Saudi Board Ophthalmology Final Written Exam (SCFHS)

A 24-year-old male presents with progressive visual blur in his left eye. Topography shows an asymmetric hourglass pattern with steepening of 49.5 D inferiorly. You plan to perform corneal collagen cross-linking (CXL). Which of the following matches the FDA-approved Dresden protocol for CXL?

• ARiboflavin 0.1% instillation every 2 minutes for 30 minutes, followed by UVA irradiation…
• BRiboflavin 0.1% instillation every 5 minutes for 15 minutes, followed by UVA irradiation…
• CRiboflavin 0.25% instillation every 2 minutes for 10 minutes, followed by UVA irradiation…
• DRiboflavin 0.5% instillation every 1 minute for 5 minutes, followed by UVA irradiation at…

Based on the Herpetic Eye Disease Study (HEDS) II, what is the primary benefit of oral acyclovir (400 mg twice daily) in patients with a history of ocular Herpes Simplex Virus (HSV) infection?

• AReducing the rate of recurrences of any form of ocular HSV by approximately 45%
• BPreventing progression from epithelial keratitis to stromal keratitis
• CImproving final visual acuity outcomes in patients with active disciform keratitis
• DDecreasing the recurrence rate of stromal disease specifically by 90%

A 45-year-old agricultural worker presents with a corneal ulcer showing feathery borders and satellite lesions. Mycological culture confirms Fusarium species. According to the Mycotic Keratitis International Trial (MUTT I), which treatment regimen is associated with superior clinical outcomes?

• ATopical natamycin 5% suspension
• BTopical voriconazole 1% solution
• COral voriconazole 200 mg twice daily combined with topical natamycin 5%
• DTopical amphotericin B 0.15% solution

A 68-year-old female with Fuchs endothelial corneal dystrophy has symptomatic corneal edema and a best-corrected visual acuity of 20/60. She is scheduled for Descemet Membrane Endothelial Keratoplasty (DMEK). Which of the following is the anatomical layer removed from the host during Descemetorhexis?

• ADescemet's membrane and endothelium
• BDescemet's membrane, endothelium, and posterior stroma
• CDescemet's membrane, endothelium, and Bowman's layer
• DDescemet's membrane only, leaving the host endothelium intact

A contact lens wearer presents with severe, out-of-proportion ocular pain and a ring-shaped corneal infiltrate. Confocal microscopy reveals double-walled cysts. Which of the following is the most appropriate first-line medical therapy?

• ATopical chlorhexidine 0.02% and polyhexamethylene biguanide (PHMB) 0.02%
• BTopical natamycin 5% and fortified vancomycin 50 mg/mL
• CTopical trifluridine 1% and acyclovir ointment 3%
• DTopical moxifloxacin 0.5% and amphotericin B 0.15%

A 32-year-old male presents with recurrent episodes of foreign body sensation, photophobia, and tearing in both eyes. Slit-lamp examination reveals multiple elevated, coarse, whitish-gray intraepithelial lesions that stain minimally with fluorescein. The stroma is entirely clear. What is the diagnosis?

• AThygeson superficial punctate keratitis
• BEpidemic keratoconjunctivitis (EKC)
• CHerpes simplex epithelial keratitis
• DReis-Bücklers corneal dystrophy

A 28-year-old female with a history of a fingernail injury to her right eye presents with recurrent episodes of severe pain upon awakening, tearing, and blurred vision. She is diagnosed with recurrent corneal erosion (RCE) syndrome. If medical therapy with hypertonic saline and bandage contact lenses fails, which surgical procedure is most appropriate?

• APhototherapeutic keratectomy (PTK)
• BDeep anterior lamellar keratoplasty (DALK)
• CDescemet stripping automated endothelial keratoplasty (DSAEK)
• DCorneal collagen cross-linking (CXL)

An 80-year-old male with chronic uveitis presents with a horizontal band of calcium deposition in the interpalpebral zone of his cornea, separated from the limbus by a clear zone. What is the most appropriate chemical agent used to chelate the calcium during treatment?

