Ptosis of the right upper lid in an infant lifts briskly each time she sucks at the breast or moves her jaw to the left, the mother reports. Which mechanism explains this?

Trigeminal-oculomotor synkinesis

Aberrant facial nerve regeneration

Painless, slowly enlarging, firm nodule in the upper lid, away from the lid margin, in a young woman with chronic blepharitis. What is its pathology?

Lipogranuloma of a meibomian gland

After a cricket ball hit his left eye during a school match, a boy of 11 is brought to casualty vomiting repeatedly. The eye looks almost normal, with little bruising or swelling, but upward gaze is severely restricted, and each attempt at elevation brings on nausea and a heart rate of 48/min. Coronal CT shows a small linear orbital floor fracture with the inferior rectus caught in it. Visual acuity is 6/6, the globe is intact and there is no hyphaema. What is the best management?

Urgent surgical release of the trapped muscle

Repair after 6 weeks if enophthalmos

Oral steroids and review in a week

Observe for 2 weeks for swelling to settle

Eyelid, lacrimal and orbit disorders

25 NEET-PG practice questions on Eyelid, lacrimal and orbit disorders, part of Ophthalmology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
Ptosis of the right upper lid in an infant lifts briskly each time she sucks at the breast or moves her jaw to the left, the mother reports. Which mechanism explains this?
1. ACongenital Horner syndrome
2. BTrigeminal-oculomotor synkinesis
3. CAberrant facial nerve regeneration
4. DMyasthenia gravis of infancy
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Answer: B · Trigeminal-oculomotor synkinesis
Marcus Gunn jaw-winking ptosis is a congenital synkinesis in which fibres of the motor branch of the trigeminal nerve to the pterygoid muscles also innervate the levator, so jaw movement or sucking elevates the ptotic lid. It is present in a few percent of congenital ptosis cases. Mild cases are observed; marked winking may need levator disinsertion with a frontalis sling.
- A: Congenital Horner gives mild ptosis with miosis and iris heterochromia, not winking.
- C: Aberrant facial regeneration links eyelid closure and mouth movement after Bell palsy.
- D: Myasthenia causes fatigable ptosis, not jaw-linked lid movement.
Remember this
Lid that rises with jaw movement or sucking: Marcus Gunn jaw-winking (trigeminal-oculomotor synkinesis).
Question 2 · Easy
Painless, slowly enlarging, firm nodule in the upper lid, away from the lid margin, in a young woman with chronic blepharitis. What is its pathology?
1. AEpidermal inclusion cyst
2. BAbscess of a gland of Zeis
3. CLipogranuloma of a meibomian gland
4. DCyst of a gland of Moll
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Answer: C · Lipogranuloma of a meibomian gland
A chalazion is a chronic, sterile lipogranulomatous inflammation of a meibomian gland: blocked secretion leaks into the tarsus and provokes a foreign-body reaction with epithelioid and giant cells. It is painless and lies within the tarsal plate, away from the margin, and is commoner with meibomian gland dysfunction and blepharitis. Small ones settle with warm compresses; persistent ones need incision and curettage.
- A: An epidermal inclusion cyst is in the skin, not the tarsal plate.
- B: An abscess of a Zeis gland is a stye: painful and at the lid margin.
- D: A Moll gland cyst is a small translucent cyst at the lid margin.
Remember this
Chalazion is a painless lipogranuloma of a meibomian gland in the tarsus.
Question 3 · Hard
After a cricket ball hit his left eye during a school match, a boy of 11 is brought to casualty vomiting repeatedly. The eye looks almost normal, with little bruising or swelling, but upward gaze is severely restricted, and each attempt at elevation brings on nausea and a heart rate of 48/min. Coronal CT shows a small linear orbital floor fracture with the inferior rectus caught in it. Visual acuity is 6/6, the globe is intact and there is no hyphaema. What is the best management?
1. AUrgent surgical release of the trapped muscle
2. BRepair after 6 weeks if enophthalmos
3. COral steroids and review in a week
4. DObserve for 2 weeks for swelling to settle
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Answer: A · Urgent surgical release of the trapped muscle
