American Board of Ophthalmology Written Qualifying Examination (WQE) — Questions and Answers

Question 1: A 3-year-old child presents with an intermittent inward turning of the right eye, first noticed six months ago. The deviation is more prominent when the child is looking at toys up close. Cycloplegic refraction reveals +5.00 D sphere in both eyes. What is the most appropriate initial treatment?

Patching of the left eye for 6 hours per day.
Botulinum toxin injection into the medial rectus muscles.
Prescription of the full cycloplegic hyperopic correction. (Correct answer)
Bilateral medial rectus muscle recession.

Correct answer: Prescription of the full cycloplegic hyperopic correction.

This is a classic presentation of refractive accommodative esotropia. The esotropia is caused by the excessive accommodative effort required to see clearly through the significant uncorrected hyperopia, which in turn drives excessive convergence. The cornerstone and initial treatment is to prescribe the full cycloplegic refractive error in spectacles. This relaxes accommodation, thereby reducing the convergence drive and straightening the eyes. Surgery is only considered if a significant esotropia persists even with full spectacle correction (partially accommodative esotropia). Patching is a treatment for amblyopia, not the strabismus itself, and botulinum toxin is not the primary therapy.

Question 2: A 50-year-old outdoor worker presents with a fleshy, triangular growth extending from the nasal conjunctiva onto the cornea. What is the most likely diagnosis?

Pinguecula
Conjunctival nevus
Squamous cell carcinoma
Pterygium (Correct answer)

Correct answer: Pterygium

A pterygium is a fibrovascular growth of the conjunctiva that crosses the limbus and encroaches onto the cornea, often in a triangular shape. It is strongly associated with chronic ultraviolet light exposure. A pinguecula, in contrast, is a degenerative lesion that is confined to the conjunctiva and does not cross onto the cornea.

Question 3: Which condition is characterized by transient visual loss in one eye described as a 'curtain' descending?

Retinal detachment
Amaurosis fugax (Correct answer)
Macular degeneration
Papilledema

Correct answer: Amaurosis fugax

Amaurosis fugax describes a transient, monocular (one eye) visual loss, often characterized by a 'curtain' descending or ascending over the field of vision. It is typically caused by temporary ischemia to the retina or optic nerve, often due to an embolus from carotid artery disease or cardiac sources. This symptom warrants urgent investigation as it can be a warning sign of an impending stroke.

Question 4: The bactericidal action of fourth-generation fluoroquinolones, such as moxifloxacin, is achieved by inhibiting which two bacterial enzymes?

Beta-lactamase and penicillin-binding protein
RNA polymerase and reverse transcriptase
Dihydropteroate synthase and dihydrofolate reductase
DNA gyrase and topoisomerase IV (Correct answer)

Correct answer: DNA gyrase and topoisomerase IV

Fluoroquinolones exert their bactericidal effect by inhibiting two essential bacterial enzymes involved in DNA synthesis: DNA gyrase (topoisomerase II) and topoisomerase IV. This dual-target mechanism is a key feature of later-generation fluoroquinolones, providing a broad spectrum of activity.

Question 5: Intra-arterial chemotherapy (IAC) for retinoblastoma is delivered directly into which artery?

Central retinal artery
Lacrimal artery
Posterior ciliary artery
Ophthalmic artery (Correct answer)

Correct answer: Ophthalmic artery

IAC involves superselective catheterization of the ophthalmic artery via femoral artery approach to deliver high local chemotherapy concentrations (melphalan, topotecan) while minimizing systemic toxicity.

Question 6: Which of the following findings is the defining feature that differentiates proliferative diabetic retinopathy (PDR) from severe non-proliferative diabetic retinopathy (NPDR)?

Neovascularization of the disc (NVD) (Correct answer)
Severe retinal hemorrhages in 4 quadrants
Venous beading in 2 quadrants
Cotton wool spots

Correct answer: Neovascularization of the disc (NVD)

The hallmark of proliferative diabetic retinopathy is neovascularization, which is the growth of new, abnormal blood vessels. These can occur on the optic disc (NVD) or elsewhere on the retina (NVE) and are a response to widespread retinal ischemia.