• ADisodium ethylenediaminetetraacetic acid (EDTA) 0.05 M (1.5% to 3.0%)
• BSodium thiosulfate 10%
• CMitomycin C 0.02%
• DProparacaine hydrochloride 0.5%

A refractive surgeon is evaluating a 26-year-old patient for LASIK. Which of the following preoperative topodiagnostic parameters carries the highest risk score for developing post-LASIK ectasia according to the Randleman Ectasia Risk Score system?

• AAbnormal preoperative corneal topography (e.g., keratoconus or pellucid marginal degenera…
• BResidual stromal bed (RSB) thickness of 290 microns
• CPreoperative central corneal thickness of 510 microns
• DPatient age of 26 years

On post-operative day 3 following uneventful LASIK, a patient presents with asymptomatic, fine granular infiltrates localized strictly under the corneal flap, sparing the peripheral interface. There is no epithelial defect or anterior chamber reaction. What is the diagnosis and initial management?

• ADiffuse Lamellar Keratitis (DLK) Stage 1; treat with intensive topical corticosteroids
• BInfectious keratitis; perform immediate flap lift, scrape interface for cultures, and sta…
• CTransient Light Sensitivity Syndrome; treat with topical NSAIDs
• DEpithelial ingrowth; perform immediate mechanical scraping of the interface

A 10-year-old boy presents with severe bilateral itching, photophobia, and thick ropy discharge. Examination reveals giant cobble-stone papillae on the superior tarsal conjunctiva and a shield ulcer on the upper cornea. What is the diagnosis?

• AVernal Keratoconjunctivitis (VKC)
• BAtopic Keratoconjunctivitis (AKC)
• CGiant Papillary Conjunctivitis (GPC)
• DPhlyctenular Keratoconjunctivitis

A 55-year-old female with long-standing rheumatoid arthritis presents with severe pain, tearing, and a crescent-shaped thinning of the peripheral cornea in her right eye, associated with an adjacent scleritis. What is the most critical initial systemic management?

• ASystemic immunosuppressive therapy (e.g., high-dose oral corticosteroids and steroid-spar…
• BTopical corticosteroid drops hourly to arrest corneal thinning
• CImmediate penetrating keratoplasty (PK)
• DTopical cyclosporine 0.05% twice daily

Which of the following corneal dystrophies is inherited in an autosomal recessive pattern and is caused by mutations in the CHST6 gene?

• AMacular corneal dystrophy
• BLattice corneal dystrophy Type I
• CGranular corneal dystrophy Type I
• DFuchs endothelial corneal dystrophy

A soft contact lens wearer presents with a rapidly progressive corneal ulcer, a 1 mm hypopyon, and a thick greenish-mucoid discharge. Culture is most likely to grow which organism, and what is the recommended empiric treatment?

• APseudomonas aeruginosa; treat with fortified tobramycin (15 mg/mL) and fortified vancomyc…
• BStaphylococcus aureus; treat with topical natamycin 5% suspension
• CStreptococcus pneumoniae; treat with topical trifluridine 1% solution
• DAcanthamoeba; treat with topical moxifloxacin 0.5% monotherapy

A 35-year-old male presents with severe ocular pain and a rapidly progressive peripheral corneal ulceration in one eye, showing a steep overhanging leading edge. Scleral involvement is absent, and the systemic workup is completely negative. What is the diagnosis?

• AMooren's ulcer
• BTerrien's marginal degeneration
• CPellucid marginal degeneration
• DPeripheral Ulcerative Keratitis (PUK)

During photorefractive keratectomy (PRK) for high myopia (-6.00 D), which intraoperative adjuvant therapy is commonly applied to the stromal bed to minimize the risk of post-operative corneal haze?

• AMitomycin C (MMC) 0.02% solution for 12 to 30 seconds
• B5-Fluorouracil (5-FU) 1% solution for 2 minutes
• CCyclosporine A 0.05% for 1 minute
• DDexamethasone sodium phosphate 0.1% for 5 minutes

Which of the following is a biomechanical or structural benefit of Small Incision Lenticule Extraction (SMILE) compared to standard LASIK?

• APreservation of the stronger anterior corneal stroma and corneal nerves due to the absenc…
• BAbility to correct hyperopia up to +6.00 D with higher predictability
• CZero risk of ectasia because no stromal tissue is removed
• DFaster visual recovery in the first 24 hours compared to LASIK

A 40-year-old female presents with fluctuating vision and mild irritation. Retroillumination reveals map-like patterns, dots, and fingerprint-like ridges in the central corneal epithelium of both eyes. What is the pathophysiological basis of this condition?

