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A 62-year-old female is brought in by EMS due to a severe right-sided headache, nausea and eye pain . She
w as fixing a light bulb, w hen she suddenly felt pain in her right eye. She decided to rest, but the eye pain only
got w orse. In the next few minutes, she developed loss of vision, photophobia and redness in the same eye.
She took medications to relieve the accompanying headache, but the eye pain persisted . She denies any
trauma . Her past medical history is significant for diabetes and hypertension . She appears to be in intense
pain w ith bouts of nausea. Her right eye is red, w ith conjunctival flushing and visual acuity of 20/200. Her right
pupil is mid-dilated and non-reactive to light. The same eye feels hard on palpation. The one treatment that
should be avoided in this patient is:

0 A. Mannitol
0

B. Acetazolamide

C. Pilocarpine

D. Timolol

E. Atropine

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A 5-year-old Caucasian female is brought to the office w ith several months history of decreased visual acuity
and decreased brightness sensation in the right eye. Slight exophthalmos of the right eye is present on
physical examination, and ophthalmoscopy show s pallor of the right optic disk. Several cafe-au-lait spots and
intensive axillary freckling are present. W hich of the follow ing is the most likely cause of this patient's visual
problems?

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0 A. Pigment retinitis
0

B. Retinal hamartoma

C. Optic glioma

D. Pituitary adenoma

E . Optic neuritis

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A 34-year-old male presents to the emergency department w ith a red eye. He says, "I just w oke up this
morning and saw that m y right eye w as red ." He denies any itching, pain or discharge. He has no know n
drug or environmental allergies. He takes no medication. His vital signs are stable. The photo of his eye is
show n below .

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W hat is the best next step in his management?

0 A. Check intraocular pressure

0 B. Refer to ophthalmologist
0 C. Check coagulation parameters
0 D. Observation
0 E . Antibiotics

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A 65-year-old female is complaining of seeing a sudden burst of flashing lights and blurred vision in her left
eye. These symptoms started this morning. She now sees small spots in her field of vision. She felt "like a
curtain came dow n" over her eye. She had a successful cataract extraction in her left eye 4 months ago. Her
vital signs are stable. Examination show s a sluggish left pupil. Ophthalmoscopy reveals retinal tears and a
grayish-appearing retina . W hat is the most probable diagnosis?

0 A. Choroidal rupture
0

B. Retinal detachment

C. Central retinal artery occlusion

D. Proliferative diabetic retinopathy

E. Exudative macular degeneration

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A 28-year-old kindergarten teacher complains of a gritty sensation and discharge from the right eye for 3
days. She also has rhinorrhea, mild sore throat, and low-grade fever of 37.9 C (100.3 F). The symptoms
began a w eek after classes started in the fall. Her past medical history is significant for genital herpes and
endometriosis. Eye examination show s mild injection and granular appearance of the tarsal conjunctiva of the
right eye w ith profuse w atery discharge. Nasal mucosa is normal, and the pharynx has mild erythema w ithout
exudates. W hich of the following is the most appropriate next step in management of this patient?

0 A. Cool, moist compresses

0 B. Erythromycin ophthalmic ointment
0

C. Olopatadine eyedrops

D. Oral valacyclovir

E. Prednisolone eyedrops

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A 30-year-old male comes to the emergency department screaming, "Something blew into m y right eye w hile I
w as drilling! " He complains of a foreign body sensation in the right eye, photophobia, and excessive
lacrimation. Gross examination of the right eye w ith a penlight after the application of a topical anesthetic is
insignificant. W hat is the best next step in the management of this patient?

0 A. Tonometry

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B. Fluorescein examination

C. Topical antibiotic

16

D. Ultrasonography

E. MRI of the orbits

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A 26-year-old man comes to the physician w ith sudden onset of redness, w atery discharge, and itching of
both eyes. His vision is slightly distorted from excess tearing but is not blurred. He otherwise feels fine. The
patient's past medical history is significant for obesity, asthma, sleep apnea, and chronic back pain. On eye
examination, there is bilateral injection w ith granular appearance of the conjunctiva. Mild eyelid sw elling and
clear discharge are also noted. Pupils are equally round and reactive to light. The lungs have a few scattered
w heezes, and the heart has a faint systolic murmur at the base. W hat is the most likely diagnosis in this
patient?

0 A. Allergic conjunctivitis
0 B. Anterior uveitis
0 C. Atopic keratoconjunctivitis
0 D. Bacterial conjunctivitis
0 E . Endophthalmitis
0 F. Kawasaki disease
0 G. Optic neuritis
0 H. Orbital cellulitis
0 I. Viral conjunctivitis
0 J. Viral keratitis

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A 65-year-old man presents with complaints of decreased vision in both eyes. His visual impairment has
been progressively worsening over the past five months. He w as diagnosed with diabetes ten years ago. His
current medications are metformin and glyburide. His blood pressure is 140/90 mm Hg, pulse is 82/min,
respirations are 14/min, and temperature is 98.4 F (36.8 C). Examination show s decreased visual acuity in
both eyes. Ophthalmoscopy reveals microaneurysms, dot and blot hemorrhages, hard exudates, and
macular edema. Which of the following is the most likely diagnosis?

0 A. Central retinal vein occlusion

0

B. Diabetic retinopathy

C. Macular degeneration

D. Retinal detachment

E. Open angle glaucoma

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A 53-year-old man comes to the office because of difficulty reading fine print over the last year. He now has to
hold books, menus, and magazines at an arms length in order to read them . He has never had visual
problems before. W hich of the follow ing is most likely abnormal in this patient?

0 A. Corneal shape
0

B. Lens elasticity

C. Lens opacity

D. Macula

E . Peripheral retina

F. Intraocular pressure

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A 33-year-old man presents w ith a 1-day history of localized, small sw elling along the margin of the upper
eyelid. He feels pain, w hich does not seem to come from the conjunctival surface. He has a 10-pack year
smoking history. He occasionally drinks alcohol. He is sexually active, and does not use condoms regularly.
He is w orried about the swelling. W hat is the best next step in the management of this patient?

0 A. Use w arm compresses

0

B . Incision and drainage

C. Incision and curettage

D. Take biopsy of the lesion

E . Oral Penicillin

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A 65-year-old male comes to the emergency department because of a sudden, painless loss of vision in his
right eye that occured a half an hour ago. Five hours ago, he experienced a similar but transient loss of vision
in the same eye, w hich lasted for five minutes. He has hypertension, diabetes, hypercholesterolemia, and
peripheral vascular disease. He had an anterior w all m yocardial infarction six years ago. His medications
include glyburide, captopril, atenolol, simvastatin, and aspirin . His temperature is 36P C (98.0 F),
respirations are 16/min, pulse is 88/min, and blood pressure is 146/88 mmHg. Examination of the right eye
reveals visual acuity of 20/60 and subtle retinal w hitening. A right carotid bruit is heard. W hich of the follow ing
is the most appropriate next step in the management of this patient?

0 A. Topical pilocarpine
0

B. Ocular massage and high flow oxygen

C. Systemic corticosteroids

D. Topical beta blocker

E. Intravenous thrombolytics

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A 62-year-old man comes to the physician due to sudden onset of pain and redness in the right eye. He also
has photophobia, nausea, and a severe headache that has not responded to ibuprofen. There has been no
trauma, and he has never had such an episode before. On review of systems, the patient has had "a mild
cold" for w hich he used an over-the-counter oral decongestant. Physical examination show s a nonreactive
mid-dilated pupil. The eye appears red w ith conjunctival flushing . W hich of the follow ing is the best next step
in evaluating this patient's condition?

0 A. CT scan of the head

0
0

B. Duplex studies of carotid artery

D. Lumbar puncture

E. Tonometry

C. Fluorescein staining of the eye

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--

A 60-year-old w oman comes to the emergency department due to a sudden onset of severe pain in her left
eye w ith blurred vision, nausea, and vomiting. The symptoms began a few minutes ago, w hile she w as
w atching a movie in a nearby theater. Her blood pressure is 140/90 mm Hg, pulse is 82/min, respirations are
14/min, and temperature is 99.4 F. Examination reveals decreased visual acuity. Her left eye appears red,
w ith a hazy cornea, shallow anterior chamber, and dilated, fixed pupil. Her left eye is stony hard to touch.
W hat is the most likely diagnosis?

