02 - Fundamentals and Principles of Ophthalmology

1. If all the nerves passing through the annulus of Zinn were transected,
what nerve would continue to function?
a. superior division of cranial nerve III
b. cranial nerve IV
c. nasociliary branch of cranial nerve V (V1)
d. optic nerve
2. Which extra ocular muscle originates from the annulus of Zinn?
a. levator palpebrae superioris
b. superior oblique
c. lateral rectus
d. inferior oblique
3. What is the ratio of optic nerve axons that cross at the optic chiasm to
those that do not cross at the optic chiasm?
a. 67:33
b. 50:50
c. 30:70
d. 53:47
4. A patient presents with left-sided ophthalmoplegia and forehead
numbness. The lesion is most likely to be located at the
a. brainstem
b. cavernous sinus
c. superior orbit
d. intraconal space
5. The first cells to develop in the embryonic retina are the
a. ganglion cells
b. photoreceptors
c. amacrine cells
d. bipolar cells

6. Which disorder is associated with a defect in a non mitochondrial gene?

a. Leber hereditary optic neuropathy
b. chronic progressive external ophthalmoplegia
c. neuropathy, ataxia, and retinitis pigmentosa
d. retinoblastoma
7. What characteristic of retinoblastoma may facilitate its diagnosis as a
familial condition?
a. It may be associated with chromosome 11 short-arm deletion syndrome and
Wilms tumor.
b. It affects approximately 1 per 100,000 live births in the United States.
c. Approximately 90% of patients with hereditary retinoblastoma have a family
history of the disease.
d. The hereditary pattern in familial retinoblastoma is autosomal dominant, but
the defect is mitochondrial at a cellular level.
8. Mutations in the rhodopsin gene are associated with what inherited
ocular disease?
a. juvenile glaucoma
b. Leber hereditary optic neuropathy
c. retinitis pigmentosa
d. Stargardt disease
9. Mitochondrial inheritance is transmitted by what route?
a. paternal mitochondria
b. maternal mitochondria
c. acquired mitochondria
d. de novo mitochondria
10. Mutations of PAX6 are associated with what disorder?
a. aniridia
b. retinal coloboma
c. renal hypoplasia
d. corneal granular dystrophy

11. An unaffected woman has a brother, maternal uncle, and son affected
with retinitis pigmentosa. What is the most likely mode of inheritance?
a. autosomal dominant
b. X-linked recessive
c. autosomal recessive
d. sporadic
12. What is the basis for complex genetic diseases?
a. a single recessive gene
b. X-linked genes
c. a single spontaneous genetic mutation
d. the resultant effect of many genes, in combination with health habits and
environmental factors
13. What structure, if inflamed, would be considered a sign of uveitis?
a. optic nerve
b. Descemet membrane
c. choroid
d. retinal pigment epithelium
14. What pair accurately matches a cell-type origin with the correct tearlayer product?
a. goblet cells- lipid layer
b. meibomian glands-mucin layer
c. glands of Krause-aqueous layer
d. glands of Wolfring-mucin layer
15. What option most accurately describes the immunoglobulin(s) that can
be found in the tear film?
a. IgA only
b. IgA and IgG only
c. IgG and IgM only
d. IgA, IgG, IgM, and IgD
16. What intraocular structure is a true basement membrane (basal
lamina)?
a. Bowman layer
b. zonule of Zinn
c. Descemet membrane
d. anterior border layer of iris

