Case-Based Clinical MCQs

A 65-year-old man with hypertension and diabetes presents with sudden painless vision loss in his left eye. On exam his visual acuity is hand motions, fundus shows a pale retina with a cherry-red spot.

A 28-year-old woman reports intermittent episodes of unilateral visual dimming lasting minutes, precipitated by heat or exercise. She also has diplopia.

A 50-year-old woman with rheumatoid arthritis presents with severe, boring eye pain, worse at night, and scleral tenderness. Vision is relatively spared.

A 7-year-old child presents with leukocoria and strabismus. B-scan shows intraocular calcifications.

A 72-year-old smoker reports gradual central vision distortion. Amsler grid shows metamorphopsia; OCT reveals subretinal fluid and pigment epithelial detachment.

A 34-year-old man after blunt trauma has pain, photophobia, tearing, and a shallow anterior chamber with high IOP.

A diabetic patient on dialysis develops vision loss; fundus shows “pizza-pie” hemorrhages with fluffy lesions.

A neonate born at 25 weeks has dilated, tortuous posterior pole vessels and extraretinal fibrovascular proliferation at the ridge.

A 45-year-old woman on chronic steroids complains of glare and halos; slit lamp shows PSC with granular deposits on the posterior capsule.

A 55-year-old man with sudden onset of floaters and photopsias notes a “curtain” descending. Exam reveals a horseshoe tear in the superior temporal retina and subretinal fluid.

A 60-year-old hypertensive woman has blurred vision; exam shows flame hemorrhages, cotton wool spots, and optic disc swelling.

A 25-year-old pregnant woman presents with sudden vision loss; exam shows subretinal fluid in the macula and “smokestack” leak on FA.

A 40-year-old migraineur reports bilateral transient visual scintillations followed by headache.

A 30-year-old man with myopia presents with acute pain, redness, decreased vision; slit-lamp shows keratic precipitates, cells in AC, and IOP 28 mmHg.

A 6-year-old with autism fails to make eye contact; exam shows horizontal pendular nystagmus, head thrust to the right.

A 50-year-old alcoholic presents with painful vision loss, color desaturation, and central scotoma; MRI shows an enhancing optic nerve lesion.

A 28-year-old with sarcoidosis has floaters, “snowballs” in mid-vitreous, and peripheral periphlebitis.

A 65-year-old with narrow angles has headache, halos, mid-dilated pupil, corneal edema, IOP 50 mmHg.

A 45-year-old man on ethambutol develops bilateral blurred vision and central scotomas; color testing shows red-green defects.

A 70-year-old diabetic on hemodialysis presents with conjunctival pallor, lid droop, and decreased tear production.

A 16-year-old with Marfan syndrome complains of sudden visual blur and sees a crescent‐shaped shadow. Slit-lamp reveals lens subluxation upward and outward.

A 55-year-old presents with binocular horizontal diplopia worse when reading. Prism testing shows worse deviation at near than distance.

A 44-year-old woman with RA develops peripheral corneal thinning with adjacent inflammatory cells and neovascularization.

A 30-year-old HIV+ patient with CD4 50 presents with painless floaters and necrotic retinal lesions that spare the macula early.

A 60-year-old presents with progressive peripheral field loss and optic disc pallor; IOP normal, perimetry shows tubular fields.

A 35-year-old pregnant woman develops sudden vision loss and “smoke-stack” leak on FA; OCT shows serous detachment.

A 5-year-old with family history of cataracts presents with a white pupillary reflex, nystagmus, and failure to fix.

A 40-year-old migraineur presents with binocular visual loss described as “looking through shimmering water” lasting 30 min, followed by headache.

A 70-year-old man with CRVO presents 6 weeks later with iris neovascularization and iris root vessels on gonioscopy.

A 55-year-old smoker with sudden vision loss and RAPD has fundus showing blot–dot hemorrhages and macular edema in a quadrant.