In children the elastic orbital floor can crack and spring back like a trapdoor, trapping the inferior rectus with few external signs (the 'white-eyed blowout'). Traction on the trapped muscle triggers the oculocardiac reflex (bradycardia, nausea, vomiting) and quickly causes muscle ischaemia and permanent restriction. Urgent surgical release within 24-48 hours is needed, unlike adults, where repair may wait for swelling to settle.
- B: Late repair for enophthalmos does not address acute muscle ischaemia.
- C: Steroids do not free an entrapped muscle.
- D: Waiting 2 weeks is for adult fractures without entrapment.
Remember this
White-eyed blowout fracture in a child with an oculocardiac reflex: urgent surgical release of the entrapped muscle.
Question 4 · Medium
A soft, bluish-red swelling of the left upper lid has grown rapidly since 3 weeks of age in a girl now 4 months old; it swells when she cries and now covers half of the pupil. Retinoscopy shows 2.5 D of astigmatism in the left eye, and echocardiography is normal. Which treatment is first-line?
1. AOral propranolol
2. BObservation till age 7
3. COral prednisolone
4. DSurgical excision
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Answer: A · Oral propranolol
This is an infantile (capillary) haemangioma, which proliferates in the first months and involutes slowly over years. One covering the visual axis or causing astigmatism threatens deprivation or anisometropic amblyopia, so it needs treatment. Oral propranolol, started after cardiac assessment, is first-line and shrinks most lesions; topical timolol suits small superficial ones.
- B: Waiting years while the pupil is covered causes amblyopia.
- C: Steroids were used before propranolol but have more side effects.
- D: Surgery is kept for small, well-defined or residual lesions.
Remember this
Periocular infantile haemangioma threatening amblyopia: oral propranolol is first-line.
Question 5 · Easy
A painful red swelling at the lid margin, pointing at the base of an eyelash, is a stye. Which gland is infected?
1. AMeibomian gland
2. BGland of Wolfring
3. CGland of Krause
4. DGland of Zeis
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Answer: D · Gland of Zeis
An external hordeolum (stye) is an acute staphylococcal infection of a gland of Zeis or Moll associated with an eyelash follicle, so it points at the lid margin around the lash. Treatment is warm compresses, epilation of the involved lash and topical antibiotic. Infection of a meibomian gland is an internal hordeolum, which points on the conjunctival side.
- A: Meibomian gland infection is an internal hordeolum, pointing on the conjunctiva.
- B: Wolfring glands are accessory lacrimal glands at the tarsal border.
- C: Krause glands are accessory lacrimal glands in the fornix.
Remember this
A stye (external hordeolum) is acute staphylococcal infection of a gland of Zeis at the lash base.
Question 6 · Medium
A recurrent chalazion of the right upper lid, now the third in the same place within a year, is seen in a woman of 68; there is loss of lashes over it and the lid margin is thickened and yellowish. Each earlier lesion was curetted at a private clinic and no tissue was sent for examination. What should be done?
1. ARepeat incision and curettage
2. BIntralesional triamcinolone injection
3. CWarm compresses and lid hygiene
4. DFull-thickness biopsy for histopathology
Answer and explanation in LearnFree account
Question 7 · Hard
Painless, slowly progressive downward and inward displacement of the right eye over 2 years is noticed by a man of 45. A firm, non-tender mass is felt under the superotemporal orbital rim. CT shows a well-defined, rounded lacrimal gland mass with smooth scalloping (excavation) of the bone of the lacrimal fossa, without bone destruction. There is no pain, numbness or lymphadenopathy, and vision is 6/6. What is the correct management?
1. AOral steroids for lacrimal gland inflammation
2. BIncisional biopsy before planning surgery
3. CRadiotherapy to the lacrimal fossa
4. DComplete excision with its capsule, no prior biopsy
Answer and explanation in LearnFree account
Question 8 · Medium
In the casualty, a woman with a sudden, severe headache has right ptosis, the right eye turned down and out, and a dilated right pupil that does not react to light. BP is 150/90 mmHg, she is not diabetic and the neck is mildly stiff. The left eye is normal. Which investigation is needed urgently?
1. AAcetylcholine receptor antibodies
2. BIce pack test for ptosis
3. CHbA1c and lipid profile
4. DCT angiography of the brain
