OKAP and BOARD REVIEW COURSE PRETEST on EYELIDS ...

<strong>OKAP</strong> <strong>and</strong> <strong>BOARD</strong> <strong>REVIEW</strong> <strong>COURSE</strong>
<strong>PRETEST</strong> on EYELIDS & LACRIMAL SYSTEM
ARTHUR L. MILLMAN, M.D.

Directions: Each of the questions or incomplete statements below is followed by five suggested
answers or completions. Select the one that is BEST in each case.
1. The nasolacrimal duct opens into the
A. superior meatus of the nose
B. middle meatus of the nose
C. inferior meatus of the nose
D. 50% of the time into the middle meatus, 50% of the time into the inferior meatus
E. 50% of the time into the superior meatus, 50% of the time into the middle meatus
REF: 8 – pp. 230-232
2. How many millimeters medial to the medial canthus is the angular vein situated?
A. 1 mm
B. 2 mm
C. 4 mm
D. 8 mm
E. 10-12 mm
REF: 8 – p. 414
3. The layers traversed in cutting through the eyelid 15 mm above the upper last line are
A. skin, orbicularis, tarsus, conjunctiva
B. skin, orbicularis, orbital septum, Muller’s muscle, levator, conjunctiva
C. skin, orbicularis, orbital septum, fat, levator, Muller’s muscle, conjunctiva
D. skin, orbicularis, levator, orbital septum, Muller’s muscle, conjunctiva
E. skin, orbicularis, levator, Muller’s muscle, conjunctiva
REF: 8 – pp. 175-176
4. All the following are true about Muller’s muscle EXCEPT that it
A. arises from the inferior aspect of the levator palpebrae behind the plane of the
posterior pole of the globe
B. inserts into the superior tarsal plate
C. is sympathetically innervated
D. gives off a superolateral nonstriated muscle which surrounds the palpebral lobe of
the lacrimal gl<strong>and</strong>
E. is approximately 15 to 20 mm wide at its origin
REF: 8 – p. 270
5. All of the following are true about the tarsi EXCEPT that
A. the substance of the tarsus is mesodermal in origin
B. the Meibomian gl<strong>and</strong>s are ectodermal in origin
C. it is a cartilaginous skeleton
D. its extremities are connected to the medial <strong>and</strong> palpebral ligaments
E. the medial end terminates at the punctum to join the medial canthal ligament
REF: 8 – p. 189

6. Which of the following relationships with the orbital septum is incorrect?
A. the palpebral portion of the lacrimal gl<strong>and</strong> is posterior to it
B. the lateral palpebral ligament is posterior to it
C. the orbicularis oculi is anterior to it
D. the lacrimal sac is posterior to it
E. the septum passes in front of the trochlea of the superior oblique
Directions: For each of the questions or incomplete statements below, ONE or MORE of the
answers or completions is correct.
Select:
A. if only 1 <strong>and</strong> 3 are correct
B. if only 2 <strong>and</strong> 4 are correct
C. if only 1, 2, <strong>and</strong> 3 are correct
D. if only 4 is correct
E. if all are correct
7. A lateral canthotomy divides which of the following layers?
(1) skin
(2) levator attachment
(3) orbicularis raphe
(4) orbital septum
REF: 4 – pp. 128-129
8. Which of the following are sweat gl<strong>and</strong>s?
(1) Gl<strong>and</strong>s of Krause
(2) Gl<strong>and</strong>s of Zeis
(3) Gl<strong>and</strong>s of Wolfring
(4) Gl<strong>and</strong>s of Moll
REF: 8 – pp. 195-197, 213-214
9. The orbicularis oculi is made up of the following elements EXCEPT:
(1) musculus procerus
(2) Horner’s muscle
(3) corrugator supercilii
(4) muscle of Riolan
REF: 8 – pp. 203-204