A 65-year-old overweight man presents with headaches and transient visual obscurations; fundus shows papilledema, visual fields show enlarged blind spot.

A 45-year-old man with sudden onset of photophobia, pain, and ciliary flush has a dendritic lesion on fluorescein stain.

A 22-year-old woman presents with bilateral optic disc edema, headache, and sixth-nerve palsy; MRI is normal, LP opening pressure is 300 mmH₂O.

A 28-year-old with progressive ptosis and ophthalmoplegia fatigues with sustained upgaze, improves with ice pack.

A 65-year-old diabetic develops progressive peripheral vision loss; exam shows neovascular tufts and fibrovascular proliferation extending into vitreous.

A 40-year-old with sudden monocular transient vision loss described as “curtain descending,” lasting minutes.

A 55-year-old with AIDS has floaters and granular “cheese-and-ketchup” fundus lesions near fovea.

A 72-year-old woman on chronic topical corticosteroids develops blurred vision; slit lamp shows PSC opacities.

A 45-year-old with sudden, painless vision loss and pale retina with cherry-red spot has no light perception after 24 hours.

A 60-year-old hypertensive presents with sudden unilateral vision loss; exam shows macular star and optic disc swelling.

A 32-year-old woman with a history of migraines presents with episodic monocular vision loss described as “curtain coming down,” lasting 10 minutes. No fundus abnormalities are noted when seen after the episode.

A 50-year-old man with poorly controlled diabetes presents with rapidly progressive vision loss and tractional membranes on OCT. Fundus exam shows fibrovascular proliferation along vessels.

A 28-year-old contact lens wearer develops severe pain, redness, photophobia, and a corneal ulcer with feathery edges on slit-lamp exam.

A 65-year-old with a long history of severe myopia presents with sudden floaters and peripheral “grey line” shadow.

A 45-year-old woman reports metamorphopsia and central scotoma. OCT shows full-thickness macular defect.

A newborn has a blue sclera, dentinogenesis imperfecta, and high myopia.

A 70-year-old with gradual peripheral vision loss has optic disc cupping and IOP of 30 mmHg.

A 6-year-old child presents with decreased vision and an afferent pupillary defect. Fundus exam reveals optic disc pallor with excavation.

A diabetic patient with chronic renal failure on peritoneal dialysis presents with doll-like granularity in the RPE on fundus exam and CME on OCT.

A 55-year-old man on tamoxifen for breast cancer presents with decreased visual acuity and crystalline deposits in the macula.

A 30-year-old pregnant woman develops acute painless vision loss in one eye; exam shows a pale retina with cherry-red spot.

A 45-year-old with tuberculosis develops choroidal tubercles on fundus exam.

A 60-year-old on hydroxychloroquine for rheumatoid arthritis presents with paracentral scotomas and bull’s-eye maculopathy on OCT.

A 30-year-old soldier with blast injury has ocular pain, iris sphincter tears, and traumatic mydriasis.

A patient presents with severe pain and vision loss; exam reveals a corneal ulcer with ring infiltrate in soft contact lens wearers.

A 70-year-old with Parkinson’s disease presents with decreased blink rate and dry eye signs.

A 50-year-old on interferon therapy for hepatitis C presents with cotton wool spots and superficial hemorrhages.

A 45-year-old smoker with head trauma shows periorbital ecchymoses, subconjunctival hemorrhage, and diplopia on upgaze. CT shows orbital floor fracture.

A 40-year-old HIV+ patient with CD4 20 presents with diminished vision; fundus shows fluffy, white retinal lesions with hemorrhage and minimal vitritis.

A 65-year-old with giant cell arteritis presents with jaw claudication, scalp tenderness, and sudden vision loss. ESR is elevated.

A 30-year-old woman with Graves’ disease presents with diplopia and restricted upgaze; CT shows enlarged extraocular muscles sparing tendon insertions.

