Beyond the Lid: The Oculoplasty Quiz

PTOSIS AND EYELID DISORDERS Question 1: A 45-year-old patient presents with unilateral ptosis. Which measurement is considered the most important for surgical planning? A) Palpebral fissure height (PFH) B) Marginal reflex distance 1 (MRD1) C) Levator function D) Upper lid crease position Question 2: In congenital ptosis, which finding is most characteristic? A) Normal lid crease B) Poor levator function C) Lid lag on downgaze D) Improved Bell’s phenomenon Question 3: The phenylephrine test is most useful for evaluating: A) Myasthenia gravis B) Horner’s syndrome C) Third nerve palsy D) Marcus Gunn jaw winking syndrome ORBITAL FRACTURES Question 4: In orbital blowout fractures, which extraocular muscle is most commonly affected? A) Superior rectus B) Lateral rectus C) Inferior rectus D) Medial rectus Question 5: What is the ‘teardrop’ sign on facial X-ray indicative of? A) Lacrimal gland prolapse B) Orbital contents herniation into maxillary sinus C) Ethmoid sinus involvement D) Optic nerve compression Question 6: Which bone forms the posterior ledge for titanium implant placement in orbital floor reconstruction? A) Greater wing of sphenoid B) Orbital process of zygomatic bone C) Orbital plate of palatine bone D) Maxillary bone LACRIMAL SYSTEM Question 7: Which valve prevents reflux of tears from the lacrimal sac into the canaliculi? A) Valve of Hasner B) Valve of Rosenmuller C) Valve of Maier D) Lacrimal pump mechanism Question 8: In dacryocystorhinostomy (DCR), the primary goal is to create an anastomosis between: A) Lacrimal sac and ethmoid sinus B) Lacrimal sac and nasal cavity C) Canaliculus and nasal cavity D) Punctum and lacrimal sac PROPTOSIS Question 9: Which extraocular muscle is most commonly affected in thyroid eye disease? A) Superior rectus B) Lateral rectus C) Inferior rectus D) Superior oblique Question 10: The ‘NO SPECS’ classification system evaluates: A) Thyroid function levels B) Severity of thyroid eye disease C) Surgical candidacy D) Proptosis measurements Question 11: Pulsatile proptosis is most closely associated with which neurocutaneous disorder? Figure 1Figure 1: Axial CT scan showing sphenoid wing dysplasia A) Von Hippel Lindau Disease B) Neurofibromatosis Type 1 C) Tuberous Sclerosis D) Neurofibromatosis Type 2 Question 12: Which imaging sequence is most useful for assessing activity in thyroid eye disease? A) T1-weighted magnetic resonance imaging (MRI) B) STIR sequence MRI C) Computed tomography with contrast D) Ultrasound ORBITAL ANATOMY Question 13: The superior oblique muscle inserts on the globe at what angle to the visual axis? A) 45 degrees B) 51 degrees C) 54 degrees D) 60 degrees Question 14: Failure of which embryonal developmental process results in microphthalmia with orbital cyst? A) Neural crest migration B) Primary optic vesicle growth C) Choroidal fissure closure D) Secondary optic vesicle degeneration EYELID MALIGNANCIES Question 15: Which eyelid malignancy has the worst prognosis? A) Basal cell carcinoma B) Squamous cell carcinoma C) Sebaceous cell carcinoma D) Melanoma Question 16: Mohs micrographic surgery is most appropriate for: A) All eyelid basal cell carcinomas B) Recurrent or high-risk lesions C) Sebaceous cell carcinomas only D) Lesions smaller than 2 mm Question 17: What is the most common form of basal cell carcinoma? A) Morpheaform B) Nodular C) Multicentric/Superficial D) Basosquamous PAEDIATRIC CONDITIONS Question 18: What is the most common primary orbital malignancy in children? A) Rhabdomyosarcoma B) Lymphoma C) Neuroblastoma D) Optic glioma Question 19: Congenital nasolacrimal duct obstruction is associated with which genetic condition? A) FOXC1 gene mutation B) FOXL2 gene mutation C) PAX6 gene mutation D) SIX3 gene mutation SURGICAL TECHNIQUES Question 20: The Hughes tarsoconjunctival flap is best described as: A) A full-thickness upper lid flap to lower lid B) A tarsoconjunctival advancement flap C) A free graft technique D) A rotational skin flap Question 21: Why is a Hughes tarsoconjunctival flap contraindicated in young children? A) Risk of amblyopia B) Immature marginal arcade C) Inadequate conjunctiva D) Flaccidity of the tarsal plate ANSWERS C) Levator functionThe levator function measurement determines the surgical approach—anterior levator resection for poor function (8 mm).B) Poor levator functionCongenital ptosis typically results from developmental abnormalities of the levator muscle, leading to poor function and often absent or poorly defined lid crease.B) Horner’s syndromePhenylephrine stimulates Müller’s muscle; improvement of 2 mm or more suggests Horner’s syndrome or mild ptosis suitable for posterior approach surgery.C) Inferior rectusThe inferior rectus is most commonly entrapped in orbital floor fractures, leading to restriction of upward gaze and diplopia.B) Orbital contents herniation into maxillary sinusThe tear drop sign represents herniation of orbital fat and possibly muscle through the fractured orbital floor into the maxillary sinus.C) Orbital plate of palatine boneThis anatomical landmark is crucial for proper implant positioning during orbital floor reconstruction surgery.B) Valve of RosenmullerThis valve is located at the junction of the common canaliculus and lacrimal sac, preventing backflow.B) Lacrimal sac and nasal cavityDCR creates a new drainage pathway by connecting the lacrimal sac directly to the nasal cavity, bypassing the obstructed nasolacrimal duct.C) Inferior rectusThe inferior rectus is the most commonly involved muscle, followed by the medial rectus.B) Severity of thyroid eye diseaseNO SPECS stands for: No signs, Only signs (ocular irritation), Soft tissue involvement, Proptosis, Extraocular muscle involvement, Corneal involvement, Sight loss.C) Neurofibromatosis Type 1Patients with neurofibromatosis type 1 have Sphenoid wing dysplasia and thus have pulsatile proptosis.B) STIR sequence MRIShort-tau inversion recovery (STIR) sequence shows muscle oedema, which correlates with disease activity.C) 54 degreesThis anatomical detail is important for understanding the muscle’s actions: intorsion, depression and abduction.C) Choroidal fissure closureMicrophthalmia with orbital cyst results from failure of the choroidal fissure to close in the embryo.D) MelanomaAmong eyelid malignancies, melanoma generally has the worst prognosis due to its metastatic potential.B) Recurrent or high-risk lesionsMohs surgery allows precise margin control and tissue preservation, particularly valuable for recurrent tumours or those in critical locations.B) NodularIt presents as a firm, raised, pearly nodule which may have telangiectasias and central ulceration.A) RhabdomyosarcomaRhabdomyosarcoma typically presents as painless proptosis in children under 7 years of age.B) FOXL2 gene mutationThe FOXL2 gene (forkhead box L2) is associated with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES).A) A full-thickness upper lid flap to lower lidThe Hughes procedure involves creating a full-thickness flap from the upper lid to reconstruct lower lid defects.A) Risk of amblyopiaA standard Hughes flap requires 4 weeks of occlusion and therefore creates a risk of amblyopia. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.