30-Item Case-Based MCQ Questionnaire: Retinal Vascular Occlusions
CENTRAL RETINAL VEIN OCCLUSION (CRVO)
Case 1: A 68-year-old hypertensive man presents with sudden painless vision loss (20/200) in his right eye. Fundus examination reveals diffuse retinal hemorrhages in all four quadrants, dilated tortuous veins, cotton-wool spots, and optic disc edema.
Question 1: What is the MOST important immediate next step in management?
- A) Start oral aspirin 325mg daily
- B) Perform fluorescein angiography to assess degree of ischemia
- C) Initiate intravitreal anti-VEGF therapy immediately
- D) Refer to stroke center within 24 hours
Question 2: Fluorescein angiography shows >10 disc areas of capillary non-perfusion. What is the PRIMARY concern requiring closest monitoring?
- A) Cystoid macular edema development
- B) Anterior segment neovascularization and neovascular glaucoma
- C) Epiretinal membrane formation
- D) Vitreous hemorrhage
Case 2: A 55-year-old diabetic woman with CRVO develops macular edema with central subfield thickness of 520 microns on OCT. Vision is 20/80.
Question 3: What is the FIRST-LINE treatment for vision-threatening macular edema in CRVO?
- A) Intravitreal corticosteroids
- B) Panretinal photocoagulation
- C) Intravitreal anti-VEGF agents
- D) Observation for 3 months
Question 4: The patient asks about steroid injections instead. What is the MOST significant risk you must counsel regarding intravitreal corticosteroids?
- A) Endophthalmitis
- B) Retinal detachment
- C) Glaucoma and cataract formation
- D) Vitreous hemorrhage
Case 3: A 62-year-old man presents with non-ischemic CRVO (visual acuity 20/40, minimal capillary dropout on FA).
Question 5: What is the MOST critical concept to communicate to this patient about his diagnosis?
- A) Vision will spontaneously improve in 90% of cases
- B) Non-ischemic CRVO can convert to ischemic type requiring vigilant monitoring
- C) No treatment is ever needed for non-ischemic CRVO
- D) Laser photocoagulation should be performed immediately
Question 6: Which systemic evaluation is ESSENTIAL in all CRVO patients?
- A) Hypercoagulability workup only in patients under 50
- B) Carotid duplex ultrasound
- C) Optimization of hypertension, diabetes, lipids, and IOP with communication to primary care
- D) Temporal artery biopsy
Case 4: A patient with ischemic CRVO returns 6 weeks later with IOP of 42 mmHg and rubeosis iridis.
Question 7: What examination technique is ESSENTIAL for detecting early angle neovascularization?
- A) Optical coherence tomography
- B) Gonioscopy
- C) B-scan ultrasonography
- D) Fundus autofluorescence
Answer: B 2
Question 8: The patient develops iris neovascularization. What is the RECOMMENDED treatment?
- A) Topical steroids
- B) Intravitreal anti-VEGF alone
- C) Panretinal photocoagulation
- D) Immediate trabeculectomy
Answer: C 1
BRANCH RETINAL VEIN OCCLUSION (BRVO)
Case 5: A 58-year-old hypertensive woman presents with superotemporal BRVO. Vision is 20/30 with macular edema on OCT.
Question 9: Where does BRVO typically occur anatomically?
- A) At the optic nerve head
- B) At an arteriovenous crossing point with common adventitial sheath
- C) In the peripheral retina only
- D) At the foveal avascular zone
Answer: B 1
Question 10: What is the FIRST-LINE treatment for macular edema causing vision loss in BRVO?
- A) Macular grid laser photocoagulation
- B) Intravitreal anti-VEGF agents
- C) Observation for 6 months
- D) Intravitreal triamcinolone
Answer: B 1
Case 6: A patient with BRVO develops retinal neovascularization in the affected quadrant.
Question 11: What is the APPROPRIATE laser treatment?
- A) Panretinal photocoagulation to all four quadrants
- B) Sectoral (angiography-guided) laser photocoagulation to affected area
- C) Macular grid laser only
- D) No laser treatment indicated
Answer: B 3
CENTRAL RETINAL ARTERY OCCLUSION (CRAO)
Case 7: A 72-year-old man presents 2 hours after sudden painless vision loss (counting fingers). Fundus shows retinal whitening, cherry-red spot, and boxcar segmentation in arterioles.
Question 12: What does boxcar segmentation in retinal arterioles indicate?
- A) Venous stasis
- B) Slow, segmented blood flow characteristic of embolic arteritis
- C) Normal arterial flow
- D) Choroidal ischemia
Answer: B 4
Question 13: What is the MOST urgent immediate action?
- A) Perform ocular massage
- B) Immediate referral to nearest stroke center for acute intervention
- C) Start oral aspirin
- D) Perform anterior chamber paracentesis
Answer: B 1
Question 14: What is the stroke risk in the first 1-4 weeks following CRAO?
- A) <1%
- B) 3-6%
- C) 10-15%
- D) >20%
Answer: B 4
Case 8: A 76-year-old woman with CRAO also has jaw claudication, temporal headache, and ESR 95 mm/hr.
Question 15: What is the MOST likely diagnosis requiring immediate treatment?
- A) Carotid stenosis
- B) Giant cell arteritis
- C) Atrial fibrillation
- D) Hypercoagulable state
Answer: B 1
Question 16: What is the IMMEDIATE treatment before temporal artery biopsy?
- A) Wait for biopsy results before treatment
- B) Urgent systemic corticosteroid therapy
- C) Intravitreal anti-VEGF
- D) Anticoagulation
Question 17: In a patient over 50 with CRAO, what is the PRIMARY reason for urgent GCA evaluation?
- A) To improve vision in the affected eye
- B) To preserve vision in the contralateral eye
- C) To prevent stroke
- D) To diagnose carotid disease
Answer: B 1
Case 9: A 45-year-old healthy woman presents with CRAO.
Question 18: What systemic workup is MOST appropriate for this patient?
- A) Embolic workup (carotid duplex, echocardiogram)
- B) Vasculitis and hypercoagulability workup
- C) Giant cell arteritis workup
- D) No workup needed
Answer: B 1
Case 10: A patient asks about treatment options to reverse vision loss from CRAO.
Question 19: What is the EVIDENCE-BASED answer regarding treatments for CRAO?
- A) Hyperbaric oxygen is proven effective
- B) Thrombolysis is standard of care
- C) There are no proven treatments to reverse vision loss from CRAO
- D) Anti-VEGF injections restore vision in most cases
Answer: C 1
BRANCH RETINAL ARTERY OCCLUSION (BRAO)
Case 11: A 65-year-old man presents with inferior altitudinal visual field defect. Fundus shows superior retinal whitening in a wedge-shaped distribution.
Question 20: What is the MOST likely diagnosis?
- A) CRVO
- B) BRVO
- C) Superior BRAO
- D) Optic neuritis
Answer: C 1
Question 21: What systemic evaluation should be performed for BRAO?
- A) No evaluation needed for asymptomatic BRAO
- B) Immediate stroke center referral for acute symptomatic BRAO
- C) Only check blood pressure
- D) Temporal artery biopsy in all cases
Answer: B 1
Case 12: A patient with BRAO has a Hollenhorst plaque at the bifurcation of a retinal arteriole.
Question 22: What does this finding indicate?
- A) Venous thrombosis
- B) Cholesterol embolus from carotid or cardiac source
- C) Giant cell arteritis
- D) Diabetic retinopathy
Answer: B 1
GIANT CELL ARTERITIS (GCA)
Case 13: A 78-year-old woman with sudden vision loss has ESR 88 mm/hr and CRP 6.5 mg/dL.
Question 23: What is the sensitivity of elevated CRP for diagnosing GCA?
- A) 50%
- B) 70%
- C) 90%
- D) 99%
Question 24: What is the negative likelihood ratio of a normal CRP in suspected GCA?
- A) 0.10
- B) 0.40
- C) 0.70
- D) 0.90
Case 14: A 68-year-old man with CRAO has normal ESR (18 mm/hr) and normal CRP (0.8 mg/dL) but has jaw claudication.
Question 25: What should you do?
- A) GCA is excluded by normal inflammatory markers
- B) Jaw claudication upgrades suspicion for GCA despite normal markers; proceed with workup
- C) Repeat labs in 1 week
- D) No further GCA evaluation needed
Question 26: Which physical finding has the HIGHEST positive likelihood ratio for GCA?
- A) Headache (LR+ 1.1)
- B) Scalp tenderness (LR+ 1.9)
- C) Temporal artery thickening (LR+ 4.7)
- D) Constitutional symptoms (LR+ 1.2)
Answer: C 1
Case 15: A patient with suspected GCA has anterior ischemic optic neuropathy (AION).
Question 27: What is the sensitivity of AION for GCA?
- A) 6%
- B) 24%
- C) 52%
- D) 88%
Answer: B 1
Question 28: What percentage of GCA patients have CRP elevated at diagnosis?
- A) 50%
- B) 70%
- C) >95%
- D) 100%
Answer: C 5
COMBINED OCCLUSIONS
Case 16: A 56-year-old man presents with cream-colored retinal edema along a macular branch artery, delayed fluorescein filling, AND dilated tortuous veins with scattered hemorrhages.
Question 29: What is the MOST likely diagnosis?
- A) CRVO alone
- B) CRAO alone
- C) Combined CRAO and CRVO
- D) Diabetic retinopathy
Answer: C 6
Question 30: A 42-year-old man with asthma and hypereosinophilia develops combined central retinal artery and vein occlusion. What underlying systemic disease should be suspected?
- A) Behçet's disease
- B) Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis)
- C) Systemic lupus erythematosus
- D) Sarcoidosis
Answer: B 7
ANSWER KEY SUMMARY: 1-B, 2-B, 3-C, 4-C, 5-B, 6-C, 7-B, 8-C, 9-B, 10-B, 11-B, 12-B, 13-B, 14-B, 15-B, 16-B, 17-B, 18-B, 19-C, 20-C, 21-B, 22-B, 23-C, 24-B, 25-B, 26-C, 27-B, 28-C, 29-C, 30-B