INI-CET High Yield Questions for Ophthalmology

Mastering the INI-CET demands a strategic approach to preparation, with an emphasis on high-yield topics proving to be a successful tactic. This blog zeroes in on exactly that – a curated list of high-yield questions in Ophthalmology that are highly likely to appear on the INI-CET. By acquainting yourself with these questions and their detailed explanations, you'll deepen your understanding of Ophthalmology concepts, enhancing your confidence and readiness for exam day.

1. A 7-year-old boy is brought to the emergency department with swelling and redness around his left eye. He complains of pain upon eye movement and has a low-grade fever. On examination, there is proptosis, restriction of extraocular movements, and tenderness to palpation. Which of the following organisms is most commonly associated with this condition in children?

A. Streptococcus pyogenes

B. Haemophilus influenzae

C. Staphylococcus aureus

D. Escherichia coli

Correct Option B - Haemophilus influenzae:

• The clinical picture of U/L involvement of the eye with low-grade fever, proptosis, and restriction of ocular movements suggests the diagnosis of Orbital cellulitis. The most common organism associated with the development of orbital cellulitis in children is Haemophilus influenzae.

Incorrect Options:

Option A - Streptococcus pyogenes: Streptococcus pyogenes is not the most common pathogen associated with orbital cellulitis in children.

Option C – Staphylococcus aureus: Staphylococcus aureus is most commonly associated with orbital cellulitis in the general population whereas Haemophilus influenzae is most commonly associated with orbital cellulitis in the pediatric population.

Option D – Escherichia coli: Escherichia coli is not a common pathogen associated with orbital cellulitis. It is more commonly associated with urinary tract infections and gastrointestinal infections.

2. A 45-year-old male patient presents with complaints of progressive vision impairment in both eyes. Upon examination, an ophthalmologist observes a distinct cataract with a unique pattern as depicted in the image. Which of the following diseases is associated with this particular cataract?

A. Diabetes Mellitus

B. Myotonic Dystrophy

C. Cataract in galactosemia

D. Morgagnian cataract

Correct Option B - Myotonic dystrophy:

• The image given in the question is of a Christmas tree cataract. Christmas tree cataract is indeed associated with Myotonic dystrophy, a genetic neuromuscular disorder. The distinctive appearance of the cataract is a result of specific crystalline deposits in the lens and is one of the ocular manifestations seen in individuals with Myotonic dystrophy.

Incorrect Options:

Option A - Diabetes Mellitus: Diabetes mellitus can lead to the development of snowstorm cataracts.

Option C - Galactosemia cataract: Galactosemia can lead to the development of Lamellar cataracts or Oil droplet cataracts

Option D - Morgagnian cataract: Morgagnian cataracts are characterized by liquefaction and disintegration of the lens cortex, leading to the sinking of the nucleus.

3. A 2-year-old child is brought to the ophthalmology clinic due to visual abnormalities, heart defects, and deafness. On examination, the child is found to have a nuclear cataract. Which of the following is the most common ocular feature associated with this condition?

A. Pearly white lens opacity

B. Microphthalmos

C. Rubella keratitis

D. Salt and pepper fundus

Correct Option D - Salt and pepper fundus:

• The triad of visual abnormalities (cataract), heart defects, and deafness is suggestive of congenital rubella syndrome.
• A salt and pepper fundus refers to a speckled appearance of the retina, resembling the seasoning on food. This appearance is caused by the presence of diffuse chorioretinitis, which is the most common ocular manifestation of Congenital Rubella Syndrome. The rubella virus affects the retina, leading to disturbed growth of the pigmentary layer.

Incorrect Options:

Option A - Pearly white lens opacity: Although pearly white lens opacity (nuclear pearly cataract) is another ocular feature of Congenital Rubella Syndrome, it is the second most common ocular feature associated with Congenital Rubella Syndrome.

Option B - Microphthalmos: Microphthalmos, or small-sized eyes, can be associated with Congenital Rubella Syndrome. However, it is not the most specific feature in this case.

Option C - Rubella keratitis: Rubella keratitis refers to inflammation of the cornea due to rubella infection. While it can occur in Congenital Rubella Syndrome, it is not the most common ocular feature.

4. A 45-year-old diabetic patient presents with complaints of cloudy vision, which is worse in bright light. The ophthalmologist observes opacities in the patient's lens shown in the image below. What is the mechanism underlying the formation of the particular cataract shown in the image?

A. Accumulation of lipids in the lens

B. Oxidative stress on lens proteins

C. NADPH-dependent Aldose Reductase activity

D. Age-related thickening of the lens capsule

Correct Option C - NADPH-dependent Aldose Reductase activity:

• The image shows a Snowflake Cataract. It is a specific type of cataract characterized by opacities in the lens of the eye that resemble snowflakes.
• These opacities are associated in conditions such as diabetes, where high level of glucose can lead to increases activity of NADPH-dependent aldose reductase, an enzyme involved in the sorbitol pathway, resulting in the accumulation of sorbitol in the lens, sorbitol is a hyperosmotic molecule and any hydration will form opacities.

