evidence of cell/flare and 2+ NS cataract. Posterior examination showed no evidence of vitritis retinal findings are shown in the figure. Which of the following should be part of your work-up in this patient?
HIV testing
Carotid Doppler ultrasonography
Chest X-ray
Brain MRI
88. (Hard) Regarding the Multicenter Uveitis Steroid Treatment (MUST) trial, what was the main conclusion based on the primary outcome at 2 years follow-up?
There was no statistically significant difference in visual acuity at 2 years.
Systemic therapy had better control of inflammation.
Most patients (70%) in the implant group developed cataracts.
There was more risk of developing malignancy in the systemic therapy group.
89. (Easy) A 60-year-old female patient is referred to you due to chronic anterior-chamber inflammation in the right eye that does not respond well to topical steroids. She has prior ocular history of cataract surgery OD and long-standing uveitis. No involvement OS. Upon questioning, patient denies any pain, redness, or discomfort. On examination, she has evidence of diffuse stellate keratin precipitate (KP) and 1+ cell with no flare. No evidence of posterior synechiae. Fundus examination shows few vitreous cells, but normal retinal examination. What is the recommended treatment for the most likely diagnosis?
Cycloplegia should be part of the treatment due to risk of synechiae with chronic inflammation.
Aggressive topical steroids due to persistent inflammation.
No treatment is recommended in most cases, despite the presence of cells.
Most patients need immunosuppression since response to steroids is poor.
90. (Easy) In a patient who presents with acute anterior granulomatous uveitis with iris nodules and negative infectious work-up, what is the single best screening test for the suspected diagnosis?
Chest CT scan
Chest X-ray (CXR)
Angiotensin-converting enzyme (ACE) levels
Tissue biopsy
91. (Medium) A 27-year-old Hispanic male patient presents for evaluation due to blurry vision, pain, and light sensitivity in both eyes for the past 4 days. He denies any prior medical or ocular history. On ROS, he admits being really stressed recently because of work and has had general malaise. On examination, his vision is 20/25 and 20/60 and normal intraocular pressure. On slit lamp examination, there is evidence of granulomatous KP, 2+ cell in the a/c, no synechiae, and mild vitreous reaction in both eyes. Optic disc margins are blurry, and there are bilateral serous detachments in both eyes extending from the nerve. OCT is shown in the figure. What is the most likely diagnosis?
Neuroretinitis
Lupus choroidopathy
Sympathetic ophthalmia
Vogt-Koyanagi-Harada (VKH) disease
92. (Medium) A 36-year-old male patient presented to the urgent care due to pain and decreased vision in the right eye. He denies any other symptoms or previous medical conditions. On examination, his vision is HM OD and 20/20 OS; IOP is 29- and 16 mm Hg. On examination, he has diffuse KP in the right eye with 3+ anterior-chamber cell, 2+ flare, and few early synechiae. Left eye is unremarkable. Posterior examination is limited in the right eye due to severe vitritis with 3+ haze. Wide-field photograph is shown in the figure. What is the most likely diagnosis from the options below?
Acute retinal necrosis (ARN)
Fungal endophthalmitis
Toxoplasma chorioretinitis
Multifocal choroiditis with panuveitis
93. (Hard) A 33-year-old female patient with PMHx of juvenile idiopathic arthritis (JIA) and chronic anterior uveitis returns to follow-up 2 years after her previous visit. She discontinued all medications. She reports blurry vision but no pain or redness. On examination, her vision is 20/100 and 20/80 and her intraocular pressure (IOP) is 3 mm Hg and 7 mm Hg. Slit lamp examination shows band keratopathy in both eyes, 1+ anterior-chamber cell OU, and multiple posterior synechiae that limit posterior segment examination. Which of the following is false about this patient’s hypotony?
Usually caused by decreased aqueous production from the ciliary body.
Despite low IOP, serous choroidal detachments are very rare in these patients.
Chronic hypotony associated to cyclitic membrane may respond to pars plana vitrectomy and membranectomy.
Vitrectomy with silicone oil may help increase IOP in some cases with significant visual improvement.
94. (Medium) Which of the following statements most likely applies to a patient who presents with retinal findings in the figure?
Constellation of findings include vision loss, unilateral optic disc atrophy, and macular star formation.
Formerly known as Fuchs’ idiopathic stellate neuroretinitis.
Most patients with Bartonella associated neuroretinitis do not exhibit anterior-chamber inflammation and vitritis.
Differential diagnosis includes bartonellosis, toxoplasmosis, sarcoidosis, and acute systemic hypertension.
95. (Medium) A 16-year-old adolescent girl with history of pars planitis presents for examination. She is asymptomatic with 20/20 vision. What is the best next step?
Fluorescein angiography
Antinuclear antibody (ANA) testing
Indocyanine green angiography (ICG)
Human leukocyte antigen (HLA) typing
96. (Hard) A 27-year-old man, intravenous drug user, presents to urgent care due to significant pain, redness, and vision loss in his right eye. ROS is positive for fever and chills. On examination, his vision is HM OD and 20/20 OS with normal intraocular pressure (IOP). Slit lamp examination shows a hypopyon in the right eye. Unremarkable examination OS. No posterior view but B scan shows significant vitritis OD. Further work-up revealed this patient has also bacteremia. What is the most common cause of this patient’s ocular condition?
Streptococcus spp.
Staphylococcus aureus
Bacillus spp.
Candida
97. (Medium) A 35-year-old male patient with history of HIV/AIDS and recent diagnosis of meningitis is consulted for evaluation due to decreased vision in both eyes. Fundus examination shows multifocal choroidal lesions with retinal hemorrhages and mild optic disc swelling in both eyes. The right eye is shown in the figure. Which of the following is the most probable diagnosis?
Coccidioidomycosis
Cryptococcosis
Aspergillus endophthalmitis
Cytomegalovirus (CMV) retinitis
98. (Easy) A 75-year-old male patient with no prior medical history comes for a second opinion regarding his diagnosis of intermediate uveitis. He says that he always responds to steroid treatment, but inflammation recurs once he tries to discontinue the medications. You schedule him for a diagnostic vitrectomy suspecting lymphoma. What is the most common type of lymphoma seen in this scenario?
Non-Hodgkin’s B cell
Hodgkin’s B cell
Non-Hodgkin’s T cell
Anaplastic large cell
99. (Hard) A 40-year-old man with no prior medical history presents for a comprehensive ophthalmic evaluation. He reports that his vision is blurry in a specific area around his central vision. Fundus examination and fluorescein angiography can be seen in the figure. Which of the following is true regarding treatment of this condition?
Periocular and intravitreal corticosteroids are contraindicated.
The addition of immunomodulatory therapy (IMT) has not shown to improve outcomes.
Cytotoxic therapy with cyclophosphamide or chlorambucil can induce long drug-free remission.
Focal laser photocoagulation can be used for treatment in cases without choroidal neovascularization (CNV).
100. (Easy) A 27-year-old male patient presents to urgent care due to acute pain, redness, and photo-phobia in his left eye. He denies any prior medical history, but ROS is remarkable right knee pain that started 2 weeks after a bout of diarrhea. He has also noticed burning on urination. On examination, there is evidence of 4+ cell in the anterior-chamber OS with 4+ flare and limited view to the retina. Right eye examination is normal. What test should you order as part of the work-up?
HIV testing
Human leukocyte antigen B27 (HLA-B27)
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
Sacroiliac imaging
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