Jaundice, vomiting and poor weight gain since starting breast feeds are noted in a 3-week-old baby. The liver is enlarged, urine tests positive for reducing substances but negative with glucose oxidase strips, and slit-lamp examination shows central 'oil-droplet' lens opacities. Which enzyme is most likely deficient?

Galactose-1-phosphate uridyl transferase

Fructose-1,6-bisphosphate aldolase

Glucose-6-phosphate dehydrogenase

Galactokinase (galactose kinase)

Three weeks after uneventful bilateral LASIK, a staff nurse returns with increasing pain, redness and blurring in the right eye. On day 1 the surgeon had treated a diffuse, fine, granular 'sands of Sahara' haze at the flap interface in that eye with intensive steroid drops, which she is still using four times a day. Slit-lamp examination now shows several small, white, 'cracked windshield' infiltrates confined to the flap interface, with mild anterior chamber reaction and an intact epithelium over the flap. Her vision has dropped from 6/6 to 6/18. What is the most appropriate next step?

Lift flap; scrape for mycobacterial culture

Increase steroid drops to hourly

Aggressive ROP is seen at 32 weeks postmenstrual age in a baby born at 25 weeks weighing 700 g: flat, ill-defined neovascularisation in zone I with severe plus disease in all four quadrants of both eyes, progressing over 4 days. The baby is still on CPAP with oxygen and had a blood transfusion last week. The SNCU is in a district hospital and the family lives 150 km away, but they have agreed to bring the baby for every review. Which plan is best?