Incorrect Options:

Options A, B, and D are incorrect. Refer to Option C for an explanation. 

Also Read: INI-CET Previous Year Question Papers

5. During a routine eye examination using slit lamp biomicroscopy, the ophthalmologist uses a specific non-contact concave lens for detailed examination of the posterior segment of the eye. Which of the following is a non-contact concave lens used in Slit lamp bimicroscopy?

A. Goldman three mirror

B. Hruby Lens

C. Scheimpflug lens

D. Keratometer

Correct Option B – Hruby lens:

• The Hruby lens is a non-contact concave lens used in slit lamp biomicroscopy for the examination of the posterior segment of the eye. It is particularly valuable for conducting indirect ophthalmoscopy, which allows for a comprehensive evaluation of the fundus, including the retina, macula, optic disc, and retinal vasculature. The Hruby lens provides a high level of magnification and offers a wide field of view, making it a versatile tool for ophthalmologists and optometrists when assessing various retinal conditions and abnormalities

Incorrect Options:

Option A - Goldmann three-mirror lens:

• The Goldmann three-mirror lens is indeed used in ophthalmology, but it is a contact lens rather than a non-contact lens. It is commonly employed for gonioscopy, which involves examining the iridocorneal angle. It is also used in slit lamp biomicroscopy with this the central as well as peripheral parts of the fundus can be visualized.

Option C - Scheimpflug lens:

• The Scheimpflug lens is not typically used in slit lamp biomicroscopy. Instead, it is associated with Scheimpflug imaging technology used in devices like Scheimpflug cameras for corneal and anterior segment imaging.

Option D - Keratometer:

• A keratometer is used to measure the curvature of the cornea and assess corneal astigmatism. It is not designed for fundus examination or slit lamp biomicroscopy.

6. During a routine eye examination, a 40-year-old patient is asked to read letters on the chart shown below. The patient struggles to read the smaller letters and reports blurred vision.

Which aspect of the patient's visual perceptions is assessed through this chart?

A. Light sense

B. Form sense

C. Color sense

D. Contrast sense

Correct Option B - Form sense:

• The Snellen chart is commonly used to assess visual acuity, which is a measure of the eye's ability to distinguish the details and form of objects. Form sense is measured by visual acuity. In this scenario, the patient's struggle to read the smaller letters and reporting blurred vision suggests a difficulty in perceiving the form or details of the letters, indicating an issue with form sense or visual acuity.

Incorrect Options:

Option A – Light sense:

• Light sense, also known as photopic vision, refers to the ability to perceive and differentiate levels of brightness or light intensity. The Snellen chart primarily assesses visual acuity (form sense) rather than sensitivity to light.

Option C – Color sense:

• Color sense, or color vision, is the ability to perceive and differentiate between different colors. The Snellen chart is not designed to assess color vision; it focuses on form sense and visual acuity.

Option D – Contrast sense:

• Contrast sense involves the ability to distinguish any object from its background. While visual acuity is related to contrast sensitivity, the Snellen chart primarily assesses the clarity and resolution of the visual image (form sense) rather than contrast sensitivity.

7. A 62-year-old male with a 15-year history of type 2 diabetes mellitus presents to the ophthalmology clinic with complaints of dimunition of vision in his left eye for the past three months. Optical coherence tomography (OCT) is performed, showing the findings given below. What is the most probable diagnosis?

A. Cystoid macular edema

B. Central serous retinopathy

C. Retinal detachment

D. Age related macular degeneration

Correct Option A - Cystoid macular edema :

• The OCT examination in the above patient shows presence of cystoid spaces filled with fluid . These findings along with the presenting clinical features indicate the presence of cystoid macular edema.

CME (Cystoid Macular Edema)

Cystoid macular edema (CME) is swelling of the layers of the neurosensory retina within the macula. When excess fluid builds in the retina, it typically collects in “pockets,” referred to as “cysts.”

Signs and Symptoms:

• Slow, painless loss of vision
• Metamorphopsia (distortion of shape)
• Micropsia (objects appear small and distorted) or macropsia (objects appear large and distorted)

Diagnostic Tools:

• Amsler's grid
• +90 D lens (best instrument to examine CME)

Investigations:

Fluorescein Angiography (FA):

• Dye used: Fluorescein Sodium
• Arm retina circulation time: 12 seconds
• Pattern of leak indicates pathology
• Limitations: invasive and may cause allergy

Optical Coherence Tomography (OCT):

• Gold standard investigation for all macular disorders
• Non-invasive
• Provides a cross-sectional view of the retina

Incorrect Options:

Option B - Central serous retinopathy: It typically presents with serous retinal detachment and fluid accumulation underneath the neurosensory retina, often occurring in younger patients and often associated with stress or corticosteroid use.

Option C - Retinal detachment : It involves the separation of the neurosensory retina from the underlying retinal pigment epithelium and is associated with symptoms like flashes of light and a sensation of a "curtain" coming down over the vision.

Option D - Age related macular degeneration : It is characterized by the gradual deterioration of the macula, often leading to central vision loss, but it usually presents with drusen and pigmentary changes, rather than cystic spaces seen in CME.