Directions: For each of the questions or incomplete statements below is followed by five
suggested answers or completions. Select the one that is BEST in each case.
10. A chalazion is to be removed from the center of the upper lid with local infiltrative
anesthesia. The most effective layer in which to inject local anesthesia is the
A. subcutaneous
B. submuscular
C. intratarsal
D. subconjunctival <strong>and</strong> submuscular
E. intratarsal <strong>and</strong> submuscular
REF: 8 – pp. 198-199
11. The pericorneal blood supply is most directly served by the
A. anterior conjunctival artery <strong>and</strong> the anterior ciliary artery
B. posterior conjunctival artery <strong>and</strong> the anterior ciliary artery
C. anterior ciliary artery <strong>and</strong> long posterior ciliary artery
D. lacrimal plexus
E. posterior conjunctival artery <strong>and</strong> the anterior conjunctival artery
REF: 8 – p. 217
12. A Bowman probe (#1) is used for lacrimal duct probing of a 12-year-old male. This probe
is marked off at 5 mm intervals. At what approximate mark would one expect to enter the
nose (<strong>and</strong> pass through the terminal valve of the nasolacrimal duct) probing through the
inferior punctum?
A. 12 mm
B. 18 mm
C. 25 mm
D. 33 mm
E. 45 mm
REF: 8 – p. 231
13. In doing a dacryocystorhinostomy under local anesthesia, the nerve to the lacrimal sac
<strong>and</strong> medial canthal area is easily blocked. This nerve is a branch of the
A. frontal nerve
B. supratrochlear nerve
C. infraorbital nerve
D. nasociliary nerve
E. supraorbital nerve
REF: 3 – vol. 5, chap. 2, p. 3

14. The most effective regional nerve block in a patient with a central upper lid marginal
lesion would be a
A. lacrimal nerve block
B. nasociliary nerve block
C. zygomatic facial nerve block
D. frontal nerve block
E. retrobulbar injection
REF: 3 – vol. 5, chap. 2, p. 3
15. One of the early symptoms of orbital invasion from a basal cell carcinoma of the lid is
A. proptosis
B. visual acuity decrease
C. optic nerve field defect
D. diplopia
E. decreased corneal reflex
REF: 2 – vol. 2, chap. 46, p. 28
16. Which of the following is true about basal cell carcinoma of the lid
A. It is more common than squamous carcinoma by 40:1
B. Keratinization is a common pathologic finding
C. Basal cell carcinoma on the upper lid is more invasive than one on the lower lid
D. All of these
E. None of these
REF: 2 – vol. 2, chap. 46, p. 27
17. Brooke’s tumor is associated with
A. cutaneous horn
B. milia
C. pilomatrixoma
D. syringoma
E. trichoepithelioma
REF: 15 – pp. 218-220
Directions: For each of the questions or incomplete statements below, ONE or MORE of the
answers or completions is correct.
Select:
A. if only 1 <strong>and</strong> 3 are correct
B. if only 2 <strong>and</strong> 4 are correct
C. if only 1, 2, <strong>and</strong> 3 are correct
D. if only 4 is correct
E. if all are correct

18. Which of the following are true about keratocanthoma of the lids?
(1) it is noninvasive
(2) it is a precancerous tumor
(3) it grows at a rapid rate over a 2- to 6-week period
(4) areas of the tumor may show squamous cell carcinoma
REF: 15 – pp. 206-207
19. Sebaceous cell carcinoma of the lids may arise from the
(1) meibomian gl<strong>and</strong>s
(2) sebaceous gl<strong>and</strong>s of the eyebrow
(3) gl<strong>and</strong>s of Zeiss
(4) caruncle
REF: 1 – p. 619
20. Factors that usually differentiate dermatochalasis <strong>and</strong> blepharochalasis are
(1) age of onset
(2) bilaterality of condition
(3) etiology of process
(4) presence of subcutaneous atrophy
REF: 15 – p. 422; 4 – p. 185
21. Surgery for entropion of the lower lid may include
(1) Wies procedure
(2) tucking of the inferior aponeurosis
(3) Quickert eyelid crease suture technique
(4) base-up tarsoconjunctival resection
REF: 11 – p. 93
22. Epiblepharon is characterized by
(1) the lower lid variant usually is self limiting in nature
(2) the upper lid variant commontly seen in Mongolian races
(3) its possible association with pseudostrabismus
(4) its extension over the lid margin pressing cilia against the globe
REF: 4 – pp. 485-486
23. An 8-month-old baby with a history of congenital epiphora is probed. Likely location(s)
for obstruction in the lacrimal system is (are)
(1) common canaliculus
(2) sac-duct junction
(3) valve of Bochdalek
(4) valve of Hasner
REF: 2 – vol. 5, chap. 11, p. 2