• AAbnormal, thickened epithelial basement membrane that projects into the epithelium
• BLoss of hemidesmosomal plaques at the level of the endothelium
• CAccumulation of amyloid fibrils in the subepithelial space
• DIntracellular edema of the basal epithelial cells due to fluid leakage

A worker presents to the emergency department immediately after sustaining an alkali splash to his left eye. What is the most critical first step in management?

• ACopious irrigation with saline or water for at least 30 minutes until the pH of the conju…
• BInstillation of topical corticosteroid drops to control inflammation
• CObtaining a detailed ocular history and performing a complete dilated fundus exam
• DDebridement of the damaged corneal epithelium under a slit-lamp

A 28-year-old male presents with bilateral interstitial keratitis, progressive sensorineural hearing loss, and vestibuloauditory dysfunction (vertigo and tinnitus). Systemic workup for syphilis is negative. What is the diagnosis?

• ACogan's syndrome
• BCongenital Syphilis
• CVogt-Koyanagi-Harada (VKH) disease
• DLyme disease

Based on the Ocular Hypertension Treatment Study (OHTS), which of the following central corneal thickness (CCT) measurements is associated with the highest risk of progression from ocular hypertension to primary open-angle glaucoma?

• ACCT < 555 microns
• BCCT 555 - 588 microns
• CCCT > 588 microns
• DCCT does not affect the risk of progression

A 62-year-old female presents with acute pain, redness, and blurred vision in her right eye. IOP is 52 mmHg, the pupil is mid-dilated and sluggish, and the angle is closed on gonioscopy. After administering medical IOP-lowering therapy, what is the definitive laser procedure, and what management is indicated for the fellow eye?

• ALaser peripheral iridotomy (LPI) in the right eye; prophylactic LPI in the left eye
• BArgon laser trabeculoplasty (ALT) in the right eye; observation of the left eye
• CSelective laser trabeculoplasty (SLT) in the right eye; SLT in the left eye
• DYAG capsulotomy in both eyes

According to the Collaborative Normal-Tension Glaucoma Study (CNTGS), what was the target IOP reduction required to demonstrate a benefit in slowing visual field progression in patients with normal-tension glaucoma?

• A30% reduction from baseline
• B10% reduction from baseline
• CFixed target IOP of 15 mmHg
• D50% reduction from baseline

A 72-year-old male with pseudoexfoliation syndrome is undergoing cataract surgery. Which of the following intraoperative complications is he at highest risk for, and what anatomical structure is primary affected?

• AZonular dialysis due to weakness of the zonular fibers
• BDescemet's membrane detachment due to endothelial cell loss
• CSuprachoroidal hemorrhage due to high scleral rigidity
• DPosterior polar rupture due to weakness of the posterior capsule

A 28-year-old myopic male presents with progressive vision loss after exercise. Slit-lamp exam shows mid-peripheral iris transillumination defects, a Krukenberg spindle on the endothelium, and dense pigmentation of the trabecular meshwork on gonioscopy. What is the pathophysiological cause of the iris defects?

• AMechanical rubbing of the posterior iris pigment epithelium against the lens zonules
• BIschemia of the iris stroma due to high IOP spikes
• CCongenital absence of the dilator muscle of the iris
• DDeposition of exfoliation material on the anterior iris surface

The Laser in Glaucoma and Ocular Hypertension (LiGHT) trial compared selective laser trabeculoplasty (SLT) with topical medication as first-line therapy. What was a key conclusion of this trial?

• ASLT achieved comparable IOP control with better cost-effectiveness and zero medication re…
• BTopical medication was significantly more effective than SLT at preventing visual field p…
• CSLT carried a 50% risk of permanent peripheral anterior synechiae (PAS)
• DSLT should only be used as a last resort before incisional surgery

A patient on post-operative day 7 following a trabeculectomy presents with a flat anterior chamber, an IOP of 3 mmHg, and choroidal elevations on B-scan. There is no conjunctival bleb leak on Seidel testing. What is the diagnosis?