Intravitreal anti-VEGF, then prolonged follow-up

Weekly review until stage 3 appears

Laser now, then discharge from ROP review

Paediatric ophthalmology, ROP and refractive surgery

25 NEET-PG practice questions on Paediatric ophthalmology, ROP and refractive surgery, 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
Jaundice, vomiting and poor weight gain since starting breast feeds are noted in a 3-week-old baby. The liver is enlarged, urine tests positive for reducing substances but negative with glucose oxidase strips, and slit-lamp examination shows central 'oil-droplet' lens opacities. Which enzyme is most likely deficient?
1. AFructose-1,6-bisphosphate aldolase
2. BGlucose-6-phosphate dehydrogenase
3. CGalactose-1-phosphate uridyl transferase
4. DGalactokinase (galactose kinase)
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Answer: C · Galactose-1-phosphate uridyl transferase
Classic galactosaemia is due to deficiency of galactose-1-phosphate uridyl transferase. Galactose from milk is reduced by aldose reductase in the lens to galactitol, which draws in water and produces an 'oil-droplet' cataract; liver failure, E. coli sepsis and vomiting follow milk feeds. Early removal of lactose from the diet can reverse the lens changes. Key point: Oil-droplet cataract with jaundice and urinary reducing sugar: classic galactosaemia (GALT deficiency); remove lactose early.
- A: Aldolase B deficiency (fructose intolerance) appears after fructose, not milk.
- B: G6PD deficiency causes haemolysis, not cataract and reducing sugar in urine.
- D: Galactokinase deficiency causes cataract alone, without liver disease or vomiting.
Question 2 · Hard
Three weeks after uneventful bilateral LASIK, a staff nurse returns with increasing pain, redness and blurring in the right eye. On day 1 the surgeon had treated a diffuse, fine, granular 'sands of Sahara' haze at the flap interface in that eye with intensive steroid drops, which she is still using four times a day. Slit-lamp examination now shows several small, white, 'cracked windshield' infiltrates confined to the flap interface, with mild anterior chamber reaction and an intact epithelium over the flap. Her vision has dropped from 6/6 to 6/18. What is the most appropriate next step?
1. AAdd oral acyclovir and review
2. BNd:YAG laser to the interface
3. CIncrease steroid drops to hourly
4. DLift flap; scrape for mycobacterial culture
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Answer: D · Lift flap; scrape for mycobacterial culture
Diffuse lamellar keratitis appears in the first days as a sterile, diffuse interface haze and responds to steroids. Painful, focal interface infiltrates appearing weeks later, especially on steroids, suggest infectious keratitis; non-tuberculous (atypical) mycobacteria classically cause 'cracked windshield' infiltrates after LASIK. The flap is lifted, the interface scraped and irrigated, and samples sent for smear and culture, including Ziehl-Neelsen staining, before treatment with amikacin, clarithromycin or a fluoroquinolone. Key point: Late, painful interface infiltrates after LASIK suggest infection, often atypical mycobacteria: lift the flap and culture.
- A: The interface infiltrates are not herpetic, so acyclovir is not the answer.
- B: YAG laser has no role in treating interface keratitis.
- C: More steroid would worsen an infection and is right only for early DLK.
Question 3 · Hard
Aggressive ROP is seen at 32 weeks postmenstrual age in a baby born at 25 weeks weighing 700 g: flat, ill-defined neovascularisation in zone I with severe plus disease in all four quadrants of both eyes, progressing over 4 days. The baby is still on CPAP with oxygen and had a blood transfusion last week. The SNCU is in a district hospital and the family lives 150 km away, but they have agreed to bring the baby for every review. Which plan is best?
1. AVitrectomy within 2 weeks
2. BIntravitreal anti-VEGF, then prolonged follow-up
3. CWeekly review until stage 3 appears
4. DLaser now, then discharge from ROP review
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Answer: B · Intravitreal anti-VEGF, then prolonged follow-up
Aggressive ROP (A-ROP in ICROP3, formerly AP-ROP) in zone I can progress to detachment within days and needs urgent treatment. Intravitreal anti-VEGF is often preferred for zone I disease because laser in zone I destroys a large area of retina and gives worse myopia, and BEAT-ROP showed fewer recurrences in zone I with bevacizumab. Because vessels may stop growing and ROP can reactivate weeks later, these babies need prolonged follow-up until the retina is vascularised. Key point: Zone I aggressive ROP: urgent anti-VEGF (or laser), then prolonged review because late reactivation can occur.
- A: Vitrectomy is for stage 4-5 detachment, not untreated stage-free A-ROP.
- C: A-ROP need not pass through stage 3; waiting allows detachment.
- D: Even after laser, babies are followed until the disease has fully regressed.
Question 4 · Medium
Regarding heritable (germline) retinoblastoma: 1. It is usually bilateral or multifocal. 2. It presents at a younger age than sporadic unilateral disease. 3. Survivors have a raised lifetime risk of osteosarcoma. 4. Removing both eyes removes the risk of second cancers. Which statements are correct?
1. A1 and 3 only
2. B2 and 4 only
3. C1, 2 and 3 only
4. D1, 2, 3 and 4
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Answer: C · 1, 2 and 3 only