24. Osteosarcoma of the orbit may be seen in association with
(1) infantile cortical hyperostosis
(2) Paget’s disease of bone
(3) fibrous dysplasia
(4) irradiation for retinoblastoma
REF: 2 – vol. 2, chap. 44, p. 38
Directions: Match the lettered items to the numbered items. Each lettered item may be used
once, more than once, or not at all.
A. Normal lacrimal system
B. Blocked (nonpatent) system
C. Functional block of the lower lacrimal system
D. Functional block of upper lacrimal system (punctum, canaliculi, common
canaliculus)
E. None of these
25. Jones I test normal
REF: 11 – p. 171
26. Jones I test abnormal; Jones II test shows presence of fluorescein
REF: 11 – p. 171
27. Jones I test abnormal; Jones II test shows clear irrigant
REF: 11 – p. 171
28. Jones II test shows failure of irrigation
REF: 11 – p. 171
Directions: Each of the questions or incomplete statements below is followed by five suggested
answers or completions. Select the one that is BEST in each case.
29. The most common cause of chronic canaliculitis is
A. pneumococcus infection
B. the presence of a canalicular foreign body
C. Aspergillus infection
D. actinomyces infection
E. C<strong>and</strong>ida infection
REF: 3 – p. 36

30. Eversion of the lower punctum may be treated by
A. removal of a conjunctival <strong>and</strong> subconjunctival ellipse inferior to the punctum
B. cauterization of the area below the punctum
C. removal of a conjunctival <strong>and</strong> subconjunctival ellipse 2 mm inferior to the
involved punctum
D. cauterization inferiorly <strong>and</strong> medially to the involved punctum
E. removal of a conjunctival <strong>and</strong> subconjunctival ellipse 5 mm below the punctum
REF: 4 – p. 287
31. Epiphora due to the seventh nerve palsy is most likely due to
A. medial punctual eversion
B. lateral lower lid ectropion
C. upper lid retraction
D. failure to close lids effectively with reflex hypersecretion
E. failure of “lacrimal pump” system
REF: 4 – p. 434
32. A 5-year-old child has ptosis of the left eye. Measurements of the palpebral fissure are:
5mm in primary gaze; 4 mm in down gaze; 9 mm in up gaze. Levator function is
therefore
A. 4 mm
B. 5 mm
C. 14 mm
D. 10 mm
E. not enough information is give
REF: 4 – pp. 361-362
33. An 18-month-old child is brought to your office with congenital ptosis of the right eye.
He is too uncooperative to get any measurements. It is noted that the lid fold is absent
OD. Probable levator function is
A. less than 3 mm
B. 3-5 mm
C. 5-9 mm
D. 9-12 mm
E. greater than 12 mm
REF: 11 – pp. 129-130

34. Using the lid positions with respect to the limbal position is often helpful in determining
the etiology of the condition. A patient with ptosis of the left eye measures: 2 mm of
upper lid coverage of the limbus OD; lower lid at border of lower limbus OD; 3 mm of
upper lid coverage of the limbus OS; lower lid cover 1-2 mm, of lower limbus OS. This
may indicative of
A. congenital ptosis
B. acquired ptosis
C. myogenic ptosis
D. neurogenic ptosis
E. synkinetic ptosis
REF: 4 – p. 361
35. A lid lag on the ptotic side on down gaze is characteristic of
A. congenital ptosis
B. traumatic ptosis
C. myogenic ptosis
D. neurogenic ptosis
E. synkinetic ptosis
REF: 12 – p. 5
Directions: Match the lettered items to the numbered items. Each lettered item may be used
once, more than once, or not at all.
A. Fasanella-Servat operation
B. Bilateral frontalis sling operation
C. Unilateral frontalis sling operation
D. Levator resection 10 mm
E. Levator resection 20 mm
36. Treatment of ptosis due to Horner’s Syndrome
REF: 4 – pp. 385-387
37. Treatment of ptosis due to Marcus-Gunn jaw-winking syndrome
REF: 4 – pp. 409-410
38. Treatment of congenital ptosis OD with 4 mm of levator function present
REF: 4 – p. 365
39. Treatment of a 3 mm ptosis that clears with instillation of neosynephrine
REF: 4 – p. 3

REFERENCE: Questions 1 – 13
1. Cogan, DG: Neurology of the Ocular Muscles, Second Edition, Springfield, Charles C.
Thomas, 1975.
2. Cordes, FC: Cataract Types. Rochester, American Academy of Ophthalmology <strong>and</strong>
Otolaryngology, 1961.
3. Duane, TD: Clinical Ophthalmology, Hagerstown, Harper & Row, 1979.
4. Fox, SA: Ophthalmic Plastic Surgery, Fifth Edition, New York, Grune & Stratton, 1976.
5. Grant, JCF: Grant’s Atlas of Anatomy, Sixth Edition, Baltimore, Williams & Wilkins,
1972.
6. Jones, LT, Reeh, MJ <strong>and</strong> Wirtschafter, JD: Ophthalmic Anatomy, Rochester, American
Academy of Ophthalmology <strong>and</strong> Otolaryngology, 1970.
7. Silver, B.: Ophthalmic Plastic Surgery, Rochester, American Academy of
Ophthalmology <strong>and</strong> Otolaryngology, 1977.
8. Warwick, R: Eugene Wolff’s Anatomy of the Eye <strong>and</strong> Orbit, Seventh Edition,
Philadelphia, W.B. Saunders, 1976.
Questions 14-37
1. Boniuk, M <strong>and</strong> Zimmerman LE: Sebaceous carcinoma of the eyelid, eyebrow, caruncle
<strong>and</strong> orbit, Trans. Am. Acad. Ophthalmol. Otolaryngol., 72:619, 1968.
2. Duane, TD: Clinical Ophthalmology, Hagerstown, Harper & Row, 1978.
3. Ellis, PP, Bausor SC <strong>and</strong> Fulmer JM: Streptothrix canaliculitis, Am. J. Ophthalmol.,
52:36, 1961.
4. Fox, SA: Ophthalmic Plastic Surgery, 5 th Edition, New York, Grune & Stratton, 1976.
5. Greer, CH: Ocular Pathology, 2 nd Edition, London, Blackwell Scientific Publishing,
1972.
6. Hornblass, A: Pupillary dilation in fractures of the floor of the orbit, Ophthalmic Surg.
10:44, 1979.
7. Jallinek, EH: The orbital pseudotumor syndrome <strong>and</strong> its differentiation from endocrine
exophthalmos, Brain, 92:35, 1969.
8. Kramer, W: Klippel-Trenaunay Syndrome, IN: Vinken, PJ, Gruyn, GW (eds.). H<strong>and</strong>book
of Clinical Neurology, New York, American Elsevier, 1972.
9. LeFort, R: Experimental study of fractures of the upper jaw, Rev. Chir. (Paris) 23:208
<strong>and</strong> 360, 1901.
10. Robertson, DM <strong>and</strong> Henderson JW: Unilateral proptosis secondary to orbital mucocele in
infancy, Am. J. Ophthalmol. 68:845, 1969.
11. Silvery, B: Ophthalmic Plastic Surgery, 3 rd Edition, Rochester, Am Acad Ophthalmol.
Otolaryngol, 1977.
12. Soll, DB (ed.): Clinicopathologic Evaluation, vol. 2, no. 4. Ptosis: Options in Surgical
Management, Philadelphia, The Hahneman Medical College <strong>and</strong> Hospital, Biomedical
Information Corp., 1978.
13. Talib, H: Orbital hydatid disease in Iraq, Brit. J. Surg. 59:391, 1972.
14. Wolff S, Fauci A, Horn R, et al.: Wegener’s granulomatosis, Ann. Intern. Med 81:513,
1974.
15. Yanoff M, <strong>and</strong> Fine BS: Ocular Pathology, Hagerstown, Harper & Row, 1975.