30-Item Sample Questions for Vitreoretina Fellowship Examination: Diabetic Retinopathy
CASE-BASED QUESTIONS
Case 1: Screening and Initial Evaluation
Question 1: A 32-year-old woman is diagnosed with type 1 diabetes mellitus. When should her first dilated comprehensive eye examination be performed?
- A. Immediately at diagnosis
- B. Within 5 years after diagnosis
- C. At age 40
- D. Only if visual symptoms develop
Answer: B 1
Question 2: A 58-year-old man presents with newly diagnosed type 2 diabetes mellitus. When should his first dilated eye examination occur?
- A. Within 5 years
- B. Within 1 year
- C. At the time of diagnosis
- D. Only if HbA1c >9%
Answer: C 1
Question 3: A 45-year-old woman with type 2 diabetes and no retinopathy on annual exams for 3 consecutive years has well-controlled HbA1c of 6.8%. What is the appropriate follow-up interval?
- A. Every 6 months
- B. Every 1-2 years
- C. Every 3 years
- D. No further screening needed
Answer: B 1
Case 2: Pregnancy and Diabetic Retinopathy
Question 4: A 28-year-old woman with type 1 diabetes for 10 years is planning pregnancy. She has mild NPDR. What is the appropriate management?
- A. Eye examination only if symptoms develop
- B. Eye examination before pregnancy, then every trimester and 1 year postpartum
- C. Eye examination in second trimester only
- D. Defer examination until after delivery
Question 5: A 32-year-old woman develops gestational diabetes at 24 weeks gestation. Does she require ophthalmologic screening during pregnancy?
- A. Yes, immediately
- B. Yes, but only in third trimester
- C. No, gestational diabetes does not increase risk of retinopathy during pregnancy
- D. Yes, but only if blood glucose is uncontrolled
Case 3: Classification and Staging
Question 6: A patient's fundus examination reveals severe intraretinal hemorrhages and microaneurysms in all 4 quadrants, venous beading in 2 quadrants, and moderate IRMA in 1 quadrant. What is the classification?
- A. Mild NPDR
- B. Moderate NPDR
- C. Severe NPDR
- D. Proliferative diabetic retinopathy
Answer: C 1
Question 7: What defines "high-risk" proliferative diabetic retinopathy requiring immediate treatment?
- A. Any neovascularization of the disc
- B. NVD ≥1/4 to 1/3 disc area, or any NVD with vitreous hemorrhage, or NVE ≥1/2 disc area with vitreous hemorrhage
- C. Presence of cotton wool spots
- D. Venous beading in any quadrant
Answer: B 1
Case 4: Diabetic Macular Edema
Question 8: A 62-year-old man with type 2 diabetes presents with center-involved diabetic macular edema and visual acuity of 20/50. OCT shows central subfield thickness of 450 μm. What is the first-line treatment?
- A. Observation
- B. Focal laser photocoagulation
- C. Intravitreal anti-VEGF injection
- D. Panretinal photocoagulation
Question 9: A patient has non-center-involved diabetic macular edema with hard exudates temporal to the fovea. What is the preferred treatment?
- A. Anti-VEGF injection
- B. Focal/grid laser photocoagulation
- C. Observation only
- D. Intravitreal steroid
Answer: B 1
Question 10: In the RIDE and RISE studies, what percentage of patients treated with ranibizumab 0.5 mg gained ≥15 letters at 24 months compared to sham?
- A. 15-20%
- B. 25-30%
- C. 34-45%
- D. 50-60%
Answer: C 3
Case 5: Proliferative Diabetic Retinopathy
Question 11: A 55-year-old woman presents with high-risk PDR. What is the risk reduction in severe visual loss with panretinal photocoagulation compared to no treatment?
- A. From 26% to 11%
- B. From 15.9% to 6.4%
- C. From 40% to 20%
- D. From 10% to 2%
Question 12: A patient with PDR is treated with ranibizumab instead of PRP. According to current evidence, how does anti-VEGF compare to traditional PRP?
- A. Inferior outcomes
- B. Non-inferior outcomes
- C. Superior in all cases
- D. Only effective in young patients
Case 6: Systemic Risk Factors
Question 13: A 50-year-old man with type 2 diabetes has HbA1c of 9.2%. What is the strength of evidence for intensive glycemic control in reducing diabetic retinopathy risk?
- A. Grade A (strong evidence)
- B. Grade B (moderate evidence)
- C. Grade C (weak evidence)
- D. No evidence
Question 14: A patient with diabetic retinopathy has blood pressure of 145/92 mmHg. What is the target blood pressure to slow retinopathy progression?
- A. <140/90 mmHg
- B. <130/80 mmHg
- C. <120/70 mmHg
- D. Blood pressure control does not affect retinopathy
Question 15: Does aspirin therapy prevent diabetic retinopathy or worsen retinal hemorrhages?
- A. Prevents retinopathy
- B. Worsens hemorrhages, contraindicated
- C. Neither prevents retinopathy nor increases hemorrhage risk
- D. Only safe in NPDR
Case 7: Examination Techniques
Question 16: What is the best method for examining the peripheral retina in a patient with suspected diabetic retinopathy?