Answer and explanation in LearnFree account
Question 9 · Medium
A tender, red, tense swelling below the medial canthal tendon of the left eye, with fever and spreading lid oedema, is seen in a woman of 55 who has had a watering left eye for years. Vision and eye movements are normal and there is no proptosis. Which is the most appropriate initial management?
1. ATopical antibiotic drops and observation
2. BSyringing and probing of the duct
3. CSystemic antibiotics and warm compresses
4. DExternal DCR at once
Answer and explanation in LearnFree account
Question 10 · Hard
Radioactive iodine is planned for relapsed Graves' hyperthyroidism in a man of 40 who smokes 15 cigarettes a day. His thyroid has relapsed twice after courses of carbimazole. He has mild, active orbitopathy: lid retraction, gritty eyes, lid swelling and a clinical activity score of 3/7, with normal vision and no diplopia. The endocrinologist asks what should be done about his eyes. Which plan is best?
1. AUrgent orbital decompression
2. BRAI with oral prednisolone cover; stop smoking
3. CRAI alone; the eyes will settle
4. DIV methylprednisolone pulses before RAI
Answer and explanation in LearnFree account
Question 11 · Medium
Rapidly progressive proptosis over 3 weeks, displacing the left eye down and out, with lid swelling but no fever, is seen in a boy of 7. CT shows a well-defined soft-tissue mass in the superonasal orbit without bone erosion. Which is the most likely diagnosis?
1. AOptic nerve glioma
2. BRuptured orbital dermoid cyst
3. CEmbryonal rhabdomyosarcoma
4. DCapillary haemangioma
Answer and explanation in LearnFree account
Question 12 · Medium
Mild ptosis of 2 mm and a smaller right pupil, more obvious in dim light, are noted in a chronic smoker with right shoulder pain. The right pupil reacts normally to light. Which result of a topical drop test confirms that the miosis is due to sympathetic denervation?
1. AAtropine 1% fails to dilate the right pupil
2. BPilocarpine 0.1% constricts the right pupil
3. CApraclonidine 0.5% reverses the anisocoria
4. DPhenylephrine 1% has no effect on either pupil
Answer and explanation in LearnFree account
Question 13 · Medium
Congenital ptosis of the left eye in a boy of 4: the lid covers the upper half of the pupil, levator function is 2 mm and Bell's phenomenon is good. He tilts his chin up to see, and his visual acuity is 6/9 in each eye with no squint. There is no jaw-winking or fatigability. Which operation is preferred?
1. AAponeurosis advancement
2. BFrontalis sling
3. CMullerectomy (Fasanella-Servat)
4. DLevator resection
Answer and explanation in LearnFree account
Question 14 · Hard
On the third day of IV ceftriaxone, vancomycin and metronidazole for right orbital cellulitis secondary to ethmoid sinusitis, a girl of 10 is worse: vision has fallen from 6/9 to 6/36, a right relative afferent pupillary defect has appeared, and the proptosis and pain have increased. Repeat contrast CT shows a large rim-enhancing collection along the medial orbital wall displacing the medial rectus, with opacified ethmoid air cells and no intracranial extension. Blood glucose is normal, and blood culture is pending. What is the next step?
1. AAdd IV amphotericin B
2. BAdd IV dexamethasone and review
3. CChange to IV meropenem and wait 48 hours
4. DUrgent drainage of the subperiosteal abscess
Answer and explanation in LearnFree account
Question 15 · Medium
Before cataract surgery at a CHC eye camp, syringing of the right lacrimal passage causes regurgitation of mucopurulent fluid through the upper punctum, and none reaches the throat. The cataract is mature, vision is hand movements and the patient, a widow from a nearby village, is keen to have surgery the next morning. What should be done before the cataract surgery?
1. AProceed with intracameral antibiotic cover
2. BTopical antibiotics for 3 days, then operate
3. CDacryocystorhinostomy first
4. DProbing of the nasolacrimal duct
Answer and explanation in LearnFree account
Question 16 · Easy
In adults, what is the commonest cause of both unilateral and bilateral proptosis?
1. AThyroid eye disease
2. BCavernous venous malformation
3. COrbital lymphoma
4. DOrbital cellulitis
Answer and explanation in LearnFree account
Question 17 · Medium
Black necrotic eschar on the hard palate, facial pain and numbness, proptosis and ophthalmoplegia of the left eye are found in a man admitted with diabetic ketoacidosis (blood glucose 486 mg/dL). A KOH mount of nasal tissue shows broad, ribbon-like, aseptate hyphae branching at right angles. What is the treatment of choice?