Question 7: A 75-year-old female reports gradual blurring of her central vision and difficulty reading. Optical coherence tomography (OCT) reveals large, soft drusen and retinal pigment epithelium (RPE) atrophy. A fluorescein angiogram (FA) is performed. Which of the following FA findings would be most consistent with a diagnosis of neovascular (wet) age-related macular degeneration (AMD) rather than the non-neovascular (dry) form?

Early hyperfluorescence with late leakage from an undefined source. (Correct answer)
Window defects corresponding to areas of RPE atrophy.
Slow, late staining of drusen.
Blocking of fluorescence due to pigment clumping.

Correct answer: Early hyperfluorescence with late leakage from an undefined source.

Early hyperfluorescence that increases in intensity and spreads into the surrounding tissue (leakage) in the late phases of the angiogram is the hallmark of choroidal neovascularization (CNV), the defining feature of wet AMD. Window defects, blocking, and drusen staining are characteristic findings of dry AMD, representing RPE atrophy, pigment, and altered Bruch's membrane, respectively, but not active leakage from new vessels.

Question 8: A 28-year-old female presents with a 5-day history of progressively worsening, painful vision loss in her right eye. Her visual acuity is 20/200 OD. Examination reveals a right relative afferent pupillary defect (RAPD) and profound loss of color vision. The optic disc appears normal. What is the most likely diagnosis?

Leber hereditary optic neuropathy (LHON)
Compressive optic neuropathy
Retrobulbar optic neuritis (Correct answer)
Non-arteritic anterior ischemic optic neuropathy (NAION)

Correct answer: Retrobulbar optic neuritis

This presentation—subacute, painful monocular vision loss with an RAPD and dyschromatopsia in a young adult—is classic for optic neuritis. [19, 25] When the optic disc appears normal, it is termed retrobulbar optic neuritis, as the inflammation is behind the globe. [17, 21] This condition has a strong association with multiple sclerosis. NAION is typically sudden, painless, and occurs in older patients. LHON is painless, and compressive neuropathy is typically gradual and painless.

Question 9: A 70-year-old patient with pseudoexfoliation glaucoma has an intraocular pressure of 28 mmHg in the right eye despite maximal tolerated medical therapy with a prostaglandin analog, a beta-blocker, and a carbonic anhydrase inhibitor. Which of the following is the most appropriate next step in management?

Switch the prostaglandin analog to a different brand.
Perform selective laser trabeculoplasty (SLT). (Correct answer)
Continue to monitor the patient on the current regimen.
Add a fourth medication, such as a miotic.

Correct answer: Perform selective laser trabeculoplasty (SLT).

This patient has inadequately controlled IOP on maximal medical therapy. Selective laser trabeculoplasty (SLT) is a well-established and effective option to further lower IOP when medications are insufficient or not tolerated. Adding a fourth medication often has limited additional effect and increases the complexity and potential for side effects. Switching between prostaglandin analogs may offer a small benefit but is less likely to achieve the required pressure reduction than SLT. Continuing to monitor without intervention is inappropriate given the high IOP and risk of progression.

Question 10: Conjunctival melanoma most frequently arises from which precursor lesion?

Conjunctival compound nevus
Primary acquired melanosis (PAM) with atypia (Correct answer)
Conjunctival papilloma
Pinguecula

Correct answer: Primary acquired melanosis (PAM) with atypia

Conjunctival melanoma most commonly (75%) arises from primary acquired melanosis with atypia, which carries a significant risk of malignant transformation proportional to the degree of cytologic atypia.

Question 11: A 5-year-old is diagnosed with intermittent exotropia. The parents report the child's left eye drifts outward primarily when tired or looking in the distance. Which of the following findings is a primary indication for considering surgical intervention?

The deviation measures 15 prism diopters at distance.
The deviation is manifest for more than 50% of waking hours. (Correct answer)
The near stereoacuity is 200 seconds of arc.
The child frequently closes one eye in bright sunlight.

Correct answer: The deviation is manifest for more than 50% of waking hours.

The decision to operate on intermittent exotropia is multifactorial, but a primary indication is deteriorating fusional control. A deviation that is manifest (tropic) for more than 50% of waking hours is a widely accepted guideline indicating poor control and is a strong indication for surgery to preserve or restore binocular function. Closing one eye in the sun is a common symptom but not a sole indication for surgery. The size of the deviation and stereoacuity are important factors, but the frequency of the manifest deviation is a more direct measure of control.

