SPEX Exam Ophthalmology — Questions and Answers
Question 1: A 65-year-old man presents with sudden-onset severe right eye pain, headache, nausea, and blurred vision. The eye appears red, the cornea is hazy, and the pupil is mid-dilated and non-reactive. The most likely diagnosis is:
- Acute anterior uveitis
- Acute angle-closure glaucoma (Correct answer)
- Bacterial conjunctivitis
- Corneal abrasion
Correct answer: Acute angle-closure glaucoma
Acute angle-closure glaucoma is an emergency characterized by sudden severe eye pain, headache (often with nausea/vomiting), decreased vision, a steamy/hazy cornea due to edema, and a mid-dilated non-reactive pupil (the iris blocks aqueous outflow). Intraocular pressure rises acutely. Anterior uveitis causes a small, irregular, photophobic pupil and perilimbal flush. Conjunctivitis produces discharge with a clear cornea. Corneal abrasion causes pain and tearing but not pupil changes or corneal haziness.
Question 2: A 72-year-old hypertensive woman reports sudden, painless, complete loss of vision in her right eye. On fundoscopy, the retina appears pale and edematous with a 'cherry-red spot' at the fovea. The most likely diagnosis is:
- Central retinal vein occlusion
- Vitreous hemorrhage
- Central retinal artery occlusion (Correct answer)
- Anterior ischemic optic neuropathy
Correct answer: Central retinal artery occlusion
Central retinal artery occlusion (CRAO) presents with sudden, painless, monocular blindness. The fundus shows diffuse retinal whitening/pallor (ischemic edema) except at the fovea, where the thin tissue allows the underlying choroidal blood supply to show through as a 'cherry-red spot.' Central retinal vein occlusion causes flame hemorrhages throughout all quadrants ('blood and thunder' fundus). Vitreous hemorrhage obscures the fundus view. AION causes optic disc pallor/swelling without the cherry-red spot pattern.
Question 3: A 30-year-old woman presents with a painful red eye, photophobia, and excessive tearing. She wears contact lenses daily and reports sleeping in them. Slit-lamp examination reveals a central corneal ulcer with mucopurulent discharge. The most appropriate initial management is:
- Topical corticosteroids to reduce inflammation
- Oral acyclovir empirically for presumed HSV keratitis
- Immediate referral to ophthalmology and discontinuation of contact lens wear (Correct answer)
- Saline irrigation and patching of the eye
Correct answer: Immediate referral to ophthalmology and discontinuation of contact lens wear
A contact lens wearer with a painful red eye and central corneal ulcer has a microbial keratitis (bacterial, often Pseudomonas aeruginosa) until proven otherwise. This is a vision-threatening emergency requiring urgent ophthalmology referral, corneal culture, and intensive topical antibiotics (fluoroquinolone). Contact lenses must be removed immediately. Topical steroids can worsen bacterial or fungal ulcers. Patching is contraindicated in bacterial ulcers. Oral acyclovir is for systemic HSV, not contact lens keratitis.
Question 4: A 60-year-old man with poorly controlled diabetes reports gradually worsening vision in both eyes over 2 years. Fundoscopy shows microaneurysms, dot-blot hemorrhages, hard exudates near the macula, and new vessel proliferation on the optic disc. The stage of retinopathy is:
- Mild non-proliferative diabetic retinopathy
- Moderate non-proliferative diabetic retinopathy
- Severe non-proliferative diabetic retinopathy
- Proliferative diabetic retinopathy (Correct answer)
Correct answer: Proliferative diabetic retinopathy
Neovascularization (new vessel growth) on the optic disc or elsewhere defines proliferative diabetic retinopathy (PDR), regardless of other background changes. PDR carries risk of vitreous hemorrhage and traction retinal detachment. Non-proliferative stages (mild, moderate, severe) are defined by increasing microaneurysms, hemorrhages, venous beading, and IRMA—but no new vessels. PDR requires urgent ophthalmology referral for panretinal laser photocoagulation or anti-VEGF therapy.
Question 5: A 25-year-old construction worker presents with sudden eye pain after hammering metal. He reports a small object hitting his eye. Visual acuity is 20/40. The eye is injected, and there is a small, irregular pupil with a positive Seidel test on slit-lamp. The priority management is:
- Irrigate the eye copiously and patch it
- Apply a topical anesthetic and foreign body removal at the bedside
- Immediate ophthalmology consultation for suspected open globe injury (Correct answer)
- Prescribe topical fluoroquinolone drops and follow up in 48 hours
Correct answer: Immediate ophthalmology consultation for suspected open globe injury
A positive Seidel test (aqueous humor streaming through fluorescein at a wound site) with an irregular pupil in the setting of penetrating trauma indicates an open globe injury. No pressure should be applied to the eye; bedside foreign body removal is contraindicated as it can express intraocular contents. The eye should be shielded (not patched), and the patient made NPO for urgent surgical repair by ophthalmology. Topical antibiotics and discharge are inappropriate for an open globe.
Question 6: A 78-year-old woman reports gradual, painless loss of central vision over 3 years. She has difficulty recognizing faces but can navigate by peripheral vision. Fundoscopy shows drusen deposits and geographic atrophy in the macular region. Which form of macular degeneration does she have?
- Wet (exudative/neovascular) AMD
- Dry (atrophic) AMD (Correct answer)
- Central serous chorioretinopathy
- Macular hole
Correct answer: Dry (atrophic) AMD
Dry (atrophic) AMD is characterized by the gradual accumulation of drusen (yellowish extracellular deposits) and progressive geographic atrophy of the retinal pigment epithelium. It causes slow central vision loss; peripheral vision is preserved. Wet AMD involves choroidal neovascularization, subretinal fluid/hemorrhage, and more rapid vision loss—it is treated with anti-VEGF injections. Central serous chorioretinopathy affects younger patients. Macular holes produce a distinct round defect on imaging.
SPEX Exam Ophthalmology
A 65-year-old man presents with sudden-onset severe right eye pain, headache, nausea, and blurred vision.
The eye appears red, the cornea is hazy, and the pupil is mid-dilated and non-reactive.
The most likely diagnosis is: