FMGE Ophthalmology Syllabus

What is the leukocoria red flag in an infant, and name three important causes of congenital cataract.

Leukocoria (white pupillary reflex) must be evaluated urgently. Causes of congenital cataract include intrauterine infections (TORCH, esp. rubella), galactosemia, and chromosomal/genetic disorders (e.g., Down syndrome, autosomal dominant inheritance).

What are the phakomatoses and name three classic examples with an ocular feature of each.

Phakomatoses are neurocutaneous syndromes with hamartomas: Sturge-Weber (choroidal hemangioma + glaucoma), neurofibromatosis (Lisch nodules/optic glioma), and von Hippel-Lindau (retinal capillary hemangioblastoma); tuberous sclerosis (retinal astrocytic hamartoma) is another.

What is the classic triad and the underlying mechanism of primary open-angle glaucoma (POAG)?

Triad: raised IOP (usually), open anterior chamber angle, and glaucomatous optic neuropathy with cupping and corresponding visual field loss. Mechanism: increased resistance to aqueous outflow at the trabecular meshwork with an open angle.

What is the characteristic visual field defect pattern in glaucoma?

Arcuate (Bjerrum) scotomas, nasal step, and progressive constriction with central vision preserved until late; the disc shows increased cup-to-disc ratio.

Describe the classic presentation of acute angle-closure glaucoma.

Sudden severe ocular pain, headache, nausea/vomiting, halos around lights, blurred vision, a fixed mid-dilated oval pupil, a red eye, and a hard (stony) globe with markedly raised IOP — an ophthalmic emergency.

Name two examples of secondary glaucoma and their mechanisms.

Neovascular glaucoma (new vessels block the angle, e.g., from diabetes/CRVO), phacomorphic/phacolytic glaucoma (lens-induced), pigmentary glaucoma, and steroid-induced glaucoma (raised IOP from corticosteroids).

List the classification stages of diabetic retinopathy.

Non-proliferative DR (mild, moderate, severe) characterized by microaneurysms, dot/blot hemorrhages, hard exudates, and cotton-wool spots; and Proliferative DR characterized by neovascularization (NVD/NVE), with diabetic macular edema possible at any stage.

What is the '4-2-1 rule' used to define severe non-proliferative diabetic retinopathy?

Severe NPDR if any of: hemorrhages/microaneurysms in all 4 quadrants, venous beading in 2+ quadrants, or intraretinal microvascular abnormalities (IRMA) in 1+ quadrant.

Compare dry (non-exudative) and wet (exudative) age-related macular degeneration (AMD).

Dry AMD (~90%) shows drusen and geographic atrophy with gradual central vision loss; wet AMD (~10% but more severe) features choroidal neovascularization causing exudation/hemorrhage and rapid central vision loss, treated with anti-VEGF injections.

What test detects metamorphopsia and central scotoma in macular disease?

The Amsler grid.

What is rhegmatogenous retinal detachment and how does it differ in mechanism from tractional and exudative types?

Rhegmatogenous = a retinal break/tear lets fluid enter the subretinal space (most common). Tractional = fibrovascular membranes (e.g., PDR) pull the retina off. Exudative = fluid accumulates without a break (e.g., tumor, inflammation, hypertension).

What field defect and fundus finding suggest a superior retinal detachment, and why is it urgent?

An inferior (ascending) field defect with a grey, ballooning, mobile retina; urgent because macular involvement causes permanent central vision loss — repair before the macula detaches.

Differentiate optic neuritis from anterior ischemic optic neuropathy (AION) on presentation.

Optic neuritis: younger patient, painful vision loss on eye movement, often associated with MS, RAPD, usually a normal or mildly swollen disc. AION: older patient, sudden painless vision loss, altitudinal field defect, pale swollen disc; arteritic AION (giant cell arteritis) is an emergency.

What fundus finding defines papilledema and what does it imply?

Bilateral optic disc swelling with blurred margins and loss of the cup, due to raised intracranial pressure; vision is usually preserved early.

Describe the eye position and pupil findings in a complete third (oculomotor) nerve palsy.

The eye is 'down and out,' with ptosis and a dilated, unreactive pupil (when pupil-involving). Pupil involvement suggests a compressive cause such as a posterior communicating artery aneurysm.

What is the characteristic deviation and head posture in a fourth (trochlear) nerve palsy?

Vertical diplopia worse on looking down (e.g., reading/stairs) due to superior oblique palsy, with a compensatory head tilt away from the affected side (positive Bielschowsky head-tilt test).