Question 12: A patient who underwent a trabeculectomy 2 months ago presents with a low IOP of 4 mmHg, a shallow anterior chamber, and choroidal folds on fundus examination. What is the most likely diagnosis?

Malignant glaucoma
Encapsulated bleb
Hypotony maculopathy (Correct answer)
Blebitis

Correct answer: Hypotony maculopathy

Hypotony maculopathy is a condition characterized by low IOP leading to chorioretinal folds, optic disc swelling, and decreased vision. It is a known complication of glaucoma filtration surgery, often resulting from over-filtration or a bleb leak.

Question 13: Which systemic disease is most commonly associated with HLA-B27 positive uveitis?

Multiple sclerosis
Systemic lupus erythematosus
Rheumatoid arthritis
Ankylosing spondylitis (Correct answer)

Correct answer: Ankylosing spondylitis

HLA-B27 positive uveitis is strongly associated with a group of systemic inflammatory diseases known as spondyloarthropathies. Among these, ankylosing spondylitis is the most common systemic condition linked to acute anterior uveitis in individuals positive for the HLA-B27 gene. This genetic marker indicates a predisposition to both the ocular and systemic inflammatory processes.

Question 14: A patient with Fuchs' dystrophy and significant corneal edema but a clear stroma is a candidate for a corneal transplant. Which procedure would be most appropriate to selectively replace the diseased tissue?

Descemet's Membrane Endothelial Keratoplasty (DMEK) (Correct answer)
Phototherapeutic Keratectomy (PTK)
Penetrating Keratoplasty (PKP)
Deep Anterior Lamellar Keratoplasty (DALK)

Correct answer: Descemet's Membrane Endothelial Keratoplasty (DMEK)

Descemet's Membrane Endothelial Keratoplasty (DMEK) is a type of partial-thickness corneal transplant that replaces only the patient's diseased endothelium and Descemet's membrane. It is the preferred procedure for isolated endothelial dysfunction like Fuchs' dystrophy as it offers faster visual recovery and lower rejection rates compared to full-thickness transplants.

Question 15: Primary intraocular lymphoma (PIOL) most commonly involves which ocular structures?

Ciliary body and zonules
Iris and anterior chamber
Vitreous and subretinal space (Correct answer)
Choroid and sclera

Correct answer: Vitreous and subretinal space

PIOL is typically a diffuse large B-cell lymphoma that most commonly involves the vitreous and subretinal space, often associated with CNS lymphoma.

Question 16: A patient looks 5 mm below the optical center of a lens with a power of -4.00 D in the vertical meridian. According to Prentice's Rule, what is the amount and direction of the induced prism?

4.0Δ Base Down
2.0Δ Base Up (Correct answer)
4.0Δ Base Up
2.0Δ Base Down

Correct answer: 2.0Δ Base Up

Prentice's Rule states that the prismatic effect (P) in prism diopters (Δ) is equal to the lens power (D) in diopters multiplied by the decentration (c) in centimeters. P = D x c. Here, D = -4.00 D and c = 5 mm = 0.5 cm. P = -4.00 * 0.5 = -2.0Δ. For a minus lens, the base of the prism is in the same direction as the decentration. Since the patient is looking down, the induced prism is Base Up.

Question 17: What is the most appropriate management for a chalazion?

Cryotherapy
Topical antiviral therapy
Enucleation
Warm compresses (Correct answer)

Correct answer: Warm compresses

A chalazion is a chronic, sterile lipogranulomatous inflammation of a meibomian gland, often presenting as a painless lump on the eyelid. The most appropriate initial management involves applying warm compresses multiple times a day. This helps to soften the hardened secretions, promote drainage of the blocked gland, and reduce inflammation, often leading to resolution without further intervention.

Question 18: What is a common complication of chronic uveitis?

Nystagmus
Cataract (Correct answer)
Presbyopia
Hyperopia

Correct answer: Cataract

Chronic uveitis, especially when involving the anterior segment, frequently leads to the development of cataracts. The persistent inflammation itself can contribute to lens opacification, and the long-term use of corticosteroids, a common treatment for uveitis, is also a significant risk factor for cataract formation. These cataracts can significantly impair vision and often require surgical intervention.