1. AOral voriconazole alone
2. BIV vancomycin and ceftriaxone
3. CFluconazole with insulin infusion
4. DLiposomal amphotericin B and debridement
Answer and explanation in LearnFree account
Question 18 · Medium
On the cataract follow-up visit, a retired postman has drooping of both upper lids that has slowly worsened since his surgery. Margin-reflex distance 1 is 1 mm, levator function is 14 mm and the upper lid crease is high and indistinct, with a thin lid above the tarsus. What is the most likely cause?
1. APartial third nerve palsy
2. BHorner syndrome
3. CLevator aponeurosis dehiscence
4. DMyogenic ptosis from dystrophy
Answer and explanation in LearnFree account
Question 19 · Medium
Ptosis that varies through the day, worse in the evening, and double vision on reading are reported by a bank cashier. Pupils are normal, and after 2 minutes of an ice pack over the closed lid the ptosis improves by 3 mm. Which blood test is most specific to confirm the diagnosis?
1. AAcetylcholine receptor antibodies
2. BSerum creatine kinase
3. CThyroid function tests
4. DSerum angiotensin-converting enzyme
Answer and explanation in LearnFree account
Question 20 · Easy
Graves' orbitopathy, statements: 1. Upper lid retraction is its commonest sign. 2. The inferior rectus is the muscle most often enlarged. 3. Smoking increases its risk and severity. 4. Radioactive iodine usually improves active eye disease. Which are correct?
1. A1 and 2 only
2. B2, 3 and 4 only
3. C1, 2, 3 and 4
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 21 · Medium
Despite regular sac massage since early infancy, a child of 14 months still has a watering, sticky left eye, with mucoid regurgitation on pressure over the sac. The cornea is clear, the corneal diameter is normal and there is no photophobia; the right eye is normal. What is the next step?
1. ASystemic antibiotics for 6 weeks
2. BProbing of the nasolacrimal duct
3. CDacryocystorhinostomy
4. DContinue massage until age 5
Answer and explanation in LearnFree account
Question 22 · Hard
Six months into Graves' disease treated with carbimazole, a woman of 52 reports that colours look 'washed out' in the right eye and that vision has fallen from 6/6 to 6/18 over 2 weeks. She has bilateral proptosis (Hertel 24 mm right, 22 mm left), lid retraction, restricted elevation and a right relative afferent pupillary defect. CT shows marked crowding of enlarged muscles at the orbital apex. Her clinical activity score is 5/7, IOP is 24 mmHg in upgaze and her free T4 is now normal. She is a non-smoker. What is the most appropriate immediate treatment?
1. AIV methylprednisolone; decompression if no response
2. BSelenium supplements and lubricants
3. CStrabismus surgery for restricted elevation
4. DOrbital radiotherapy alone
Answer and explanation in LearnFree account
Question 23 · Easy
Watering of the left eye with sticky discharge since 3 weeks of age is noted in a baby now 3 months old; pressure over the lacrimal sac brings mucopus out of the punctum. The cornea is clear, the eye is not photophobic and the corneal diameter is normal. What is the first-line treatment?
1. ALacrimal sac massage with clean hands
2. BIntubation with silicone tubes
3. CDacryocystorhinostomy
4. DProbing under general anaesthesia
Answer and explanation in LearnFree account
Question 24 · Medium
CT of the orbits, coronal and axial sections: both inferior and medial recti are enlarged at their muscle bellies, with the tendinous insertions spared, and there is crowding at the orbital apex. The patient, a woman with hyperthyroidism, has bilateral lid retraction. Which condition fits these findings?
1. ACarotid-cavernous fistula
2. BOrbital lymphoma
3. CIdiopathic orbital myositis
4. DThyroid eye disease
Answer and explanation in LearnFree account
Question 25 · Medium
Fever, a swollen red right upper lid and proptosis follow a week of a cold in a schoolboy; eye movements are painful and restricted and vision is 6/12. There is no RAPD, temperature is 38.9 °C and the total leucocyte count is 16,800/mm3. Which is the most appropriate next step?
1. AOral amoxicillin-clavulanate and review
2. BWarm compresses and topical antibiotics
3. CIncision and drainage of the upper lid
4. DAdmit, IV antibiotics, CT orbits and sinuses
Answer and explanation in LearnFree account