In heritable retinoblastoma every cell carries one mutant RB1, so tumours arise early, often in both eyes and multifocally, and the child has a lifelong risk of second cancers, especially osteosarcoma and soft-tissue sarcomas, made worse by radiotherapy. Enucleation treats the eye tumours but cannot remove a germline risk. Siblings and offspring need genetic counselling and screening. Key point: Germline retinoblastoma: early, bilateral tumours and lifelong second-cancer risk (osteosarcoma), which enucleation does not remove.
- A: Statement 2 is also true: heritable disease presents earlier.
- B: Statement 4 is false, and statements 1 and 3 are true.
- D: Statement 4 is false: the germline mutation remains in every cell.
Question 5 · Easy
The retinoblastoma gene RB1, whose two-hit inactivation causes the tumour, lies on which chromosome band?
1. A22q12
2. B11p13
3. C17p13
4. D13q14
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Answer: D · 13q14
RB1 on chromosome 13q14 is a tumour suppressor gene whose protein holds cells at the G1-S checkpoint. Knudson's two-hit hypothesis explains the disease: in heritable cases one mutation is inherited in every cell and a second somatic hit is needed, so tumours are early and often bilateral; in sporadic cases both hits are somatic. Key point: Retinoblastoma is caused by loss of both copies of RB1 on 13q14 (Knudson two-hit).
- A: 22q12 carries NF2, linked with bilateral vestibular schwannomas.
- B: 11p13 carries WT1 and PAX6, linked with Wilms tumour and aniridia.
- C: 17p13 carries TP53, mutated in Li-Fraumeni syndrome.
Question 6 · Medium
Primary posterior capsulotomy with anterior vitrectomy is done as a routine step during cataract surgery with IOL implantation in a 3-year-old with a dense lamellar cataract, at a tertiary eye centre in Hyderabad. The parents ask why the surgeon is cutting the back of the lens bag. Why is it added in young children?
1. AIt lowers the risk of postoperative endophthalmitis
2. BIt lowers the risk of postoperative glaucoma
3. CCapsule opacification is near certain in children
4. DIt allows a larger IOL to be implanted
Answer and explanation in LearnFree account
Question 7 · Medium
ROP screening of a baby now at 35 weeks postmenstrual age shows, in the right eye, a ridge with extraretinal fibrovascular proliferation in zone II, and dilated, tortuous vessels at the posterior pole in more than 2 quadrants. The left eye is similar. What should be done?
1. ARepeat examination in 2 weeks
2. BLens-sparing vitrectomy within 72 hours
3. CLaser photocoagulation within 72 hours
4. DRepeat examination in 1 week
Answer and explanation in LearnFree account
Question 8 · Easy
Watering, light sensitivity and constant eye-rubbing since birth are reported in a boy of 4 months whose corneas look large and slightly hazy; horizontal curvilinear lines are seen on the back of both corneas. The horizontal corneal diameter is 13 mm in each eye. What is the most likely diagnosis?
1. AX-linked megalocornea
2. BCongenital nasolacrimal duct obstruction
3. CCongenital hereditary endothelial dystrophy
4. DPrimary congenital glaucoma
Answer and explanation in LearnFree account
Question 9 · Medium
Dense central cataracts in both eyes, with no red reflex, are found at the 6-week immunisation visit of a baby girl who does not fix or follow. There is no family history, she was born at term after an uneventful pregnancy and she is otherwise well, with normal TORCH screening. What is the best plan?
1. ASurgery on one eye now, the other at age 5
2. BWait until 2 years for surgery with an IOL
3. CCataract surgery on both eyes in the coming weeks
4. DDilating drops and review at 6 months
Answer and explanation in LearnFree account
Question 10 · Easy
Under the Indian national guidelines, which preterm babies must be screened for retinopathy of prematurity?
1. ABelow 37 weeks or below 2500 g
2. BBelow 34 weeks or below 1750 g
3. CBelow 28 weeks or below 1000 g
4. DBelow 32 weeks or below 1500 g
Answer and explanation in LearnFree account
Question 11 · Medium
Corneal topography of a call-centre worker, aged 24, seeking LASIK for -4.5 D myopia shows inferior steepening with an inferior-superior asymmetry of 2.4 D, and pachymetry shows the thinnest point to be 470 um, displaced inferiorly. His spectacle prescription has changed by 1.0 D in the past year. What should he be advised?
1. ALASIK after a year of contact lenses
2. BLASIK with a thinner flap
3. CPRK instead of LASIK
4. DNo LASIK; assess for corneal cross-linking
Answer and explanation in LearnFree account
Question 12 · Hard
Bilateral retinoblastoma is diagnosed in a girl of 14 months at a regional cancer centre. The right eye has a tumour filling more than half of the globe with neovascular glaucoma and no visual potential (group E); the left eye has a single 4 mm tumour away from the fovea and the optic disc (group B). MRI shows no optic nerve or pineal involvement, and there is no family history. The family lives near the centre and can attend every cycle of treatment. Her parents ask whether both eyes must be removed. What is the best plan?
1. AChemotherapy alone for both eyes, no surgery
2. BExternal beam radiotherapy to both eyes
3. CBoth eyes enucleated at the same sitting
4. DRight enucleation; left chemotherapy plus focal therapy
Answer and explanation in LearnFree account
Question 13 · Easy
Leukocoria in the right eye is noticed in family photographs of a toddler of 18 months, and the mother says that eye sometimes turns in. The red reflex test at the PHC shows a white reflex on the right. Which diagnosis must be excluded first?
1. ACongenital cataract
2. BRetinoblastoma
3. CPersistent fetal vasculature
4. DCoats disease
Answer and explanation in LearnFree account
Question 14 · Medium