What gaze limitation results from a sixth (abducens) nerve palsy?

Failure of abduction of the affected eye, causing horizontal diplopia worse at distance and when gazing toward the lesion side (lateral rectus paralysis).

What three features make up Horner's syndrome and what is the lesion?

Ptosis (mild, from Muller's muscle), miosis, and anhidrosis on the affected side, due to interruption of the oculosympathetic pathway; may also show apparent enophthalmos.

What lesion causes internuclear ophthalmoplegia (INO) and what is its clinical sign?

A lesion of the medial longitudinal fasciculus (MLF); causes impaired adduction of the ipsilateral eye with nystagmus of the abducting contralateral eye on lateral gaze; bilateral INO is classic for multiple sclerosis.

Define amblyopia and name its three main causes.

Amblyopia ('lazy eye') is reduced best-corrected visual acuity in a structurally normal eye due to abnormal visual development in childhood. Causes: strabismic, refractive (anisometropic/ametropic), and deprivational (e.g., congenital cataract, ptosis).

What is the mainstay of amblyopia treatment and why is age critical?

Treat the cause (correct refraction/remove obstruction) then occlusion (patching) or atropine penalization of the good eye to force use of the amblyopic eye; treatment must occur before the end of the critical period (~7-8 years) for best results.

Differentiate esotropia from exotropia, and define a tropia versus a phoria.

Esotropia = inward (convergent) deviation; exotropia = outward (divergent) deviation. A tropia is a manifest (constant) misalignment; a phoria is a latent deviation revealed only when fusion is broken (cover test).

What cover test finding identifies the deviated eye in manifest strabismus?

On the cover-uncover test, covering the fixing eye causes the deviated eye to move to take up fixation; an inward-moving eye indicates exotropia, an outward-moving eye indicates esotropia.

Name two congenital anomalies of the eye and one defining feature of each.

Anophthalmos (absence of the eyeball), microphthalmos (abnormally small eye), coloboma (gap from failed embryonic fissure closure, classically inferonasal), and congenital glaucoma/buphthalmos (enlarged cloudy cornea with epiphora and photophobia).

What triad suggests congenital glaucoma (buphthalmos) in an infant?

Epiphora (watering), photophobia, and blepharospasm, with corneal enlargement/haze (Haab's striae) and raised IOP.

Differentiate viral, bacterial, and allergic conjunctivitis by discharge and key features.

Viral: watery discharge, follicular reaction, preauricular lymphadenopathy, often bilateral; Bacterial: purulent/mucopurulent discharge with sticky lids; Allergic: stringy/mucoid discharge, intense itching, and papillae with bilateral involvement.

What is the most serious cause of hyperacute purulent neonatal conjunctivitis (ophthalmia neonatorum) and its timing?

Neisseria gonorrhoeae, presenting within the first 2-5 days of life with copious purulent discharge and risk of corneal perforation — a medical emergency requiring systemic treatment.

Distinguish the two main types of dry eye syndrome and name a key diagnostic test.

Aqueous-deficient (low tear production, e.g., Sjogren's) and evaporative (meibomian gland dysfunction). Tests: Schirmer test (<10 mm wetting in 5 min suggests deficiency) and tear break-up time (TBUT <10 s).

Differentiate anterior from posterior blepharitis.

Anterior blepharitis affects the eyelash base (staphylococcal — crusting/collarettes; or seborrheic — greasy scales); posterior blepharitis is meibomian gland dysfunction with frothy tears, often linked to rosacea.

What is the most common primary intraocular malignancy in children versus adults, and the most common ocular malignancy overall?

Retinoblastoma is the most common primary intraocular malignancy in children (leukocoria, RB1 gene); uveal (choroidal) melanoma is the most common primary intraocular malignancy in adults; metastasis (e.g., from breast/lung) is the most common intraocular malignancy overall.

What is the most common primary orbital malignancy of childhood and the most common cause of unilateral and bilateral proptosis in adults?

Rhabdomyosarcoma is the most common primary orbital malignancy in childhood. In adults, thyroid eye disease (Graves' orbitopathy) is the most common cause of both unilateral and bilateral proptosis.

What is the most common cause of proptosis overall and its key clinical features?

Thyroid eye disease (Graves' orbitopathy): bilateral or unilateral proptosis, lid retraction (Dalrymple sign), lid lag (von Graefe sign), restrictive myopathy (inferior > medial rectus enlargement, sparing tendons), and risk of compressive optic neuropathy.