Question 19: A 9-month-old infant presents with a history of persistent tearing and mild mattering in the left eye since birth. The eye is not red, and the cornea is clear. The mother reports that symptoms are worse in the cold or wind. What is the most appropriate initial management for this patient?

Referral for a dacryocystorhinostomy (DCR).
Observation and instruction on digital lacrimal sac massage. (Correct answer)
Prescription of a topical antibiotic-steroid combination.
Immediate surgical probing of the nasolacrimal duct.

Correct answer: Observation and instruction on digital lacrimal sac massage.

This presentation is classic for congenital nasolacrimal duct obstruction (NLDO). The vast majority of cases (>90%) resolve spontaneously within the first year of life. Therefore, the most appropriate initial management is conservative, consisting of observation and teaching the parent how to perform Crigler (digital lacrimal sac) massage to increase hydrostatic pressure and open the membranous obstruction at the valve of Hasner. Surgical probing is typically deferred until after 12 months of age if the condition persists. Antibiotics are only for active infection (dacryocystitis), and steroids are not indicated. DCR is a much more invasive surgery reserved for complex cases or failures of less invasive procedures.

Question 20: When calculating intraocular lens (IOL) power for a patient with a very short axial length (<22.0 mm), which of the following formulas is generally considered more accurate?

Hoffer Q (Correct answer)
Holladay 1
SRK II
SRK/T

Correct answer: Hoffer Q

The Hoffer Q formula is a third-generation formula that is specifically optimized for eyes with short axial lengths. It tends to provide more predictable and accurate refractive outcomes in hyperopic eyes, reducing the risk of a postoperative hyperopic surprise that can occur with other formulas in this group.

Question 21: Which of the following is considered the strongest predisposing risk factor for the development of a rhegmatogenous retinal detachment (RRD)?

Blunt ocular trauma.
Lattice degeneration.
Posterior vitreous detachment (PVD). (Correct answer)
High myopia.

Correct answer: Posterior vitreous detachment (PVD).

While high myopia, lattice degeneration, and trauma are all significant risk factors for RRD, the inciting event for the vast majority of RRDs is a posterior vitreous detachment (PVD). The dynamic vitreoretinal traction created during a PVD is what causes the retinal break (the 'rhegma'), allowing liquefied vitreous to enter the subretinal space. The other factors increase the likelihood that a PVD will result in a retinal break and subsequent detachment.

Question 22: The effect of vertex distance is most clinically significant when prescribing spectacles for which of the following refractive errors?

-12.00 D sphere (Correct answer)
-1.50 D sphere
+3.00 D sphere with +1.00 D cylinder
+2.00 D sphere

Correct answer: -12.00 D sphere

Vertex distance is the distance between the back surface of the spectacle lens and the front of the cornea. Its effect on the effective power of the lens is negligible for low powers but becomes clinically significant for powers greater than +/- 4.00 diopters. For a high myope (-12.00 D), a small change in vertex distance can significantly alter the power delivered to the eye.

Question 23: A patient presents 12 hours after cataract surgery with diffuse limbus-to-limbus corneal edema, mild anterior chamber reaction, and no vitritis. The symptoms are improving with topical steroids. This presentation is most consistent with:

Uveitis-Glaucoma-Hyphema (UGH) Syndrome
Acute postoperative endophthalmitis
Retained lens fragment
Toxic Anterior Segment Syndrome (TASS) (Correct answer)

Correct answer: Toxic Anterior Segment Syndrome (TASS)

TASS is a sterile, non-infectious inflammatory reaction typically occurring within 12-48 hours of anterior segment surgery. It is caused by a toxic substance introduced into the eye, leading to characteristic diffuse corneal edema and a rapid response to intensive topical corticosteroids, distinguishing it from infectious endophthalmitis which has a later onset and involves the vitreous.

Question 24: Which test is most appropriate to confirm papilledema?

Fundus photography
Fluorescein angiography
Tonometry
Lumbar puncture (Correct answer)

Correct answer: Lumbar puncture

Papilledema is swelling of the optic disc due to increased intracranial pressure (ICP). While fundus photography can document the appearance, a lumbar puncture is the definitive test to measure cerebrospinal fluid (CSF) pressure and confirm elevated ICP, which is the underlying cause of papilledema. This helps differentiate true papilledema from pseudopapilledema or other optic disc anomalies.