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0 A. Primary open angle glaucoma

0

B. Conjunctivitis

C. Acute angle closure glaucoma

D. Anterior uveitis

E. Corneal abrasion

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An 80-year-old w hite male comes to the emergency department due to a sudden loss of vision in his left eye
that occurred this morning upon w aking up. He has had hypertension for the past several years. Current
medications include ramipril and atenolol. His blood pressure is 140/90 mm Hg, pulse is 86/min, respirations
are 14/min, and temperature is 36.8c (98.4 F). Examination of the left eye reveals no abnormalities.
Funduscopic examination show s sw elling of the optic disk, retinal hemorrhages, dilated and tortuous veins,
and cotton w ool spots. W hich of the follow ing is the most likely diagnosis?

0 A.

Acute angle-closure glaucoma

B. Central retinal vein occlusion

C. Optic neuritis

D. Amaurosis fugax

E. Acute anterior uveitis

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A 32-year-old man complains of right eye pain and discharge. His symptoms began acutely on aw akening in
the morning. He uses extended-w ear contact lenses and has had difficulty removing the lenses for the last
w eek. His past medical history is significant for obesity, chronic back pain, asthma, and acid reflux disease.
On examination, thick, globular yellow discharge is present at the medial eye corner and on the lid margins.
The cornea is edematous, hazy, and ulcerated and there is extensive scleral injection, as show n in the image.
W hat is the most likely diagnosis in this patient?

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0 A. Angle-closure glaucoma
0 B. Anterior uveitis
0 C. Episcleritis
0 D. Pneumococcal conjunctivitis
0 E. Pseudomonal keratitis
0 F. Subconjunctival hemorrhage
0 G. Viral conjunctivitis

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A 32-year-old male construction worker presents w ith complaints of pain, w atering, and redness in his left eye
for the past 2 days . He reports having similar symptoms in the same eye a few months ago. Examination of
his left eye reveals vesicles and dendritic ulcers in the cornea . His vital signs are stable. W hat is the most
likely diagnosis?

0 A. Bacterial keratitis
0

B. Herpes simplex keratitis

C. Herpes zoster ophthalmic us

D. Corneal abrasion

E. Fungal keratitis

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A 30-year-old man is concerned about "floating spots" and blurred vision in his right eye. He had a penetrating
injury to his left eye several w eeks ago, w hich eventually led to vision loss in that eye. Inspection reveals a
moderate perilimbal flush. W hat is the most probable cause of this patient's condition?

0 A. Reagin-mediated disease
0

B. Circulating immune complexes

C. Non-caseating granulomas

D. Uncovering of 'hidden' antigens

E . Non-immune injury

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17

A 65-year-old man comes to the emergency department due to a sudden loss of vision in his right eye. He
has had diabetes, and has been treated w ith metformin and glyburide for the past 10 years. Visual acuity is
reduced to light perception in his right eye, and normal in his left. His vital signs are normal. Ophthalmoscopy
reveals loss of fundus details, floating debris and a dark red glow . W hat is the most likely diagnosis?

0 A.

Retinal detachment

B. Diabetic retinopathy

C. Vitreous hemorrhage

D. Central retinal vein occlusion

E. Age related macular degeneration

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A 65-year-old w oman presents w ith complaints of pain and sw elling over the inner aspect of her right eye for
the past two days. Examination of the eye reveals tenderness, edema, and redness over the medial canthus.
Slight pressure over the area causes expression of purulent material. Visual acuity is normal. W hat is the
most likely diagnosis?

0 A. Episcleritis
0

B . Dacryocystitis

C. Hordeolum

D. Chalazion

E . Orbital cellulitis

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-21

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25

A 65-year-old man comes to the physician for follow -up. Earlier this morning, he experienced sudden loss of
vision in his left eye that resolved after 5 minutes. The patient says, "It felt like a curtain w as falling dow n in m y
eye! " He recalls a similar episode 3 months ago that lasted only a few seconds. He has never seen light
flashes or floaters in his eyes. The patient's past medical history is significant for hypertension . His
temperature is 37.1 C (98.8 F), blood pressure is 140/90 mm Hg, pulse is 72/min, and respirations are
14/min. Pupillary reflexes are normal. Funduscopy show s zones of w hitened, edematous retina follow ing the
distribution of the retinal arterioles in the left eye. W hich of the follow ing is the most likely explanation for this
patient's symptoms?

0 A. Detached retina
0

B. Displaced retinal embolus

C. Occluding central retinal vein thrombus

D. Retinopathy due to hypertension

E. Vitreous bleeding

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A 35-year-old w hite female is complaining of blurry vision and pain w ith eye movements. She is on no
medications and denies any trauma . Last year, she developed bladder incontinence and an episode of leg
w eakness, w hich both improved w ithout therapy. Physical examination reveals reduced vision and sw ollen
optic discs. The one diagnosis that may explain her symptoms is:

0 A. Parkinson disease
0

B. Myasthenia gravis

C. Multiple sclerosis

D. Subdural hematoma

E. Transient ischemic attacks

-20

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A 60-year-old w oman complains of decreasing vision and a dull ache over her left eye for the past 12 hours.
She had a successful surgical cataract extraction in her left eye five days ago. Her blood pressure is 140/90
mmHg, pulse is 92/min, respirations are 14/min, and temperature is 38.1c (101 .r F). Examination of the left
eye reveals a sw ollen eyelid, edematous conjunctiva, and exudates in the anterior chamber. Testing w ith
Snellen's chart demonstrates decreased visual acuity in her left eye. W hat is the most likely diagnosis?

11

12
13
14
15
16
17
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19

0 A. Conjunctivitis
0

B. Corneal ulceration

C. Uveitis

D. Postoperative endophthalmitis

E . Cavernous sinus thrombosis

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20

An 85-year-old man presents w ith a rash over his forehead, tip of nose and left eye. He also complains of
pain and decreased vision. He has had fever, malaise, and a burning sensation around his left eye for the
past 5 days. His blood pressure is 140/90 mm Hg, pulse is 92/min, respirations are 14/min, and temperature
is 38 .1o C (101 o F). Physical examination reveals a vesicular rash on the periorbital region and lid margins.
The left eye is red, w ith chemosis of the conjunctiva. Dendriform ulcers are seen on the cornea . W hat is the
most likely diagnosis?

0 A. Herpes simplex keratitis

0

B. Dacryocystitis

C. Bacterial keratitis

D. Trigeminal neuralgia

E. Herpes zoster ophthalmic us

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19

A 32-year-old w oman comes to the office distraught because ''he colors look w ashed out! " She has had this
vision impairment since yesterday. She also complains of pain on eye movements. Her vital signs are stable,
and she is afebrile. Examination reveals decreased visual acuity, sluggish afferent pupillary response to light,
and changes in color perception. Fundoscopy reveals a sw ollen disc. What is the most likely diagnosis?

0 A. Orbital cellulitis
0

B. Optic neuritis

C. Acute anterior uveitis

D. Open angle glaucoma

E. Episcleritis

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A 67 -year-old Caucasian male complains of progressive visual loss in his right eye over the past several
months. He has a history of hypertension and type 2 diabetes mellitus. Current medications include a daily
baby aspirin, hydrochlorothiazide, lisinopril, and metformin. There is no family history of visual problems. He
has a 35 pack year smoking history and admits to occasional alcohol use. He is afebrile w ith a blood
pressure of 137/82 mmHg and pulse of 73/min. Cardiac and pulmonary examinations are unremarkable. A
neurologic examination demonstrates no focal motor or sensory abnormalities. The patient is asked to cover
his left eye and to look at a small spot on a grid made of parallel vertical and horizontal lines. He describes the
vertical lines as being bent and w avy. W hich of the follow ing is the most likely cause of this patient's
complaints?

0 A. Lens opacity
0

B. Enlarged blind spot

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C. Increased intraocular pressure

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D. Macular degeneration

E . Peripheral retinal degeneration

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A 65-year-old man complains of gradual onset blurred vision for the past two months. He also has difficulty
driving at night and reading fine print. He has diabetes and hypertension. His medications include ramipril and
metoprolol. His vital signs are stable. His best corrected vision is OD (right eye) 20/80, OS (left eye) 20/ 100,
w ith full fields. Ophthalmoscopic examination w ith good pupillary dilatation reveals a loss of transparency of
lens in both eyes. The red fundal reflex is normal, but retinal details are difficult to visualize. W hat is the most
likely diagnosis?

0 A. Open angle glaucoma.

0

B. Retinal detachment.

C. Macular degeneration.

D. Cataract.

E. Central retinal vein occlusion .

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A 38-year-old man w ith AIDS (Acquired Immune Deficiency Syndrome) is complaining of diminished vision in
both eyes. His CD4 count last month w as 50 cells/ul. He has been on highly active antiretroviral therapy for
the past several months. He is afebrile, and his vital signs are stable. Ophthalmoscopic examination reveals
yellow -w hite patches of retinal opacification and retinal hemorrhages. W hat is the most likely diagnosis?

0 A. Ocular toxoplasmosis.
0

B . Herpes simplex keratitis.

C. Herpes-zoster ophthalmic us.

D. CMV Retinitis.

E . HIV retinopathy.

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A 69-year-old w hite male presents to your office complaining of progressive bilateral loss of vision over the
past several months. He only has problems w ith his central vision. His peripheral field and navigational vision
are not affected. He denies smoking and alcohol intake. He does not have any history of diabetes or
hypertension. Tw o years ago, he had cataracts removed from both eyes. W hat is the most likely diagnosis?

0 A. Open angle glaucoma

0

B. Macular degeneration

C. Recurrent cataracts

D. Central retinal artery occlusion

E. Retinal detachment

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A 75-year-old African American man comes to your office for his annual check up. He is a know n diabetic and
hypertensive. His medications include lisinopril and atenolol. His vital signs are normal. Examination of his
fundus reveals cupping of the optic disc. Visual field examination reveals constricted peripheral vision. W hat
is the most likely diagnosis?

0 A. Diabetic retinopathy
0

B . Closed angle glaucoma

C. Macular degeneration

D. Primary open angle glaucoma

E . Cataract

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A 57 -year-old female w ith a history of type 2 diabetes mellitus complains of fatigue, urinary frequency,
increasingly blurred vision and w orsening leg cramps over the past w eek. She reports that the symptoms all
began follow ing an upper respiratory infection 7 or 8 days ago. She does not take any medications, but
adheres to a diet low in saturated fat and simple carbohydrates to manage her diabetes. On physical
examination, her blood pressure is 160/90 mmHg and her heart rate is 90/min. Her mucous membranes are
dry. Her urine is positive for glucose but negative for ketones. W hich of the follow ing is the most likely cause
of this patient's vision impairment?

0 A. Cataracts
0

B. Diabetic retinopathy

C. Arterial hypertension

D. Hyperosmolarity

E. Eye infection

F. Lacunar infarction

G. Metabolic acidosis

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A 50-year-old man comes in for his annual check-up. There is a sw elling on his left eyelid, w hich he casually
acknow ledges by saying that it has appeared "on-and-off for the past 2 years." It initially starts as a painful
lesion w hich regresses w ith hot compresses, but then eventually reappears. On examination of his left eye,
you note a nodular, painless, rubbery lesion on the eyelid w ithout any discharge, redness or other
abnormalities. W hat is the best next step in the management of his eye lesion?

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0 A. Anti-staphylococcal antibiotics
0

B. Direct steroid injection

C. Incision and curettage

D. Frequent hot compresses

E . Histopathological examination

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A 35-year-old HIV-positive male is complaining of deterioration of his vision over the past w eek. He initially
experienced eye pain and mild conjunctivitis, follow ed by rapid progressive visual loss. Examination of his
eyes reveals marked keratitis. Funduscopy show s w idespread, pale, peripheral retinal lesions and central
necrosis of the retina. W hich of the follow ing is the most likely causative organism of this patient's condition?

0 A. Pseudomonas
0

B . Cytomegalovirus

C. Herpes simplex

D. Candida albicans

E . Epstein Barr virus

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