A 70-year-old with wet AMD presents with subretinal hemorrhage and detachment.

A 45-year-old alcohol user with poor nutrition presents with nyctalopia and Bitot’s spots.

A 50-year-old presents with acute bilateral vision loss, headache, and temporal artery tenderness. Temporal biopsy is positive.

A 25-year-old cyclist presents with bilateral fluctuating vision and sees oscillating blur when moving head.

A 60-year-old diabetic with proliferative retinopathy develops sudden painless vision loss; exam shows tractional membranes pulling on macula.

A 50-year-old with thyroid orbitopathy has corneal exposure and peripheral ulceration.

A 30-year-old presents with photopsias, floaters, and vitreous hemorrhage; exam shows neovascular tufts at disc edge.

A 70-year-old on hydroxychloroquine presents with paracentral scotoma and subtle changes on near-infrared fundus.

A 65-year-old woman with systemic sclerosis presents with dry eyes and keratoconjunctivitis sicca.

A 45-year-old man with homocystinuria presents with lens subluxation inferonasally and thrombosis.

A 55-year-old on chloroquine therapy presents with difficulty reading and paracentral scotomas.

A 65-year-old presents with downward gaze limitation, lid retraction, and convergence-retraction nystagmus.

A 70-year-old with chronic renal failure has band keratopathy and sclerotic vessels.

A 50-year-old HIV+ patient with CD4 25 presents with opportunistic infection causing optic nerve sheath enhancement on MRI.

A 30-year-old with Behçet’s disease presents with rapid vision loss, hypopyon, and occlusive retinal vasculitis.

A 40-year-old alcoholic with Wernicke’s encephalopathy has horizontal gaze-evoked nystagmus and ophthalmoplegia.

A 35-year-old presents with acute vision loss and neurological signs; MRI shows periventricular plaques.

A 65-year-old with poorly controlled hypertension has grade III retinopathy and macular star.

A 50-year-old presents with progressive central vision loss; OCT shows subretinal drusen and RPE atrophy.

A 28-year-old man presents with unilateral eye pain, redness, and blurred vision. Slit-lamp exam shows stellate keratic precipitates, iris atrophy, and elevated IOP.

A 65-year-old woman complains of photopsias and floaters. Fundus shows a horseshoe tear at the vitreous base and corrugation of the detached retina.

A 45-year-old diabetic on dialysis complains of bilateral visual blurring. OCT reveals CME; fundus shows dot–blot hemorrhages without neovascularization.

A 70-year-old man presents with sudden painful vision loss, headache, and mid-dilated pupil. Tonometry shows IOP 55 mmHg.

A 6-year-old child with leukocoria and a microphthalmic eye on ultrasound shows a retrolental fibrovascular stalk.

A 55-year-old woman presents with central vision loss and metamorphopsia. OCT shows subretinal fluid and CNV; FA shows classic hot spot leakage.

A 30-year-old man with head trauma has proptosis, chemosis, and conjunctival arterialization.

A 40-year-old presents with bilateral visual loss and perivenular “candle-wax drippings” on fundus. He also has pulmonary infiltrates.

A 25-year-old woman with myopia and flashes of light now sees a gray curtain in her peripheral vision. Fundus exam reveals lattice degeneration and a horseshoe tear.

A 65-year-old hypertensive woman presents with sudden painless vision loss. Fundus shows a cherry-red spot and boxcarring of arterioles.

A 45-year-old with AIDS presents with painful ocular redness and granulomatous keratic precipitates. FA shows hypofluorescent choroidal lesions.

A 60-year-old with long-standing hypertension has copper wiring and arteriolar narrowing on fundus exam.

A 35-year-old patient complains of transient unilateral blindness with amaurosis fugax and has carotid bruit. Duplex ultrasound shows 80% stenosis.

A 70-year-old man on chloroquine for malaria prophylaxis has paracentral field defects and “bull’s-eye” lesions on fundus exam.

