The Massachusetts Eye and Ear Infirmary Review Manual for

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3rd Edition, © 2006 by Lippincott Williams & Wilkins
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Library of Congress Cataloging-in-Publication Data

The Massachusetts Eye and Ear Infirmary review manual for ophthalmology /
Veeral S. Sheth … [et al.]. — 4th ed.
p. ; cm.
Review manual for ophthalmology
Red. ed. of: The Massachusetts Eye and Ear Infirmary review manual for ophthalmology / Rama D.
Jager, Jeffrey C. Lamkin.
3rd ed. c2006.
Includes bibliographical references and index.
 ISBN 978-1-4511-1136-1 (alk. paper)
1. Ophthalmology—Examinations, questions, etc. 2. Eye—Diseases—Examinations,
questions, etc. I. Sheth, Veeral S. II. Jager, Rama D. Massachusetts Eye and Ear Infirmary
review manual for ophthalmology. III. Massachusetts Eye and Ear Infirmary. IV. Title:
Review manual for ophthalmology.
[DNLM: 1. Eye Diseases—Examination Questions. 2. Eye—Examination Questions. WW 18.2]
RE49.L35 2011
617.7’15—dc23
2011014078

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dosage set forth in this text are in accordance with current recommendations and practice at the time
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 Dedicated to
To our mentors—past, present, and future—who guide us.
To our daughters, born during the production of this edition:
Simryn, Sophia, and Margaux.
CONTENTS

1 General Medicine

2 Fundamentals of Ophthalmology

3 Optics

4 Ocular Pathology

5 Neuroophthalmology

6 Oculoplastics

7 Intraocular Inflammation and Uveitis

8 Glaucoma, Lens, and Anterior Segment Trauma

9 Cornea, External Disease, and Refractive Surgery

10 Pediatric Ophthalmology and Strabismus

11 Retina and Vitreous

12 High-Yield Review: Facts and Mnemonics

Foreword to the Fourth Edition
It is very gratifying once again to write a foreword for the latest Massachusetts Eye and Ear
Infirmary Review Manual for Ophthalmology. Dr. Rama D. Jager, joined by Dr. Veeral Sheth, along
with their colleagues, have expended great effort creating and revising this new edition. The text is
superbly designed to help physicians maintain and update their fund of knowledge in the ever-
changing landscape of ophthalmology. The greatly enhanced photographic content in this edition
acknowledges the importance of pattern recognition in our field.
Ophthalmology continues to change rapidly, and there have been significant advances in the 6 years
since the previous edition. Maintaining familiarity with new findings in diagnosis and treatment is a
requisite for any well-rounded practitioner or trainee. Self-assessment, a major feature of this review,
offers an effective pathway for new learning. Coupled with continuing medical education, this
exercise forms the cornerstone for continuous updating of our fund of knowledge.
As in earlier editions, the self-assessment questions in this book have been carefully prepared to help
the reader identify the clinically significant areas within ophthalmology and the basic science
concepts which underpin the latest advances. No effort has been made to reconstruct questions from
current or previous board examinations; rather, the editors aim to capture the essentials of the latest
developments in all areas of ophthalmology for the practitioner or trainee who wishes to be informed
of recent scientific progress and the refashioned foundations of clinical science.
I congratulate Drs. Sheth and Jager for their contribution to ophthalmology through this fourth edition
of the Review.
Joan W. Miller, MD
Henry Willard Williams Professor of Ophthalmology
Chief and Chair, Department of Ophthalmology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
Foreword to the First Edition
It is a great pleasure to write a brief foreword to The Massachusetts Eye and Ear Infirmary Review
Manual for Ophthalmology. Dr. Jeffrey Lamkin, the primary organizer and executor of this project
with the secondary help of the residents of the Massachusetts Eye and Ear Infirmary, initially
conceived it as part of his teaching obligation to the residents while serving as Chief Resident. A
highly professional and scholarly set of questions was prepared. It became apparent that many other
residents and ophthalmologists seeking to identify the strengths and weaknesses in their ophthalmic
knowledge could profit from the dissemination of the material.
The past decade witnessed an explosion in ophthalmic knowledge that was truly daunting and
unprecedented. We can expect this expansion to accelerate in the future at an exponential rate. How
does one keep abreast of new developments, and how does one form judgments as to what is
clinically relevant knowledge and what is of more theoretical or marginal interest at the moment?
Most of us are highly specialized in either the knowledge industry or in our clinical practice patterns.
If we wish to stay in touch with other specialties of ophthalmology, we tend to need help. Self-
assessment and continuing medical education should by now be cornerstones of our professional
lives, but these tasks will also be progressively shared with others! We will be increasingly held to
higher quality assurance standards, and recertification examinations are to be put in place.
Furthermore, the ability to practice medicine in the future may become aligned with profiles of the
clinical outcomes of the patients we treat, as could be mandated by federal agencies and insurance
payers. Sound and constantly remodeled knowledge will thus be the best basis for protecting and
advancing our clinical practices.
The questions in this publication have been prepared with great care, in order to achieve balance
among the various subspecialties of our field and to highlight clinically significant subjects and basic
scienceconcepts and findings that under-gird them. No effort has been made to reconstruct questions
from Board or OKAP examinations; rather, the questions have been created in a way that proceeds
from what one group of people has determined to be an essential database for the practicing
ophthalmologist who wishes to be informed of recent scientific discoveries and the refashioned
foundations of clinical science.
As they say in the movies, any resemblance to questions that appear on formal examinations is
completely coincidental and reflects the fact that people who are serious students of the subject have
independently identified topics that should be within the purview and common fund of knowledge of a
contemporary clinician. The questions themselves are less important than the subjects they represent.
A well-positioned cadre that can serve as an arbiter for this fund of knowledge is residents-in-
training who are eager to equip themselves for their impending clinical professional lives, and who
daily critically assess and internalize the rivulets of information that are flowing toward them from
their teachers and clinical preceptors.
This textbook is the distinctive product of a unique mind and constellation of talents possessed by
Jeffrey Lamkin. I can think of nobody bette r suited to shepherd this project than Jeffrey because he is
guided by an insightful and retentive mind, a capacity for detail and global integration, and an ardent
love of knowledge and its transmission to those around him. Due to the depth of his commitment to
resident education and that of other colleagues, he has made a tremendous gift of his energies and time
to our entire field.
Frederick A. Jakobiec, MD
Preface
More than 6 years have passed since the release of the third edition of the Massachusetts Review
Manual for Ophthalmology. During this period, the field of ophthalmology has continued to evolve at
a breakneck pace. This evolution has led not only to a better understanding of the pathophysiologic
processes responsible for several blinding diseases, but also to better outcomes for our patients.
Therefore, maintaining a current and deep fund of knowledge in ophthalmology, however
challenging, remains a crucial requisite for excellent patient care.
The fourth edition of the Massachusetts Eye and Ear Infirmary Review Manual for
Ophthalmology differs from the third in several ways. The new edition has been updated with an
extensive number of new questions and images to reflect the latest teachings in the field. Although this
edition is markedly different from its predecessor, the intent of this book remains constant: to humbly
attempt to help our fellow colleagues—whether they are attending physicians, fellows-in-training,
residents, or medical students—assimilate useful information in the vast and ever-expanding field of
ophthalmology. We posit that “learning”—remembering what is important—is often better
accomplished through self-assessment with questions and answers, rather than with elaborative rote
memorization. This hypothesis has not only been tested with our own empirical experience but has
also been partially validated by recent scientific research.1
However, we do want to emphasize that this book should not serve as the sole method of
preparation for any specific examination and is no way intended to duplicate the American Board of
Ophthalmology
(ABO) certification exam or any other ophthalmology examination, for that matter. Instead, we hope
to help you retain knowledge already gleaned from reading, as well as provide a tool for accurate
self-assessment.
I (RDJ), would like to recognize my fellow coauthors who have collaborated with me on this book.
First and foremost, my friend and former fellow Dr. Veeral Sheth graciously agreed to take the lead in
organizing this edition, and he has done an outstanding job. Drs. Harit K. Bhatt, Paul Chiranand,
Marcus Marcet, and Jeffrey Lamkin have been great friends to work with, and they have done an
incredible job going through each question, ensuring its appropriateness, and creating new and
relevant questions with many more clinical images for this new edition. Finally, we would like to
sincerely thank Jonathan Pine, the Senior Executive Editor at Lippincott who supported this project
from the start, and Emilie Moyer and Ashley Fischer who have been extraordinarily patient and have
been instrumental in creating this revised edition.
Working with friends to revise a book, which will help in the practice of ophthalmology, has been a
truly wonderful experience. We hope that you, the reader, will benefit from our efforts.
Rama D. Jager, M.D., M.B.A., F.A.C.S.
Veeral S. Sheth, M.D.
Harit K. Bhatt, M.D.
Paul Chiranand, M.D.
Marcus M. Marcet, M.D.
 Jeffrey C. Lamkin, M.D.
Chicago, Illinois
1Science. Feb 11;331 (6018):772–5
CHAPTER 1
General Medicine

Questions
1. Which of the following statements about the normal microbial flora is false?
a. The microorganisms on the epithelial surfaces of the body remain in place chiefly through
adherence.
b. When mechanical defenses of the epithelial layers are breached so as to expose normally
sterile areas, severe infections can result from the normal microbial flora.
c. There is little benefit of these microorganisms to humans.
d. If antimicrobial agents eliminate normal flora, the host’s susceptibility to normally excluded
pathogenic microorganisms is increased.
2. Which of the following statements about Staphylococcus aureus is false?
a. 25% of tertiary care isolates are resistant to beta-lactam antibiotics.
b. Transmission of organisms is by direct contact.
c. Resistance of organisms to antimicrobials is usually plasmid determined and varies by
institution.
d. First-generation cephalosporins are the treatment of choice for life-threatening infections.
3. Which of the following is true of Staphylococcus epidermidis?
a. Staphylococcus epidermidis is present in up to 90% of skin cultures and cannot produce local
infections.
b. Its characteristic adherence to prosthetic devices makes it the most common cause of
prosthetic heart infections and is a common infectious organism of intravenous catheters and
cerebrospinal fluid shunts.
c. Most isolates are not resistant to methicillin or cephalosporins; therefore, the drugs of choice
are first-generation cephalosporins.
d. Management of an infected prosthetic device or vascular catheter only requires appropriate
antibiotic administration.
4. Which of the following associations regarding Streptococcus is incorrectly paired?
a. Streptococcus pneumoniae: Lancet-shaped diplococci that cause alpha-hemolysis on blood
agar.
b. Group A beta-hemolytic streptococci: Acute suppurative infections transmitted through
droplets mediated by an opsonizing antibody.
c. Streptococcus pyogenes: Highly sensitive to Penicillin G.
d. Streptococcus pneumoniae: Can lead to pneumococcal pneumonia that is highly sensitive to
penicillin and has a low mortality rate in the elderly.
5. Which of the following patients would not require endocarditis prophylaxis during invasive
surgery?
a. a patient with a history of severe coronary artery disease.
 b. a patient with a prosthetic heart valve.
c. a patient with a previous history of bacterial endocarditis.
d. a patient with acquired valvular dysfunction such as rheumatic heart disease.
6. What type of ocular surgery would require endocarditis prophylaxis?
a. cataract surgery.
b. vitrectomy.
c. tear duct reconstruction.
d. corneal transplant.
7. Which of the following is a false statement regarding pseudomembranous enterocolitis?
a. It is most commonly caused by Clostridium difficile.
b. Clostridium difficile is an anaerobic gramnegative bacterium.
c. Typically occurs within 1 to 14 days of starting antibiotic therapy in which patients develop
fever and diarrhea.
d. Treatment includes discontinuing the causative antibiotic and administering metronidazole for
10 days.
8. Which of the following is true regarding Haemophilus influenzae?
a. Long-term immunity follows with the development of bactericidal antibodies to the type B
capsule in the presence of complement.
b. Haemophilus influenzae is uncommonly found in the respiratory tracts of children.
c. Macrolides, such as erythromycin, are the treatment of choice.
d. Immunized patients are no longer susceptible to all strains of Haemophilus influenza.
9. Which of the following statements regarding Neisseria gonorrhoeae is false?
a. Gonococci are not part of the normal microbial flora.
b. 50% of women and 95% of men infected with gonococci are symptomatic.
c. Chlamydia trachomatis is found in as many as half of all women and one-third of all men
infected with gonococci.
d. Macrolides and quinolones are generally not good agents to treat gonococcal infections.
10. Which of the following is true regarding Neisseria meningitidis?
a. Infection with Neisseria meningitidis is limited to meningitis.
b. Meningitis with a petechial or puerperal exanthema is the classic presentation.
c. The routine administration of meningococcal vaccine is recommended.
d. The treatment of choice for meningococcal meningitis is vancomycin.
11. Which of the following statements about syphilis is false?
a. The treatment of choice for patients with neurosyphilis is Penicillin G 2.4 million units
intramuscularly weekly for 3 weeks.
b. Transplacental transmission from an untreated pregnant female to her fetus before 16 weeks’
gestation can result in congenital syphilis.
c. Serum FTA-ABS titers do not decrease with successful treatment.
d. Serum VDRL becomes negative after successful therapy.
12. Which of the following spirochetes causes Lyme disease?
 a. Treponema pallidum.
b. Ixodes scapularis.
c. Borrelia burgdorferi.
d. Leptospira interrogans.
13. Which statement is true regarding Chlamydia trachomatis?
a. Chlamydia trachomatis is the most common sexually transmitted infection.
b. Chlamydial infections are treated with third-generation cephalosporins.
c. Chlamydia is a small extracellular parasite.
d. Chlamydia trachomatis can survive long periods outside the body and it is essential to avoid
contact with patients that are infected.
14. Which of the following regarding tuberculosis is false?
a. Infection usually occurs through inhalation of infective droplets and rarely by way of the skin
or gastrointestinal tract.
b. Treatment of active infection often involves use of two or three drugs because of the
emergence of resistance.
c. Laboratory diagnosis involves culture of infective material on Lowenstein-Jensen medium for
6 to 8 weeks and use of the acid-fast type of Ziehl-Neelsen stain.
d. A positive PPD reaction is defined as an area of induration of 5 mm or greater read 48 to 72
hours after administration.
15. Which of the following is part of the normal flora that is present in the oral cavity, lower
gastrointestinal tract, and female genital tract?
a. Histoplasma capsulatum.
b. Candida albicans.
c. Aspergillus fumigatus.
d. Blastomyces dermatitidis.
16. Toxoplasmosis is most commonly caused by
a. exposure to cat feces.
b. exposure to dog feces.
c. eating raw eggs.
d. exposure to human feces.
17. Which of the following statements about herpes-viruses is false?
a. EBV is associated with nasopharyngeal carcinoma.
b. EBV is associated with Burkitt’s lymphoma.
c. Resolution of lesions caused by herpes simplex may be followed by postherpetic neuralgia.
d. Untreated neonatal herpes infection carries an 80% mortality rate.
18. Which of the following methods of transmission of hepatitis viruses is incorrect?
a. hepatitis A: fecal–oral route.
b. hepatitis B: fecal–oral route.
c. hepatitis C: blood transfusions.
d. hepatitis D: sexual transmission.
19. Which of the following is false of these viruses or viral conditions?
a. Severe acute respiratory syndrome (SARS) originated in China and rapidly spread by air
travel to other countries.
b. The hantavirus is a highly virulent respiratory pathogen transmitted by ticks.
c. The Ebola virus can cause severe hemorrhage, generally occurring from the gastrointestinal
tract.
d. The West Nile virus is transmitted by a mosquito vector, and illness may vary from a flulike
syndrome to meningitis and encephalitis.
20. Which of the following statements regarding AIDS is true?
a. Approximately 200 million people in the world have AIDS.
b. The majority of individuals infected with HIV live in the United States.
c. The ELISA test for HIV is 99% sensitive, but only 75% specific for HIV.
d. Breast milk can also be a method of transmission of HIV.
21. Pneumocystis carinii pneumonia is generally treated with
a. trimethoprim–sulfamethoxazole.
b. ceftriaxone.
c. doxycycline.
d. penicillin.
22. Ganciclovir is used in the treatment of CMV retinitis and colitis in immunocompromised patients.
Ganciclovir’s major toxicity is
a. hepatotoxicity
b. bone marrow suppression.
c. nephrotoxicity
d. encephalopathy
23. Hypertension is defined as
a. systolic blood pressure of 140 mm Hg or higher.
b. a single blood pressure reading of 140/80.
c. diastolic pressure of 80 mm Hg or higher.
d. systolic blood pressure of 130 mm Hg or higher.
24. Causes of secondary hypertension include all of the following, except
a. pheochromocytoma.
b. hypothyroidism.
c. hyperaldosteronism.
d. Cushing’s syndrome.
25. Which of the following statements about lifestyle factors affecting blood pressure is false?
a. Processed foods account for 75% of sodium intake in the United States.
b. Patients with mild hypertension who smoke a pack of cigarettes a day have a fivefold higher
risk of coronary artery disease.
c. Alcohol consumption of more than 1 oz of ethanol (10 oz of wine or 24 oz of beer) is