Examination under anaesthesia of a baby of 5 months with photophobia and watering: horizontal corneal diameters 13.5 mm, IOP 30 mmHg in both eyes, cup-disc ratio 0.6, and both corneas too hazy to see the angle structures. Haab striae are seen in both eyes and the anterior chambers are deep. Which surgery is preferred?
1. ASelective laser trabeculoplasty
2. BTrabeculotomy
3. CNd:YAG iridotomy
4. DGoniotomy
Answer and explanation in LearnFree account
Question 15 · Medium
Fundoscopy of a boy of 6 with a squint and poor vision in the right eye shows dilated, telangiectatic vessels in the temporal periphery with extensive yellow intraretinal and subretinal exudation and an exudative retinal detachment. B-scan shows no calcification, and the left eye is normal. Which diagnosis fits best?
1. AToxocara granuloma
2. BRetinopathy of prematurity
3. CCoats disease
4. DRetinoblastoma
Answer and explanation in LearnFree account
Question 16 · Medium
Bilateral retinoblastoma has been diagnosed by examination under anaesthesia in a girl of 10 months whose father had an eye removed in childhood. The left eye has two tumours and the right eye has one, with calcification on ultrasound in all three. Which imaging should be used to stage the tumour and look for a pineal tumour?
1. ACT of the orbits and brain
2. BPlain X-ray of the skull and orbits
3. CPET-CT of the whole body
4. DMRI of the orbits and brain
Answer and explanation in LearnFree account
Question 17 · Medium
Risk factors for retinopathy of prematurity in an SNCU audit: 1. Low gestational age at birth. 2. Unmonitored supplemental oxygen. 3. Neonatal sepsis. 4. Post-term delivery. Which are correct?
1. A1, 2, 3 and 4
2. B1 and 2 only
3. C2, 3 and 4 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 18 · Medium
Awaiting surgery for congenital glaucoma, an infant aged 2 months is given drops to lower the IOP. Which drug should be avoided at this age?
1. ABrimonidine
2. BTimolol 0.25%
3. CDorzolamide
4. DLatanoprost
Answer and explanation in LearnFree account
Question 19 · Medium
In the paediatric eye OPD, a white intraocular mass with calcification on B-scan is found in the left eye of a 2-year-old. The parents noticed a white pupil a month ago. A junior resident suggests fine-needle aspiration of the mass to confirm the diagnosis before treatment. Why is this wrong?
1. AIt will cause a traumatic cataract
2. BCytology cannot identify these tumour cells
3. CIt can seed tumour cells into the orbit
4. DAspiration permanently raises the IOP
Answer and explanation in LearnFree account
Question 20 · Medium
A preterm baby born at 30 weeks, weighing 1300 g, is stable in the SNCU of a district hospital in Odisha after 5 days of oxygen therapy and one episode of suspected sepsis. She is gaining weight and may go home within a week. The paediatrician asks when the first ROP examination should be done. When should it be done?
1. AAt 40 weeks postmenstrual age
2. BOnly at discharge from the SNCU
3. CBy 30 days of life
4. DAt 3 months of age
Answer and explanation in LearnFree account
Question 21 · Hard
Refraction is -12.00 D in both eyes, stable for 3 years, in a 26-year-old software tester who wants to be free of spectacles. Central corneal thickness is 480 um and topography is normal. He plays football on weekends and has no eye disease. The surgeon plans a LASIK flap of 110 um, and the excimer ablation needs about 12 um of stroma per dioptre for a 6 mm optical zone. A residual stromal bed of at least 250 um is required for safety. Which option is best for him?
1. ARadial keratotomy
2. BBilateral clear lens extraction
3. CLASIK with a thinner 100 um flap
4. DPhakic intraocular lens (ICL)
Answer and explanation in LearnFree account
Question 22 · Hard
Unilateral dense congenital cataract of the left eye was removed at 7 weeks of age in a baby boy, and the eye was left aphakic and fitted with a high-plus contact lens. At the 4-month review the parents say the lens stays in most of the day. The right eye is normal. The child fixes and follows well with the right eye but protests strongly whenever it is covered, while fixation with the left eye is poor and unsteady. The left fundus is normal and the IOP is normal. Which step is now most important for the left eye to develop useful vision?
1. AAtropine drops in the left eye
2. BPart-time patching of the right eye
3. CSecondary IOL in the left eye now
4. DSwitch to aphakic spectacles
Answer and explanation in LearnFree account
Question 23 · Medium
Histopathology of an enucleated eye from a child with leukocoria: a tumour arising from the retina, made of sheets of small round blue cells with areas of necrosis and calcification, and tumour cells reaching the optic nerve head but not beyond the lamina cribrosa. Which feature is most characteristic of this tumour?
1. APerivascular ependymal pseudorosettes
2. BPsammoma bodies
3. CFlexner-Wintersteiner rosettes
4. DHomer Wright rosettes
Answer and explanation in LearnFree account
Question 24 · Medium
Stage 2 ROP in zone II, a ridge without extraretinal tissue, with no plus disease, is found in both eyes of a baby born at 29 weeks (birth weight 1150 g) and now 34 weeks postmenstrual age. The baby is off oxygen and feeding well in the SNCU. How should this baby be managed?
1. AIntravitreal anti-VEGF injection now
2. BLaser photocoagulation within 72 hours
3. CDischarge; review at 6 months
4. DReview in a week; treat if it progresses
Answer and explanation in LearnFree account
Question 25 · Easy
After uneventful LASIK, which complication is the most common?
1. ACorneal ectasia
2. BEpithelial ingrowth
3. CDry eye
4. DDiffuse lamellar keratitis
Answer and explanation in LearnFree account