A newborn has cloudy corneas, photophobia, and elevated IOP. Examination shows buphthalmos and Haab’s striae.

A 55-year-old woman with rheumatoid arthritis presents with peripheral corneal ulceration and severe pain.

A 28-year-old postpartum woman presents with sudden vision loss and pale retina without cherry-red spot. Fluorescein angiography shows delayed perfusion in branch of CRA.

A 40-year-old presents with binocular diplopia that worsens at near and improves with convergence; cover testing reveals esotropia at near.

A 55-year-old diabetic with proliferative retinopathy develops vitreous hemorrhage causing sudden vision loss; B-scan shows mobile dense opacities.

A 65-year-old woman presents with peripheral vision loss; visual fields show inferior altitudinal defect and disc swelling. Blood tests reveal high ESR.

A 50-year-old on ethambutol reports color vision changes and central scotoma.

A 30-year-old woman with lupus presents with acute painless visual field defect; FA shows segmental vessel leakage and sheathing.

A 70-year-old man with Parkinson’s disease has reduced blink rate and exposure keratopathy with corneal ulceration.

A 45-year-old complains of metamorphopsia; OCT shows epiretinal membrane with retinal surface wrinkling.

A 55-year-old man with COPD and cor pulmonale presents with conjunctival chemosis and papilledema.

A 60-year-old with chronic pancreatitis and malnutrition presents with xanthelasma and corneal arcus.

A 35-year-old woman with sarcoidosis presents with optic nerve granulomas and uveitis.

A 28-year-old presents with photophobia, tearing, and dendritic ulcer on cornea that stains with fluorescein.

A newborn with blue sclera, brittle bones, and dentinogenesis imperfecta presents for eye exam.

A 65-year-old with long-term topical steroid use presents with increased IOP and PSC.

A 45-year-old crash victim has orbital floor fracture with inferior rectus entrapment; exam shows diplopia on upgaze and enophthalmos.

A 50-year-old with intermediate uveitis has “snowbanking” along the pars plana and vitreous cells.

A 70-year-old diabetic with proliferative DR presents with sudden vision loss and B-scan shows mobile membranes with undulating echoes.

A 35-year-old pregnant woman with preeclampsia has retinal arterial spasms and cotton wool spots.

A 28-year-old with optic disc swelling, headache, and sixth-nerve palsy; LP shows high opening pressure.

A 60-year-old man with giant cell arteritis complains of jaw claudication and vision loss; fundus shows pale swollen disc.

A 45-year-old presents with progressive peripheral field loss; IOP is normal, OCT shows RNFL thinning.

A 25-year-old with thyroid eye disease develops compressive optic neuropathy with decreased color vision.

A 65-year-old with long-standing hypertension presents with Roth spots and cotton wool spots.

A 30-year-old with Marfan syndrome has upward lens subluxation and acute monocular vision blur with a shallow anterior chamber.

A 55-year-old smoker with a history of hypertension presents with sudden, painless vision loss in one eye. Fundus shows “blood and thunder” appearance with widespread hemorrhages and dilated tortuous veins.

A 45-year-old woman with Graves’ disease and proptosis develops worsening diplopia and decreased color vision. MRI shows apical crowding.

A 6-month-old infant presents with excessive tearing and a palpable lacrimal sac. Lacrimal irrigation yields reflux through puncta.

A 70-year-old diabetic complains of gradual peripheral vision loss despite normal IOP. OCT shows RNFL thinning and cup-to-disc ratio of 0.8.

A 30-year-old HIV-positive patient with CD4 count of 40 presents with floaters and “pizza pie” fundus appearance.

A 50-year-old myopic patient reports flashes and floaters. Exam reveals posterior vitreous detachment without retinal tears.

A 28-year-old woman presents with photophobia, red eye, and granulomatous KPs. Chest imaging shows hilar lymphadenopathy.

A 65-year-old man presents with sudden monocular vision loss; exam shows a pale retina and cherry-red spot. He has atrial fibrillation.

A 45-year-old diabetic on long-term dialysis reports slowly progressive blurry vision; exam shows drusenoid deposits and RPE atrophy.

A 7-year-old child presents with an afferent pupillary defect and pale, excavated optic disc. Visual evoked potentials show reduced amplitude.

A 50-year-old with hypertension presents with headache and transient visual obscurations; exam reveals bilateral papilledema.

A 45-year-old farmer presents with severe ocular pain, photophobia, and a corneal ulcer with dendritiform lesions.

A 60-year-old diabetic presents with sudden onset of double vision; exam shows isolated abduction deficit.

A 35-year-old pregnant woman complains of bilateral visual distortion; OCT shows subretinal fluid without CNV.

A 70-year-old presents with progressive bilateral peripheral field loss and nyctalopia; fundus shows bone-spicule pigmentation.

A 50-year-old on ethambutol therapy complains of decreased central vision and color desaturation.

A 40-year-old with a history of malignancy presents with bilateral painless vision loss; exam is unremarkable but VEP shows delayed latency.

A 65-year-old presents with epiphora and mucopurulent discharge since infancy; probing at age 1 failed.

A 60-year-old woman presents with headache, scalp tenderness, and jaw claudication; visual acuity is 20/200 in one eye.

A 35-year-old with lupus presents with hypopyon and vasculitis; FA shows segmental staining and leakage.

A 45-year-old presents with acute painful vision loss, disc edema, and central scotoma; blood pressure is 240/120.

A 30-year-old alcoholic with poor nutrition presents with bilateral vision loss and central scotomas; ESR is normal.

A 55-year-old with end-stage renal disease has corneal calcifications and conjunctival chemosis.

A 40-year-old with Behçet’s disease presents with bilateral hypopyon uveitis and occlusive vasculitis.

A 65-year-old diabetic presents with sudden floaters; B-scan reveals mobile echoes and no RD.

A 50-year-old reports progressive central vision loss; Amsler grid reveals metamorphopsia; FA shows classic CNV with leakage.

A 6-year-old child presents with a white pupillary reflex and microphthalmia; ultrasound shows a retrolental plaque.

A 55-year-old with chronic steroid use develops bilateral PSC and IOP of 30 mmHg.

A 45-year-old presents with sudden onset of floaters and photopsias; exam shows a lattice degeneration tear.

A 70-year-old hypertensive patient presents with flame hemorrhages, cotton wool spots, and AV nicking.

A patient presents with sudden, painless loss of vision in one eye; fundus exam shows a “cherry-red” spot at the fovea and pale retina.

A patient reports transient episodes of monocular vision loss described as a “curtain” descending, each lasting several minutes. No abnormalities are seen after each event.

A patient with sudden-onset pulsing proptosis, chemosis, and arterialized conjunctival vessels.

A patient notes metamorphopsia; OCT reveals subretinal fluid and pigment epithelial detachments; FA shows classic “hot spot” leakage.

A patient presents with photophobia, tearing, and a dendritic epithelial corneal lesion that stains with fluorescein.

A patient has acute onset of severe ocular pain, headache, corneal edema, mid-dilated pupil, and IOP elevated above 45 mmHg.

A patient reports progressive peripheral vision loss; visual field testing shows nasal step and enlarged cup-to-disc ratio; IOP is normal.

A patient on ethambutol therapy notes bilateral central scotomas and red–green color defects.

A patient with HIV and CD4 count <50 presents with floaters and fluffy white retinal lesions with hemorrhage, described as “pizza pie.”

A patient presents with headache, transient visual obscurations, and bilateral optic disc swelling; neuroimaging is unremarkable; lumbar puncture shows elevated opening pressure.