associated with resistance to antihypertensive therapy.
 d. Regular aerobic exercise contributes to reduced mortality and morbidity from hypertension.
26. Which medication is incorrectly paired with a common side effect?
a. doxazosin: postural hypotension.
b. atenolol: bronchospasm.
c. spironolactone: gynecomastia.
d. amlodipine: drug-induced lupus.
27. What types of antihypertensive agent should be used to start initial therapy for hypertension in a
newly diagnosed patient without other comorbidity?
a. thiazide diuretics.
b. calcium channel blockers.
c. angiotensin II receptor blockers (ARBs).
d. alpha-adrenergic antagonists.
28. What is the definition of a transient ischemic attack (TIA)?
a. a loss of neurologic function caused by ischemia that lasts for <24 hours and clears without
residual signs.
b. a progressively enlarging cerebral infarct that produces neurological deficits, which worsen
over 24 to 48 hours.
c. an ischemic event that produces a stable permanent neurological disability.
d. an ischemic, but not infarcted area of the brain, which has been shown to have some plasticity
with regard to recovery.
29. Which of the following statements with regard to stroke is false?
a. Clopidogrel has a better side effect profile than ticlopidine with regard to bone marrow
suppression.
b. The use of tissue plasminogen activator (TPA) within 24 hours of the onset of symptoms
improves outcome in patients with stroke.
c. Aspirin offers a moderate benefit in the prevention of recurrent stroke.
d. Hypertension should be controlled, although blood pressure reduction during acute ischemic
stroke may cause harmful decreases in local perfusion.
30. Which of the following statements regarding intracranial hemorrhage or causes of intracranial
hemorrhage is false?
a. The most common site of berry aneurysms is at the origin of the posterior communicating
artery from the internal carotid artery.
b. Immediate CT examination demonstrates blood in the subarachnoid space in approximately
95% of the cases of ruptured aneurysm or AVM.
c. The most common symptom of subarachnoid hemorrhage is a generalized seizure.
d. Initial restoration of normal blood pressure and its maintenance at normal levels are
mandatory in the treatment of ruptured aneurysms.
31. Ocular and cerebral conditions associated with carotid stenosis include all of the following,
except
a. amaurosis fugax.
b. ocular ischemic syndromes.
 c. transient ischemic attack (TIA).
d. intracranial hemorrhage.
32. Which of the following statements about carotid endarterectomy (CEA) is false?
a. CEA should only be considered if the surgeon performing the operation has a perioperative
morbidity rate of <3%.
b. In the Asymptomatic Carotid Atherosclerosis Study, patients with asymptomatic carotid
stenosis of >60% who underwent CEA did not show a significantly lower risk of having another
major ischemic stroke, compared to patients who solely had medical management.
c. CEA provided a significant benefit in reducing the risk of ipsilateral stroke in patients with
symptomatic stenosis of 50% or more.
d. In the North American Symptomatic Carotid Endarterectomy Trial, CEA was shown to have
increasing benefit with higher degrees of carotid stenosis.
33. Folic acid can reduce the risk of stroke in patients by reducing the plasma levels of
a. high-density cholesterol (HDL).
b. homocysteine.
c. triglycerides.
d. low-density cholesterol (LDL).
34. What is the best procedure for determining a cardiac source in patients presenting with isolated
amaurosis fugax or transient vision loss?
a. transesophageal echocardiography.
b. transthoracic echocardiography.
c. MRI of the chest.
d. CT scan of the chest.
35. What is the number one killer in the United States and around the world?
a. lung cancer.
b. breast cancer.
c. coronary artery disease.
d. HIV.
36. What is the number one preventable risk factor for cardiovascular disease worldwide?
a. physical inactivity.
b. smoking.
c. obesity.
d. diet high in saturated fat and cholesterol.
37. All of the following can impede the supply of oxygen to the myocardium except
a. anemia.
b. carotid artery stenosis.
c. reduced mean arterial pressure.
d. hypoxemia.
38. It has become clear that markers of inflammation are strong risk factors for CAD. What is the best
marker that correlates most with future cardiovascular events?
a. interleukin-6.