Eyelid, lacrimal and orbit disorders

Ptosis of the right upper lid in an infant lifts briskly each time she sucks at the breast or moves her jaw to the left, the mother reports. Which mechanism explains this?

Painless, slowly enlarging, firm nodule in the upper lid, away from the lid margin, in a young woman with chronic blepharitis. What is its pathology?

A soft, bluish-red swelling of the left upper lid has grown rapidly since 3 weeks of age in a girl now 4 months old; it swells when she cries and now covers half of the pupil. Retinoscopy shows 2.5 D of astigmatism in the left eye, and echocardiography is normal. Which treatment is first-line?

A painful red swelling at the lid margin, pointing at the base of an eyelash, is a stye. Which gland is infected?

In the casualty, a woman with a sudden, severe headache has right ptosis, the right eye turned down and out, and a dilated right pupil that does not react to light. BP is 150/90 mmHg, she is not diabetic and the neck is mildly stiff. The left eye is normal. Which investigation is needed urgently?

A tender, red, tense swelling below the medial canthal tendon of the left eye, with fever and spreading lid oedema, is seen in a woman of 55 who has had a watering left eye for years. Vision and eye movements are normal and there is no proptosis. Which is the most appropriate initial management?

Rapidly progressive proptosis over 3 weeks, displacing the left eye down and out, with lid swelling but no fever, is seen in a boy of 7. CT shows a well-defined soft-tissue mass in the superonasal orbit without bone erosion. Which is the most likely diagnosis?

Mild ptosis of 2 mm and a smaller right pupil, more obvious in dim light, are noted in a chronic smoker with right shoulder pain. The right pupil reacts normally to light. Which result of a topical drop test confirms that the miosis is due to sympathetic denervation?

In adults, what is the commonest cause of both unilateral and bilateral proptosis?

Ptosis that varies through the day, worse in the evening, and double vision on reading are reported by a bank cashier. Pupils are normal, and after 2 minutes of an ice pack over the closed lid the ptosis improves by 3 mm. Which blood test is most specific to confirm the diagnosis?

Graves' orbitopathy, statements: 1. Upper lid retraction is its commonest sign. 2. The inferior rectus is the muscle most often enlarged. 3. Smoking increases its risk and severity. 4. Radioactive iodine usually improves active eye disease. Which are correct?

Despite regular sac massage since early infancy, a child of 14 months still has a watering, sticky left eye, with mucoid regurgitation on pressure over the sac. The cornea is clear, the corneal diameter is normal and there is no photophobia; the right eye is normal. What is the next step?

Watering of the left eye with sticky discharge since 3 weeks of age is noted in a baby now 3 months old; pressure over the lacrimal sac brings mucopus out of the punctum. The cornea is clear, the eye is not photophobic and the corneal diameter is normal. What is the first-line treatment?

Fever, a swollen red right upper lid and proptosis follow a week of a cold in a schoolboy; eye movements are painful and restricted and vision is 6/12. There is no RAPD, temperature is 38.9 °C and the total leucocyte count is 16,800/mm3. Which is the most appropriate next step?