A patient with rheumatoid arthritis presents with severe ocular pain, redness, and peripheral corneal thinning with adjacent inflammatory infiltrate.

A patient presents with floaters and vitreous “snowballs,” and peripheral perivascular exudates in a “string of pearls” pattern.

A patient has sudden-onset diplopia; exam shows impaired adduction of one eye with nystagmus of the other on abduction.

A patient with lupus presents with retinal vessel sheathing, cotton wool spots, and segmental fluorescein leakage.

A contact lens wearer develops severe pain, redness, and a corneal ulcer with a ring-shaped infiltrate.

A patient with sarcoidosis presents with granulomatous anterior uveitis and mutton-fat keratic precipitates.

A patient has sudden, painless vision loss; fundus shows segmental retinal whitening along a branch retinal artery and a visible embolus.

A patient reports intermittent diplopia worse when looking down stairs and compensatory head tilt toward the opposite shoulder.

A patient on long-term hydroxychloroquine therapy presents with paracentral scotomas and parafoveal RPE changes on OCT.

A child presents with leukocoria and a mass on B-scan with calcifications.

A patient presents with fluctuating ptosis and diplopia, worsened by sustained upgaze and improved by an ice pack.

A patient develops sudden floaters and a shadow descending; exam reveals retinal tear with subretinal fluid but no fibrovascular membranes.

A patient with tuberculosis develops multiple small yellow choroidal lesions on fundus exam.

A patient with hypertension presents with flame hemorrhages, cotton wool spots, and arteriolar narrowing without papilledema.

A patient complains of central vision distortion; exam shows epiretinal membrane with surface wrinkling on OCT.

A patient presents with sudden onset of diplopia; exam shows limited abduction in one eye with esotropia at distance.

A patient on tamoxifen therapy presents with crystalline deposits in the macula and decreased visual acuity.

A patient presents with recurrent episodes of mild anterior uveitis and markedly elevated IOP spikes with few cells.

A patient reports shimmering lines and scotoma lasting 20 minutes, followed by headache.

A patient with end-stage renal disease has calcium deposits in Bowman’s layer visible as band keratopathy.

A patient presents with a mild, chronic anterior uveitis, stellate KPs, and iris heterochromia, but minimal symptoms.

A patient with optic disc swelling, headache, and diplopia has a sixth nerve palsy; CSF opening pressure is normal.

A patient notices progressive constriction of peripheral vision (“tunnel vision”) and nyctalopia; fundus shows attenuated vessels and bone-spicule pigment.

A patient on isoniazid therapy develops bilateral central scotomas and dyschromatopsia without pain.

A patient complains of sudden floaters and photopsias; exam shows a pigment clump on the vitreous surface (“Shafer’s sign”).

A patient with thyroid eye disease develops lagophthalmos, exposure keratopathy, and decreased tear film.

A patient presents with transient episodes of binocular diplopia and ptosis that worsen in heat and with exertion.

A patient with metastatic breast carcinoma develops a serous detachment at the macula with leopard-spot pattern on FA.

A patient presents with unilateral painful vision loss, periorbital swelling, and CT shows enlarged orbital muscles with tendon sparing.

A patient reports central vision loss and Amsler grid distortion; exam shows a macular telangiectasia with right-angled vessels on OCT.

A patient presents with sudden onset of flashing lights, floaters, and a “ring” around light; exam reveals posterior vitreous detachment.

A patient with sarcoidosis develops “candle-wax drippings” along venules on fundus exam.

A patient with a history of head trauma has diplopia on upgaze and CT shows orbital floor fracture with muscle entrapment.

A patient on hydroxychloroquine screening shows paracentral thinning on visual fields and parafoveal RPE disruption on OCT.

A patient develops acute severe eye pain after injuring their eye; exam reveals a deformed, low-pressure globe with positive Seidel test.

A patient presents with photophobia, tearing, and dendritiform epithelial lesions on the cornea; prophylactic steroid use is noted.