17. What is the principal structural protein in the Descemet membrane?

a. type I collagen
b. type II collagen
c. type III collagen
d. type IV collagen
18. What mechanism holds the flap created during laser in situ
keratomileusis (LASIK) in place after surgery?
a. endothelial- Descemet membrane interaction
b. endothelial pump
c. Bowman layer- stromal adhesions
d. Stromal collagen adhesions
19. What property of the retina renders it susceptible to oxidative stress?
a. high content of polyunsaturated fatty acids in photoreceptor outer segments
b. high concentration of carotenoids compared with other intraocular structures
c. presence of vitamin E
d. absence of retinal vessels in the foveal avascular zone
20. What pigment within the retinal pigment epithelium is responsible for
the signal generated in fundus auto fluorescence imaging?
a. melanin
b. lipofuscin
c. rhodopsin
d. lutein
21. The retinal pigment epithelium is the first site of melanogenesis in the
body. Ocular melanin has been shown to participate in what process?
a. pathogenesis of retinitis pigmentosa
b. vitamin A metabolism
c. retinal adhesion
d. retinal development and neuronal migration
22. Age-related loss of type IX collagen has been implicated in what process
related to the vitreous?
a. vitreous hemorrhage
b. angiogenesis
c. increased diffusion of oxygen from the anterior segment into the posterior
segment
d. vitreous liquefaction

23. What vitamin is most critical for the photoreceptor response to light?
a. A
b. B
c. C
d. E
24. In prescribing for elderly patients, what pharmacologic adjustments
must be considered?
a. Hepatic perfusion and enzymatic activity increase with age.
b. Renal function decreases with age.
c. Elderly patients have more albumin relative to weight.
d. Elderly patients have more body water relative to weight.
25. What technique or strategy improves the ocular absorption of eye
drops?
a. rapid instillation of eye drops one after the other without interruption
b. application of digital pressure at the lateral canthus to prevent the eye drop
from escaping
c. keeping the eye open and rolling the eye around after instillation of each drop
d. increasing the viscosity of the delivery vehicle
26. Atropine, 1%, has how many milligrams of drug per drop, assuming 20
drops per milliliter?
a. 1 mg
b. 0.5 mg
c. 0.1 mg
d. 0.05 mg
27. How much epinephrine is present in 1 mL of the 1:10,000 epinephrine
solution?
a. 1 mg of epinephrine
b. same amount of epinephrine as in 1 mL of 0.01% epinephrine
c. same amount of epinephrine as in 1 mL of 1:1000 epinephrine
d. same amount of epinephrine as in 1 mL of 0.1% epinephrine
28. Direct-acting muscarinic agents (miotics) have what clinical effect?
a. hyperopic shift in refraction
b. increased range of accommodation
c. central anterior chamber deepening
d. increased night vision

29. What management strategy has been shown to reduce postsurgical

endophthalmitis?
a. preoperative preparation of the eye with topical povidone-iodine
b. intracameral vancomycin
c. intracameral aminoglycosides
d. subconjunctival fluoroquinolones
30. What property of latanoprost may limit its usefulness?
a. It is a pro drug of prostaglandin E20.
b. It reduces intraocular pressure by increasing trabecular meshwork outflow.
c. It can cause darkening of the iris and periocular skin and hypertrichosis of the
eyelashes.
d. It increases the number of melanocytes.
31. What systemic side effect may result from treatment with oral carbonic
anhydrase inhibitors?
a. insomnia
b. weight gain
c. hyperkalemia
d. aplastic anemia
32. What is a clinically important property of brimonidine?
a. Brimonidine is a selective a 1-adrenergic agonist.
b. Brimonidine is more lipophilic than apraclonidine.
c. Brimonidine has been associated with tachycardia and hyperventilation when
used in infants.
d. Rates of tachyphylaxis and allergic reaction are higher in brimonidine than in
apraclonidine.

