Ophthalmology Prometric exam questions

The Ophthalmology exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked Ophthalmology practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Medical and Surgical Retina, Vitreous

   A 28-year-old man with poorly controlled type 1 diabetes presents with vision of counting fingers in the right eye. There is a dense vitreous haemorrhage precluding a fundus view, and B-scan ultrasonography demonstrates a taut posterior hyaloid with tractional retinal detachment involving the macula. What is the most appropriate management?

   1. AObserve for three months to allow spontaneous clearing of the haemorrhage
   2. BIntravitreal anti-VEGF monotherapy with review in six weeks
   3. CAttempt panretinal photocoagulation through the haemorrhage
   4. DPrompt pars plana vitrectomy with membrane delamination and endolaser
   Show answer and explanation

   Correct answer: D. Prompt pars plana vitrectomy with membrane delamination and endolaser

   Macula-involving tractional retinal detachment in proliferative diabetic retinopathy is an indication for prompt vitrectomy with segmentation or delamination of fibrovascular tissue and endolaser, since delay risks irreversible photoreceptor loss. Observation is appropriate only for vitreous haemorrhage with an attached retina. Anti-VEGF monotherapy does not relieve traction and, if given without early surgery, may precipitate contraction of fibrovascular tissue and worsening detachment. Adequate photocoagulation cannot be delivered through a dense haemorrhage.

   Reference: AAO Preferred Practice Pattern, Diabetic Retinopathy, 2019 (updated); Diabetic Retinopathy Vitrectomy Study reports

2. Question 2 · Cornea, External Disease and Ocular Surface

   A 40-year-old man has high against-the-rule astigmatism. Slit-lamp examination shows a 1-2 mm band of inferior corneal thinning about 1 mm from the limbus, with the cornea protruding above the band of thinning and no Fleischer ring or Vogt striae. Axial topography shows a butterfly or crab-claw pattern with flattening along the vertical meridian. Which is the most likely diagnosis?

   1. AKeratoconus
   2. BTerrien marginal degeneration
   3. CPellucid marginal degeneration
   4. DKeratoglobus
   Show answer and explanation

   Correct answer: C. Pellucid marginal degeneration

   Pellucid marginal degeneration is defined by a narrow inferior band of thinning separated from the limbus by a clear zone, with maximal protrusion above the thinnest point and a crab-claw axial topography producing marked against-the-rule astigmatism. In keratoconus the cornea is thinnest at the apex of the protrusion and Fleischer ring and Vogt striae are typical. Terrien marginal degeneration causes superior peripheral thinning with a lipid line, vascularisation and an intact epithelium and is usually painless with against-the-rule astigmatism but no crab-claw pattern of protrusion below. Keratoglobus produces generalised limbus-to-limbus thinning.

   Reference: AAO BCSC Section 8 (2023-2024); Kanski's Clinical Ophthalmology, 9th edition (Salmon, 2020)

3. Question 3 · Neuro-Ophthalmology

   A 46-year-old man with chronic progressive external ophthalmoplegia has bilateral ptosis with a levator function of 3 mm and marked chin elevation, but his Bell phenomenon is absent and corneal sensation is intact. Which consideration is most important when planning ptosis surgery?

   1. AAggressive maximal levator resection is preferred to achieve a symmetrical high lid position
   2. BConservative undercorrection, typically with a frontalis sling, because of high risk of exposure keratopathy
   3. CSurgery is contraindicated in all mitochondrial myopathies
   4. DMuller muscle-conjunctival resection is the procedure of choice given the poor levator function
   Show answer and explanation

   Correct answer: B. Conservative undercorrection, typically with a frontalis sling, because of high risk of exposure keratopathy

   In chronic progressive external ophthalmoplegia the orbicularis is also weak and the Bell phenomenon is often absent, so the cornea is poorly protected and deliberate undercorrection, usually via a frontalis suspension with careful lubrication, is the safe approach. Maximal levator resection risks severe lagophthalmos and exposure keratopathy in exactly this setting. Surgery is not contraindicated but must be conservative, and Muller muscle-conjunctival resection requires good levator function and a phenylephrine response, which are absent here.

   Reference: American Academy of Ophthalmology, Basic and Clinical Science Course Section 7: Oculofacial Plastic and Orbital Surgery (2023-2024)

4. Question 4 · Uveitis, Ocular Immunology and Ocular Infection

   An 8-year-old girl with JIA-associated uveitis has required prednisolone acetate four times daily for 8 months to remain quiet, and has developed a posterior subcapsular cataract and an intraocular pressure of 27 mmHg. Which is the most appropriate next step?

   1. AIncrease topical steroid to hourly and add oral prednisolone long term
   2. BStop all anti-inflammatory therapy and observe
   3. CProceed directly to cataract surgery and continue current topical steroid
   4. DStart a steroid-sparing agent such as methotrexate, aiming to reduce topical steroid to two drops daily or fewer
   Show answer and explanation

   Correct answer: D. Start a steroid-sparing agent such as methotrexate, aiming to reduce topical steroid to two drops daily or fewer

   Chronic topical steroid dependence beyond about 2 drops per day, with steroid-induced cataract and ocular hypertension, is the accepted trigger to introduce systemic steroid-sparing immunomodulation, with methotrexate the standard first-line agent in JIA uveitis (adalimumab added if control is inadequate). Escalating steroid would worsen the cataract and pressure. Operating on an eye with poorly controlled inflammation invites severe postoperative complications, and stopping all therapy risks rapid relapse with synechiae, band keratopathy and hypotony.

   Reference: American College of Rheumatology / Arthritis Foundation Guideline for the Screening, Monitoring and Treatment of JIA-Associated Uveitis, 2019

5. Question 5 · Optics, Refraction and Visual Function

   A 48-year-old emmetrope has a measured accommodative amplitude of 3.00 D. She wants to read comfortably at 33 cm and you plan to leave half of her amplitude in reserve. What near addition should you prescribe?

   1. A+0.75 D
   2. B+1.50 D
   3. C+2.50 D
   4. D+3.00 D
   Show answer and explanation

   Correct answer: B. +1.50 D

   The accommodative demand at 33 cm is 1/0.33 = 3.00 D; holding half the 3.00 D amplitude in reserve leaves 1.50 D usable, so the add is 3.00 - 1.50 = +1.50 D. Prescribing the full 3.00 D would ignore her residual accommodation and unnecessarily shorten the near range, while +0.75 D leaves her using more than half her amplitude and she will fatigue. The final add should always be verified with a near range-of-clear-vision check.

   Reference: AAO Basic and Clinical Science Course, Section 3: Clinical Optics and Vision Rehabilitation, 2023-2024

6. Question 6 · Ocular Oncology, Pathology and Systemic Disease

   Before a diagnostic vitrectomy for suspected primary vitreoretinal lymphoma, which practical step most improves the diagnostic yield of the vitreous specimen?

   1. ALoading the patient with intravenous methylprednisolone the day before surgery to reduce inflammation
   2. BDiluting the vitreous with balanced salt solution and refrigerating it overnight before transport
   3. CTaking only diluted cassette washings and discarding the undiluted specimen
   4. DWithholding corticosteroids for a period before the biopsy and delivering the undiluted vitreous sample promptly to the laboratory in appropriate transport medium
   Show answer and explanation

   Correct answer: D. Withholding corticosteroids for a period before the biopsy and delivering the undiluted vitreous sample promptly to the laboratory in appropriate transport medium

   Lymphoma cells are fragile and lyse rapidly, and corticosteroids are directly lymphocytolytic, so tapering or withholding steroids beforehand and delivering an undiluted vitreous sample immediately (with the surgeon and cytopathologist coordinated) markedly improves diagnostic yield. Preoperative steroid loading destroys the malignant cells and causes false negatives. Dilution and delay both degrade cellularity; the undiluted specimen is the highest-yield sample and should never be discarded, although cassette washings can be sent as an adjunct.

   Reference: Chan CC et al. Primary vitreoretinal lymphoma: a report from an International PVRL Collaborative Group symposium (The Oncologist, 2011); AAO BCSC Section 9 (2023-2024)

7. Question 7 · Medical and Surgical Retina, Vitreous

   A trainee proposes replacing fluorescein angiography entirely with OCT angiography in a medical retina clinic. What is the most important limitation of OCT angiography that argues against this?

   1. AIt cannot resolve the deep retinal capillary plexus
   2. BIt requires intravenous dye and therefore carries an anaphylaxis risk
   3. CIt does not demonstrate dye leakage or staining, so lesion activity must be inferred from structural OCT findings
   4. DIt cannot be performed in pseudophakic eyes
   Show answer and explanation

   Correct answer: C. It does not demonstrate dye leakage or staining, so lesion activity must be inferred from structural OCT findings

   OCT angiography images blood flow by decorrelation between repeated B-scans and therefore visualises vascular structure but cannot show leakage, staining or pooling, which remain the angiographic markers of activity in neovascular and inflammatory disease; activity must instead be judged from fluid on structural OCT. It resolves the deep capillary plexus better than fluorescein angiography does, it is dye-free and therefore free of anaphylaxis risk, and it is readily performed in pseudophakic eyes. Its practical drawbacks are a limited field of view, segmentation errors and projection and motion artefacts.

   Reference: Spaide RF et al., Optical Coherence Tomography Angiography, Progress in Retinal and Eye Research 2018

8. Question 8 · Cornea, External Disease and Ocular Surface

   A 64-year-old woman with 20 years of seropositive rheumatoid arthritis presents with a painful red eye and a crescentic peripheral corneal ulcer with an overhanging epithelial edge, stromal thinning to 40% and adjacent scleral injection. Which management principle is most important?

   1. AIntensive topical corticosteroid alone is sufficient and safe
   2. BTopical antibiotics alone, since peripheral ulcerative keratitis is always infectious
   3. CTopical ciclosporin monotherapy with observation for 3 months
   4. DUrgent systemic immunosuppression (for example cyclophosphamide or rituximab) with rheumatology co-management, because rheumatoid peripheral ulcerative keratitis signals systemic vasculitis and carries significant mortality
   Show answer and explanation

   Correct answer: D. Urgent systemic immunosuppression (for example cyclophosphamide or rituximab) with rheumatology co-management, because rheumatoid peripheral ulcerative keratitis signals systemic vasculitis and carries significant mortality

   Peripheral ulcerative keratitis in rheumatoid arthritis is a marker of active systemic vasculitis and is associated with a markedly increased mortality, mostly from cardiovascular and vasculitic disease, so control requires prompt systemic immunosuppression alongside rheumatology input; rituximab and cyclophosphamide are established options. Topical corticosteroid alone does not control the systemic process and can promote collagenolysis and perforation in a thinning cornea. Infection must be excluded but is not the usual cause in this setting, and topical ciclosporin alone is inadequate for vasculitic disease.

   Reference: Foster CS et al., Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis, Ophthalmology 1984; AAO BCSC Section 8 (2023-2024)

9. Question 9 · Neuro-Ophthalmology

   A 52-year-old woman has 8 months of slowly progressive painless visual loss in the left eye, now 6/36, with a left relative afferent pupillary defect, optic disc pallor and optociliary shunt vessels on the left disc. Fundus examination is otherwise normal and inflammatory markers are unremarkable. What is the most likely diagnosis?

   1. AOptic nerve sheath meningioma
   2. BNon-arteritic anterior ischaemic optic neuropathy
   3. CLeber hereditary optic neuropathy
   4. DChronic papilloedema from idiopathic intracranial hypertension
   Show answer and explanation

   Correct answer: A. Optic nerve sheath meningioma

   The classic triad of slowly progressive unilateral visual loss, optic atrophy and optociliary (retinochoroidal) shunt vessels indicates chronic optic nerve compression, most typically an optic nerve sheath meningioma, and MRI with fat-suppressed contrast showing tram-track enhancement confirms it. NAION presents acutely with altitudinal loss and does not produce shunt vessels. Leber hereditary optic neuropathy is usually bilateral sequential in young men with peripapillary telangiectasia, and idiopathic intracranial hypertension causes bilateral disc swelling rather than a unilateral progressive atrophic picture.

   Reference: Miller NR, Subramanian PS, Patel VR (eds). Walsh & Hoyt's Clinical Neuro-Ophthalmology: The Essentials, 3rd edition (2016)

10. Question 10 · Uveitis, Ocular Immunology and Ocular Infection

    A 30-year-old man from the eastern Mediterranean has recurrent explosive attacks of panuveitis with a shifting mobile hypopyon in a relatively painless eye, together with occlusive retinal vasculitis affecting both arteries and veins. He reports recurrent painful oral and genital ulceration. Which treatment is most appropriate to preserve long-term vision?

    1. ATopical corticosteroid and cycloplegia only, with observation between attacks
    2. BLong-term systemic immunomodulation, with anti-TNF or interferon therapy for sight-threatening posterior involvement
    3. CRepeated intravitreal antibiotic injections
    4. DPanretinal photocoagulation as first-line therapy
    Show answer and explanation

    Correct answer: B. Long-term systemic immunomodulation, with anti-TNF or interferon therapy for sight-threatening posterior involvement

    Ocular Behcet disease with occlusive retinal vasculitis carries a high risk of irreversible visual loss with each attack, so guidelines recommend early systemic immunosuppression, with anti-TNF agents such as infliximab or adalimumab, or interferon alfa, for sight-threatening posterior segment disease rather than corticosteroid monotherapy. Topical therapy alone treats only the anterior segment and permits cumulative retinal damage. Intravitreal antibiotics treat endophthalmitis, and laser photocoagulation only addresses established ischaemia and neovascularisation, not the underlying inflammation.

    Reference: EULAR recommendations for the management of Behcet's syndrome, Annals of the Rheumatic Diseases, 2018 update

11. Question 11 · Optics, Refraction and Visual Function

    During biometry for cataract surgery in an eye of average dimensions, a 1 mm error is made in the measurement of axial length. Approximately how much postoperative refractive error at the spectacle plane would this produce?

    1. AApproximately 0.25 D
    2. BApproximately 1.0 D
    3. CApproximately 2.7 D
    4. DApproximately 6.0 D
    Show answer and explanation

    Correct answer: C. Approximately 2.7 D

    In an eye of average axial length, each millimetre of axial length error translates to roughly 2.5-3.0 D of spectacle-plane refractive error, which is why axial length is the dominant source of biometric error. A 0.25 D or 1.0 D estimate grossly understates the effect, while 6.0 D overstates it and is closer to what a 2 mm error would generate. The proportional effect is larger in short eyes and smaller in long eyes, which is why formula choice matters most at the extremes of axial length.

    Reference: AAO Basic and Clinical Science Course, Section 3: Clinical Optics and Vision Rehabilitation, 2023-2024

12. Question 12 · Ocular Trauma and Ophthalmic Emergencies

    A 42-year-old with a total ('eight-ball') traumatic hyphaema has been on maximal medical therapy for 4 days. Intraocular pressure is 40 mmHg and slit-lamp examination now shows a yellow granular discolouration of the posterior corneal stroma. What is the most appropriate next step?

    1. AAdd oral acetazolamide and review in a further 72 hours
    2. BCommence topical aminocaproic acid and continue observation
    3. CProceed to surgical evacuation of the hyphaema
    4. DPerform urgent Nd:YAG laser to disperse the clot
    Show answer and explanation

    Correct answer: C. Proceed to surgical evacuation of the hyphaema

    Early corneal blood staining is an absolute indication for surgical evacuation, as it may take years to clear and causes dense deprivation amblyopia in children. Other accepted surgical thresholds include pressure above about 50 mmHg for 5 days or above 35 mmHg for 7 days despite maximal therapy, a total hyphaema persisting beyond 5 days, and lower thresholds in sickling disorders. Continued medical therapy or antifibrinolytics will not reverse staining once it has begun, and Nd:YAG laser has no role in clot management.

    Reference: AAO Basic and Clinical Science Course Section 8 / Section 10 (2023-2024); Yanoff & Duker, Ophthalmology, 6th ed. (2023)

Ophthalmology reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our Ophthalmology questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.