Question 25: A 2-day-old infant is noted to have bilateral leukocoria. What is the most common cause of bilateral, non-traumatic congenital cataracts?

Galactosemia
Rubella infection
Lowe syndrome
Idiopathic (Correct answer)

Correct answer: Idiopathic

While numerous genetic syndromes, metabolic disorders (like galactosemia), and intrauterine infections (like TORCH infections) can cause congenital cataracts, the most common finding is that they are idiopathic, meaning no specific cause is identified. Genetic mutations are often presumed in these cases but may not be part of a known syndrome.

Question 26: Which condition presents with sudden, painful proptosis and ophthalmoplegia?

Orbital tumor
Graves orbitopathy
Orbital cellulitis (Correct answer)
Preseptal cellulitis

Correct answer: Orbital cellulitis

Orbital cellulitis is a severe infection of the tissues behind the orbital septum. It presents with sudden, painful proptosis (forward displacement of the eyeball) and ophthalmoplegia (paralysis or weakness of eye muscles) due to inflammation and swelling within the confined orbital space. This condition is an ophthalmologic emergency requiring prompt diagnosis and treatment to prevent vision loss and intracranial spread.

Question 27: What is the primary cause of ectropion in elderly patients?

Involutional changes (Correct answer)
Cicatricial scarring
Trauma
Paralysis

Correct answer: Involutional changes

Involutional ectropion, common in elderly patients, is primarily caused by age-related weakening and laxity of the lower eyelid tissues. This includes horizontal laxity of the tarsal plate and canthal tendons, as well as weakening of the orbicularis oculi muscle. These changes lead to the outward turning of the eyelid margin, exposing the conjunctiva.

Question 28: A 22-year-old who sleeps in their soft contact lenses presents with severe eye pain, discharge, and a corneal infiltrate with an overlying epithelial defect. Which organism is most notoriously associated with this clinical scenario?

Streptococcus pneumoniae
Pseudomonas aeruginosa (Correct answer)
Moraxella catarrhalis
Staphylococcus aureus

Correct answer: Pseudomonas aeruginosa

Pseudomonas aeruginosa is a gram-negative bacterium commonly associated with contact lens-related infectious keratitis, particularly with overnight wear. It can be highly virulent, causing rapid corneal destruction and perforation if not treated aggressively.

Question 29: A 55-year-old female presents with sudden, severe right eye pain, blurred vision, and nausea. On examination, her intraocular pressure (IOP) is 58 mmHg, the cornea is hazy, and the pupil is mid-dilated and nonreactive. Gonioscopy of the left eye reveals a narrow, occludable angle. What is the most appropriate definitive initial treatment for the affected right eye after the acute attack is medically controlled?

Topical prostaglandin analog therapy
Trabeculectomy
Laser peripheral iridotomy (LPI) (Correct answer)
Selective laser trabeculoplasty (SLT)

Correct answer: Laser peripheral iridotomy (LPI)

This patient is experiencing an acute angle-closure glaucoma attack. The definitive treatment to relieve pupillary block and prevent recurrence is a laser peripheral iridotomy (LPI). This procedure creates a new channel for aqueous humor to flow from the posterior to the anterior chamber. Prostaglandin analogs are generally used for open-angle glaucoma. SLT is used for open-angle glaucoma and is not effective for angle-closure. Trabeculectomy is a surgical option for more advanced or uncontrolled glaucoma, not the initial definitive procedure for acute angle-closure.

Question 30: The DecisionDx-UM gene expression profiling (GEP) test classifies uveal melanoma into which prognostic classes?

Stage I through Stage IV
Grade 1 and Grade 2
Class 1A, Class 1B, and Class 2 (Correct answer)
Low, intermediate, and high risk

Correct answer: Class 1A, Class 1B, and Class 2

The DecisionDx-UM GEP test classifies uveal melanoma into Class 1A (lowest metastatic risk), Class 1B (low-to-intermediate risk), and Class 2 (highest metastatic risk, ~72% 5-year metastasis rate).

American Board of Ophthalmology Written Qualifying Examination (WQE)

The ABO Written Qualifying Examination (WQE) is a 250-question, single-best-answer multiple-choice exam that evaluates the breadth and depth of basic science and clinical knowledge across all ophthalmology subspecialties required for board certification.

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33 min

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70%

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