Answers
1. b. Cranial nerve IV passes through the superior orbital fissure but not through
the annulus Of Zinn.
2. c. The lateral rectus muscle originates from the annulus of Zinn. The superior,
inferior, medial, and lateral rectus muscles all arise from the annulus of Zinn.
3. d. Anatomical studies demonstrate that more axonal fibers cross at the optic
chiasm than do not cross, in a 53:47 ratio.
4. b. The cavernous sinus is where the trigeminal nerve (ophthalmic branch) and
the nerves controlling eye movement are in proximity to one another.
5. a. The ganglion cells are the first cells to differentiate in the embryonic eye.
6. d. The hereditary pattern in familial retinoblastoma is autosomal dominant and
associated with a mutation in the nuclear tumor-suppressor gene on chromosome
13 (the retinoblastoma, or RBl, gene). The other conditions named have been
associated with mutations in mitochondrial genes.
7. c. The retinoblastoma gene is located on the long arm of chromosome 13. The
aniridia gene, PAX6, and the Wilms tumor gene are adjacent on chromosome 11;
their proximity is important to recognize, as children with aniridia need to be
screened for Wilms tumor.
Retinoblastoma occurs at a rate of approximately 1 per 15,000-20,000 li\e births.
Most cases of retinoblastoma are unilateral and not inherited. Of people who
inherit the gene mutation, 90% will develop retinoblastoma (90% penetrance).
8. c. More than 100 different mutations in the rhodopsin gene are known to cause
retinitis pigmentosa. Juvenile glaucoma is associated with myocilin mutations,
Leber hereditary optic neuropathy is associated with mitochondrial DNA
mutations, and Stargardt disease is associated with ABCA4 gene mutations.
9. b. A significant number of disorders associated with the eye or visual system
involve mitochondrial deletions or mutations. Because a fertilized embryo
receives most of its mitochondria from the egg (maternal side), mitochondrial
disease should be considered whenever the inheritance pattern of a trait suggests
maternal transmission.

10. a. A PAX6 mutation is associated with aniridia. The PAX6 gene product is a
transcription factor that is required for normal development of the eye. Almost
all cases of aniridia are the result of PAX6 mutations.
11. b. Three affected males connected through an unaffected female suggest an
X-linked inheritance. The other modes are possible but much less likely.
12. d. Many common eye diseases are complex genetic diseases involving the
effects of multiple genes. Examples include glaucoma, age-related macular
degeneration, and myopia.
The combined effects of many genes, along with health habits and environmental
factors, result in the disease.
13. c. The optic nerve, cornea, and retinal pigment epithelium are not part of the
uvea. The uveal tract is the main vascular compartment of the eye and consists of
the iris, ciliary body, and choroid.
14. c. Goblet cells produce the mucin layer, and meibomian glands form the lipid
layer. Glands of Krause and Wolfring produce the aqueous layer.
15. d. Proteins in the tear film include immunoglobulin A (IgA) and secretory
IgA (sigA). IgA is formed by plasma cells in interstitial tissues of the main and
accessory lacrimal glands and by the substantia propria of the conjunctiva. The
secretory component is produced within lacrimal gland acini, and sigA is
secreted into the lumen of the main and accessory lacrimal glands. IgA plays a
role in local host -defense mechanisms of the external eye, as shown by
increased levels of IgA and IgG in human tears associated with ocular
Inflammation. Other immunoglobulins in tears are IgM, IgD, and IgE. Vernal
conjunctivitis causes elevated tear and serum levels of IgE, increased IgEproducing plasma cells in the giant papillae of the superior tarsal conjunctiva,
and elevated histamine levels.
16. c. The Descemet membrane is a true basement membrane produced by the
basolateral surfaces of the basal layer of the corneal endothelium.
17. d. The Descemet membrane is a 10-12-f.Lm-thick basement membrane
between the endothelium and the posterior corneal stroma. Type IV collagen is
the most abundant collagen in the Descemet membrane. Type I collagen,
however, is the major collagen component of the corneal stroma.