8. A 45-year-old patient presents with a complaint of visual disturbances. After ocular examination, the ophthalmologist decides to perform B-scan ultrasonography. The ultrasound reveals a dome-shaped elevation with a hypoechoic center and a hyperechoic rim resembling a collar button. Which of the following is the most likely diagnosis?

A. Retinoblastoma

B. Neurofibroma

C. Choroidal malignant melanoma

D. Retinal astrocytoma

Correct Option C – Choroidal malignant melanoma:

• The characteristic B-scan finding of a dome-shaped elevation with a hypoechoic center and a hyperechoic rim resembling a collar button is highly suggestive of an intraocular tumor, particularly a choroidal malignant melanoma. Choroidal melanomas often present with this distinctive appearance on ultrasound.

Incorrect Options:

Option A - Retinoblastoma: Retinoblastoma is a malignant tumor that arises from immature retinal cells in young children, typically before the age of 5, and is characterized by leukocoria (commonest presentation), strabismus, an absent red reflex on physical examination, and CT head shows calcification of the tumor. 

Option B - Neurofibroma: Neurofibromas are tumors that arise from nerve sheath cells and are often associated with the genetic disorder neurofibromatosis. In plexiform neurofibroma, S-shaped deformity of the lid is observed.

Option D - Retinal astrocytoma: Astrocytoma of the retina and optic nerve head are endophytic, protruding into the vitreous. Most frequently seen in tuberous sclerosis and occasionally in association with neurofibromatosis type 1 and retinitis pigmentosa. On the B scan, hyperautofluorescence is seen in calcified areas with hypoautofluorescence elsewhere.

9. A 59-year-old female presents to the emergency department with complaints of sudden difficulty seeing and headache. She has a history of lung cancer. Upon examination, the patient was unable to move her body. The visual field of this patient is illustrated in the image below:

Which of the following is the most likely site of the lesion in this patient?

A. Meyer Loop

B. Parietal Lobe

C. Right Occipital Lobe

D. Macula

Correct Option A - Meyer Loop:

• This female patient, who presented with sudden difficulty in vision, headache, and a history of lung cancer (commonly metastasizing to the brain), is most likely suffering from a lesion in the left temporal lobe causing right superior quadrantanopia.
• Meyer's loop comprises the most anterior extension of the optic radiation in the temporal horn. Any lesion to these fibers leads to contralateral superior quadrantanopia, as seen in this case.

Incorrect Options:

Option B - Parietal Lobe:

• The lesion to the parietal lobe results in inferior quadrantanopia instead of superior quadrantanopia. The inferior quadrantanopia is illustrated in the image below:

Option C - Right occipital lobe

• The lesion to the right occipital lobe results in left hemianopia with macular sparing, as shown in the image below:

Option D – Macula

• The lesion to the macula results in central scotoma and not superior quadrantanopia.

10. A 40-year-old man recently recovered from a stroke and complains of double vision when he gazes to the right since the episode of stroke. On examination, when the patient was asked to focus on a finger placed to his right, his left eye was observed to abduct. He could also not focus on a finger placed at the tip of his nose. What is the most likely underlying defect?

A. Lesion of the paramedian pontine reticular formation

B. Bilateral internuclear ophthalmoplegia

C. Frontal eye field lesion

D. Unilateral internuclear ophthalmoplegia

Correct Option B - Bilateral internuclear ophthalmoplegia:

• Complaints of double vision when gazing to the right suggest dysfunction in horizontal eye movement coordination. The left eye abducts when focusing on the right, which is a characteristic sign of Bilateral INO.
• The difficulty converging on a finger placed at the tip of the nose is consistent with the horizontal eye movement coordination impairment seen in INO. When seen in association with the symptom above it is called WEBINO syndrome.
• WEBINO (Wall-Eyed Bilateral Internuclear Ophthalmoplegia) specifically refers to a syndrome where bilateral INO is associated with exotropia (eyes turned outward) in the primary position of gaze. This gives the appearance of both eyes deviating outward, resembling a "wall-eyed" appearance.

Incorrect Options:

Option A - Lesion of paramedian pontine reticular formation:

• Lesions in the paramedian pontine reticular formation can cause ipsilateral horizontal gaze palsy. However, the specific findings of the left eye failing to adduct when focusing to the right and difficulty converging on a finger placed at the tip of the nose are more indicative of a lesion in the medial longitudinal fasciculus (MLF), which is associated with internuclear ophthalmoplegia.

Option C - Frontal eye field lesion:

• Frontal eye field lesions typically result in contralateral horizontal gaze palsy (eyes deviating toward the side opposite the lesion). The described symptoms, such as the left eye failing to adduct when focusing to the right, are inconsistent with a frontal eye field lesion.

Option D - Unilateral internuclear ophthalmoplegia:

• Unilateral Internuclear Ophthalmoplegia (INO) typically involves impairment of horizontal eye movement coordination due to dysfunction of the medial longitudinal fasciculus (MLF) on one side. It results in the inability of one eye to adduct when looking laterally. Here convergence is normal.

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