Paediatric ophthalmology, ROP and refractive surgery

The retinoblastoma gene RB1, whose two-hit inactivation causes the tumour, lies on which chromosome band?

ROP screening of a baby now at 35 weeks postmenstrual age shows, in the right eye, a ridge with extraretinal fibrovascular proliferation in zone II, and dilated, tortuous vessels at the posterior pole in more than 2 quadrants. The left eye is similar. What should be done?

Watering, light sensitivity and constant eye-rubbing since birth are reported in a boy of 4 months whose corneas look large and slightly hazy; horizontal curvilinear lines are seen on the back of both corneas. The horizontal corneal diameter is 13 mm in each eye. What is the most likely diagnosis?

Under the Indian national guidelines, which preterm babies must be screened for retinopathy of prematurity?

Leukocoria in the right eye is noticed in family photographs of a toddler of 18 months, and the mother says that eye sometimes turns in. The red reflex test at the PHC shows a white reflex on the right. Which diagnosis must be excluded first?

Risk factors for retinopathy of prematurity in an SNCU audit: 1. Low gestational age at birth. 2. Unmonitored supplemental oxygen. 3. Neonatal sepsis. 4. Post-term delivery. Which are correct?

Awaiting surgery for congenital glaucoma, an infant aged 2 months is given drops to lower the IOP. Which drug should be avoided at this age?

In the paediatric eye OPD, a white intraocular mass with calcification on B-scan is found in the left eye of a 2-year-old. The parents noticed a white pupil a month ago. A junior resident suggests fine-needle aspiration of the mass to confirm the diagnosis before treatment. Why is this wrong?

Stage 2 ROP in zone II, a ridge without extraretinal tissue, with no plus disease, is found in both eyes of a baby born at 29 weeks (birth weight 1150 g) and now 34 weeks postmenstrual age. The baby is off oxygen and feeding well in the SNCU. How should this baby be managed?

After uneventful LASIK, which complication is the most common?