- A. Direct ophthalmoscopy only
- B. Indirect ophthalmoscopy or slit-lamp biomicroscopy
- C. Fundus photography alone
- D. OCT imaging
Answer: B 1
Question 17: A patient presents with elevated IOP and suspected neovascularization of the iris. When should gonioscopy be performed?
- A. After dilation
- B. Before dilation
- C. Gonioscopy is not indicated
- D. Only if IOP >30 mmHg
Answer: B 1
Case 8: Ancillary Testing
Question 18: Which ancillary test is most useful for detecting and quantifying center-involved diabetic macular edema?
- A. Fluorescein angiography
- B. Optical coherence tomography (OCT)
- C. B-scan ultrasonography
- D. Fundus autofluorescence
Answer: B 1
Question 19: What is the primary indication for fluorescein angiography in diabetic retinopathy?
- A. Routine screening
- B. Detecting areas of capillary nonperfusion and neovascularization
- C. Measuring central retinal thickness
- D. Assessing vitreous hemorrhage
Answer: B 1
Case 9: Pediatric Considerations
Question 20: A 12-year-old boy with type 1 diabetes for 3 years enters puberty. How does puberty affect diabetic retinopathy risk?
- A. No effect on progression
- B. Accelerated progression with relative risk of 4.8 compared to prepubescent patients
- C. Decreased risk during puberty
- D. Only affects type 2 diabetes
Answer: B 1
Question 21: When is vision-threatening diabetic retinopathy rare in children with type 1 diabetes?
- A. Never, can occur at any age
- B. Prior to puberty
- C. Before age 18
- D. Only in poorly controlled diabetes
Answer: B 1
Case 10: Urgent Referral Criteria
Question 22: A 48-year-old woman with type 2 diabetes presents with sudden blurry vision. What is the appropriate management?
- A. Routine referral within 1 month
- B. Urgent same-day dilated comprehensive eye examination
- C. Optimize glycemic control and reassess in 2 weeks
- D. Refer only if vision does not improve in 1 week
Answer: B 2
Question 23: Which of the following findings requires prompt referral to a vitreoretinal specialist?
- A. Mild NPDR without macular edema
- B. Any level of macular edema
- C. Microaneurysms only
- D. Well-controlled diabetes with no retinopathy
Question 24: A patient has severe NPDR. What is the appropriate management?
- A. Observation with annual follow-up
- B. Prompt referral to ophthalmologist experienced in diabetic retinopathy management
- C. Immediate PRP
- D. Increase diabetes medications only
Answer: B 1
Case 11: Treatment Outcomes
Question 25: In Studies D-1 and D-2, what percentage of patients treated with ranibizumab 0.3 mg achieved ≥2-step improvement in ETDRS-DRSS at 24 months?
- A. 10-15%
- B. 20-25%
- C. 37-39%
- D. 50-55%
Answer: C 3
Question 26: What percentage of patients treated with focal/grid laser in DME studies received laser by Month 24 compared to those treated with ranibizumab?
- A. Similar rates in both groups
- B. 72% in sham group vs 38% in ranibizumab group
- C. 90% in both groups
- D. Laser not used in these studies
Answer: B 3
Case 12: Pathophysiology
Question 27: What is the earliest clinically visible manifestation of diabetic retinopathy?
- A. Cotton wool spots
- B. Neovascularization
- C. Microaneurysms and intraretinal hemorrhages
- D. Vitreous hemorrhage
Answer: C 1
Question 28: Diabetic retinopathy is now recognized as which type of complication?
- A. Pure microvascular disease
- B. Inflammatory, neuro-vascular complication with neuronal injury preceding microvascular damage
- C. Purely neurological disease
- D. Autoimmune disorder
Case 13: Special Populations
Question 29: A 70-year-old man with type 2 diabetes for 15 years presents at diagnosis with what percentage likelihood of having some manifestation of diabetic retinopathy?
- A. 10%
- B. 20%
- C. 30%
- D. 50%
Answer: C 1
Question 30: What percentage of patients with newly diagnosed type 2 diabetes at age 30 or later will have center-involved macular edema or high-risk PDR at initial diagnosis?
- A. Up to 3%
- B. 10%
- C. 20%
- D. 30%
Answer: A 1
KEY EXAMINATION ELEMENTS TO ASSESS
Clinical examination components that must be evaluated: 1
- Visual acuity measurement
- Slit-lamp biomicroscopy
- Intraocular pressure
- Gonioscopy before dilation when neovascularization suspected
- Pupillary assessment for optic nerve dysfunction
- Stereoscopic examination of posterior pole
- Peripheral retina and vitreous examination
Critical features indicating vision-threatening disease: 1
- Macular edema (center-involved vs non-center-involved)
- Signs of severe NPDR (extensive hemorrhages/microaneurysms, venous beading, IRMA)
- Neovascularization of disc or elsewhere
- Vitreous or preretinal hemorrhage
Treatment decision-making based on evidence: 1, 2
- Anti-VEGF agents are first-line for center-involved DME with vision loss
- PRP remains standard for high-risk PDR, though anti-VEGF is non-inferior
- Focal/grid laser preferred for non-center-involved DME
- Systemic optimization (HbA1c, blood pressure, lipids) is Grade A recommendation for prevention and slowing progression