The Eye-Q Challenge: From Clinics to Curiosity

QUIZ QUESTIONS A 28-year-old asymptomatic male presents for a routine eye examination. His visual acuity is 6/6 in both eyes. Fundus image [Figure 1] is given below. No signs of hemorrhage or exudation are seen. The other eye appears normal. What will be the treatment plan for the patient? A 42-year-old male following blunt ocular trauma to right eye presented to OPD with complaints of mild pain. Vision was normal and IOP being 16 mmHg in both eyes. Gonioscopy revealed the following picture [Figure 2]. Rest ocular examination was normal. What is the finding shown and risk associated? A 7-year-old girl is brought in by her parents for a routine eye examination. Visual acuity in the right eye is 6/12 and left eye is 6/6. Clinical photograph is shown [Figure 3]. There is no history of ocular trauma, systemic illness, or medication use. Identify the type of disease and treatment plan? A 52-year-old male had sustained road traffic accident and presented with eye pain and gross diminution of vision [Figure 4]. The clinical picture is provided. Which suturing technique is preferred while doing a limbal to limbal corneal wound repair? Newly diagnosed patient with B cell ALL referred from Oncology had presented with drop in left eye vision and pain. Fundus examination is shown [Figure 5], and the right eye of the patient was normal. What is the possible reason for the fundus appearance. A 12-year-old boy presents with gradually progressive bilateral diminution of vision. Slit-lamp picture has been given [Figure 6]. Gonioscopy reveals angle crowding, and IOP is 28 mmHg in both eyes. Systemic examination shows long fingers and hypermobile joints. Identify the systemic condition and type of glaucoma associated commonly. A 64-year-old female patient presented with gradual onset gross diminution of vision following cataract surgery. Name three conditions commonly associated with the slit-lamp picture shown [Figure 7] A 6-year-old child presents with developmental delay, coarse facial features, hepatosplenomegaly, and corneal clouding. Ophthalmic exam reveals bilateral diffuse stromal haze with intact epithelium and endothelium [Figure 8]. Fundus view is obscured. Hearing loss, recurrent respiratory infections, and CNS dysfunction are also reported. Treatment options for the condition and will corneal clouding reduce with treatment? A 29-year-old girl is brought with complaints of droopy eyelids since birth. Clinical picture has been provided [Figure 9]. Her father also has similar facial features. What is the diagnosis and common genetic association. A 34-year-old one-eyed male patient presented with difficulty in vision and IOP of 28 mmHg. The optic disc picture is given [Figure 10]. What is the best possible mode of intervention? Figure 1: Fundus photograph of patient showing defined CHRPE lesionsFigure 2: Gonioscopic picture showing widened ciliary body band and wide open angleFigure 3: Slitlamp photograph showing sutural cataract with co-existing blue dot componentFigure 4: Clinical photograph of patient with open globe injury with limbus to limbus corneal tearFigure 5: Fundus photograph showing extensive disc edema with surrounding hemorrhageFigure 6: Slit-lamp photograph showing subluxation of crystalline lens with intact zonulesFigure 7: Slit-lamp photograph showing Anterior lens capsule phimosisFigure 8: Clinical photograph showing dense corneal clouding with central sparingFigure 9: Clinical photograph showing blepharophimosis, ptosis and telecanthusFigure 10: Disc photograph of patient showing signs of advanced cuppingANSWERS CHRPE lesion. Referral to gastro-enterology for ruling out FAP. Annual ophthalmology review.Explanation: The lesion described is consistent with Congenital Hypertrophy of Retinal Pigment Epithelium. While solitary CHRPE is typically benign and requires no treatment, multiple, bilateral, or atypical (bear track or “groucho” shaped) CHRPE lesions can be associated with Familial Adenomatous Polyposis (FAP), especially in patients with a family history of colorectal cancer.Widening of ciliary body band. Angle recession. Check IOP and regular follow-up.Explanation: Blunt trauma can cause a tear between the longitudinal and circular muscle fibers of the ciliary body, leading to a widened ciliary body band visible on gonioscopy. Over time, this can damage the trabecular meshwork, leading to reduced aqueous outflow and secondary open-angle glaucoma. This mechanism is not inflammatory, nor does it involve angle closure or neovascularization in most cases. It can occur from days to years after trauma.Congenital cataract: Sutural cataract with Blue dot cataract. Plan for lens extraction with Posterior Chamber Intra-ocular lens placement in same sitting.Explanation: Cataract is one of the leading causes of reversible blindness worldwide in paediatric population. In general, paediatric cataract significantly impacts the child visual development and also their family both emotionally and financially. However, there are certain types of developmental cataract like Blue dot cataract, are innocuous and will not cause any visual morbidity. Sutural cataract involves opacification of the anterior and posterior Y suture, which can rarely affect vision and when affected it is wise to intervene early.Rowsey Hayes Technique of corneal wound repairExplanation: The limbal sutures are placed first. Sutures in corneal periphery should be long and closely placed with adequate tightness. The sutures towards the visual axis should be short and widely spaced and no suture placement at the corneal apex. The conjunctiva must be dissected to look for any scleral extension of wound and needs to be repaired to the posterior most extent possible.Direct leukemic infiltration of the optic nerve headExplanation: B-cell ALL commonly involves the central nervous system (CNS) and orbit. The optic nerve head is a site where systemic chemotherapy penetrates poorly, predisposing to direct leukemic infiltration. Clinical features: unilateral vision loss, optic disc swelling with creamy infiltrate, sometimes vitreous cells. Differentiation from papilledema: papilledema is usually bilateral and linked to raised intracranial pressure, whereas leukemic infiltration may be unilateral and nodular.Weil-Marchesani syndrome and Secondary angle closure glaucoma due to forward subluxation of small lensExplanation: Microspherophakia = abnormally small, spherical crystalline lens. Seen in Weill–Marchesani syndrome. Association of microspherophakia with temporal coloboma is extremely rare. Anterior dislocation of crystalline lens leads to pupillary block and secondary glaucoma in these patients.ALC Phimosis. High myopia, Pseudoexfoliation, and Retinitis pigmentosa.Explanation: Anterior lens capsule phimosis refers to constriction and shrinkage of the capsulorhexis opening after cataract surgery, leading to a progressive reduction in the size of the anterior capsule opening. Nd:YAG capsulotomy and surgical release can be performed.Enzyme replacement therapy and bone marrow transplantation. Corneal clouding is irreversible.Explanation: Hurler syndrome, Scheie and Maroteaux-Lamy are commonly associated with corneal opacity. Hunter and San-fillippo are not commonly associated with corneal clouding.BPES (Blepharaphimosis Ptosis Epicanthus inversus) syndrome. FOXL2 gene mutation.Explanation: Blepharophimosis, Ptosis, Epicanthus Inversus Syndrome (BPES) is a rare genetic disorder characterized primarily by four distinct features including telecanthus. BPES is an autosomal dominant disorder caused by mutations in the FOXL2 gene located on chromosome 3q23. Two types of BPES has been described, type 1 BPES with ovarian insufficiency and type 2 with only major ocular features.Augmented Trabeculectomy (MMC 0.02%)Explanation: The optic disc image shows advanced cupping and best method to reduce IOP is by performing an Augmented (MMC) trabeculectomy as IOP lowering is maximum with trabeculectomy than tube surgery. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.