18. b. The endothelial pump is responsible for generating the negative

hydrostatic pressure that is necessary for holding the laser in situ keratomileusis
(LASIK) flap in place after surgery.
19. a. polyunsaturated fatty acids have increased numbers of carbon-carbon
double bonds, which enhances their susceptibility to lipid peroxidation.
Other aspects of the retina that increase its susceptibility to oxidative stress
include an increased concentration of mitochondria, a high oxygen tension, and
photo-oxidation triggered by light exposure.
20. b. Lipofuscin molecules are the fine yellow-brown pigment granules of the
retina. They are thought to be "wear-and-tear" deposits resulting from
phagosomal activity. Histologically, lipofuscin stains with Sudan stain and
exhibits auto fluorescence.
21. d. Melanin acts as a neutral-density filter on all wavelengths of light. Patients
with oculo cutaneous albinism have foveal hypoplasia and more contralateral
projections of the retinal ganglion cells, thought to be due to reduced melanin
levels resulting from defects in the tyrosinase gene. Additional functions of
melanin include stabilization of free radicals and detoxification.
22. d. Vitreous liquefaction, also known as syneresis, begins with the breakdown
of collagen fibrils into smaller fragments. This liquefaction is thought to occur
because of a loss of "shielding" of type II collagen by type IX collagen. This
process has no direct effect on the development of vitreous hemorrhage unless it
leads to the development of posterior vitreous detachment (PVD).
A PVD can protect against retinal neovascularization by eliminating the scaffold
for fibrovascular proliferation. Oxygen tension increases in the posterior
chamber in post vitrectomized eyes.
23. a. 11-cis-retinal is a vitamin A derivative. Vitamins C and E play antioxidant
roles in the retina but do not participate in the light response of the retina.
24. b. Compared with younger patients, older patients have less lean body mass
because of decreased muscle bulk, less body water, decreased albumin, and
increased relative adipose tissue. These physiologic differences alter tissue
binding and drug distribution.
Human renal function decreases with age. Hepatic perfusion and enzymatic
activity decrease with age.

25. d. Increased viscosity of the vehicle generally increases drug retention in the
inferior culde-sac, aiding drug penetration.
26. b. A 1% solution has 1 g/ 100 mL, or 1000 mg/ 100 mL, of active ingredient.
Assuming there are 20 drops/mL, 1 drop contains 0.05 mL of drug. Multiplying
1000 mg/100 mL x 0.05 mL yields 0.5 mg per drop of atropine available for
systemic absorption.
27. b. A 1:10,000 dilution has 1 g of drug in 10,000 mL (or 1000 mg/10,000
mL). This concentration is equivalent to a 0.01% solution (0.01 g/100 mL, or 10
mg/100 mL). One milliliter of the 1:10,000 dilution of epinephrine contains 0.1
mg of epinephrine. If the concentration of the solution increases to 1:1000, 0.1
mL of it contains the same amount of epinephrine as in 1 mL of the 1:10,000
solutions.
28. b. Miotic agents constrict the pupillary sphincter and the ciliary muscle.
Ciliary muscle contraction results in increased myopia and a decreased central
anterior chamber. Pupillary constriction causes decreased night vision but
increases the range of accommodation (pinhole effect).
29. a. Topical povidone-iodine solution, 5%, exhibits broad-spectrum
antimicrobial activity when used to prepare the surgical field and rinse the ocular
surface. It has been shown to have a significant effect on postsurgical
endophthalmitis.
30. c. Latanoprost is a prodrug of prostaglandin F2a that reduces the intraocular
pressure primarily by increasing the uveoscleral outflow. It increases the number
of melanosomes (increased melanin content, or melanogenesis) within the
melanocytes but has not been shown to cause melanocytosis (increased number
of melanocytes).
31. d. Use of oral carbonic anhydrase inhibitors can cause paresthesias,
imbalance, anorexia, weight loss, hypokalemia, somnolence, kidney stones,
metabolic acidosis, and aplastic anemia.
32. b. Brimonidine is a selective a2-adrenergic agonist. It is more lipophilic than
apraclonidine and penetrates the blood- brain barrier better. Its use in infants is
contraindicated, and it should be used with caution in small children because of
severe systemic toxicities, in particular bradycardia and apnea. Brimonidine has
lower rates of tachyphylaxis and allergic reaction than apraclonidine.