• ABleb overfiltration causing hypotony and choroidal effusion
• BPupillary block glaucoma
• CAqueous misdirection (malignant glaucoma)
• DSuprachoroidal hemorrhage

Which of the following describes the key difference between the Ahmed Glaucoma Valve and the Baerveldt Glaucoma Implant?

• AThe Ahmed has a venturi-style chamber valve mechanism that restricts flow at low pressure…
• BThe Baerveldt has a valve mechanism, while the Ahmed requires temporary ligation with a s…
• CThe Ahmed has a much larger surface area (350 mm²) than the Baerveldt (184 mm²)
• DThe Baerveldt is made of polymethylmethacrylate (PMMA), while the Ahmed is made of soft s…

A 58-year-old male with a history of central retinal vein occlusion presents with severe eye pain. IOP is 48 mmHg. Gonioscopy shows arborizing blood vessels crossing the scleral spur onto the trabecular meshwork. What is the most appropriate first-line therapy to arrest the neovascular process?

• AIntravitreal anti-VEGF injection and Panretinal Photocoagulation (PRP)
• BImmediate trabeculectomy with Mitomycin C
• CCyclophotocoagulation (CPC) laser
• DHigh-dose topical prostaglandin analogs

An infant is brought to the clinic with bilateral tearing, photophobia, blepharospasm, and cloudy corneas. Corneal diameters are 13.5 mm in both eyes. What is the diagnosis, and what is the preferred initial surgical treatment if the cornea is too cloudy to visualize the angle?

• APrimary Congenital Glaucoma; Trabeculotomy
• BPrimary Congenital Glaucoma; Goniotomy
• CCongenital Rubella; Penetrating Keratoplasty
• DAxenfeld-Rieger Syndrome; LPI

A 55-year-old patient who underwent myopic LASIK 10 years ago requires cataract surgery. Which of the following describes the primary error in standard IOL calculations for post-refractive eyes, and which formula is designed to correct it?

• AOverestimation of corneal power leading to post-operative hyperopia; corrected by Haigis-…
• BUnderestimation of corneal power leading to post-operative myopia; corrected by SRK/T
• COverestimation of effective lens position (ELP); corrected by Hoffer Q
• DUnderestimation of axial length; corrected by Holladay 1

A patient who has been taking tamsulosin (Flomax) for benign prostatic hyperplasia is undergoing phacoemulsification. What is the classic triad of Intraoperative Floppy Iris Syndrome (IFIS) associated with this medication?

• AFlaccid iris stroma that billows, progressive intraoperative pupillary miosis, and iris p…
• BIris transillumination defects, pigment dispersion, and elevated IOP
• CPupillary block, anterior synechiae, and corneal edema
• DPhacodenesis, iridodonesis, and zonular dialysis

During phacoemulsification, a posterior capsule rupture (PCR) occurs with vitreous prolapse into the anterior chamber. What is the most appropriate next step in management?

• AInject a cohesive ophthalmic viscosurgical device (OVD) to stabilize the vitreous face be…
• BImmediately pull the phaco handpiece out of the eye to stop irrigation
• CIncrease the bottle height/infusion pressure to maintain anterior chamber depth
• DPerform a rapid manual expression of the lens nucleus

A patient presents with visual blur 6 weeks after undergoing uncomplicated cataract surgery. OCT reveals cystoid macular edema (CME) and subretinal fluid. What is the eponym for this condition, and what is the standard first-line medical therapy?

• AIrvine-Gass syndrome; topical NSAIDs and topical corticosteroids
• BGass-Milauskas syndrome; oral acetazolamide and intravitreal anti-VEGF
• CJampol syndrome; intravitreal triamcinolone
• DTerson syndrome; pars plana vitrectomy

A patient presents on post-operative day 5 after cataract surgery with severe pain, hypopyon, and visual acuity limited to Hand Motion (HM). Based on the Endophthalmitis Vitrectomy Study (EVS), what is the appropriate management?

• AVitreous tap and inject of intravitreal vancomycin and ceftazidime
• BImmediate pars plana vitrectomy (PPV) and intravitreal antibiotics
• CIntravenous vancomycin and ceftazidime hospitalization
• DTopical fortified antibiotics hourly and oral prednisone

On postoperative day 1 following cataract surgery, a patient has diffuse corneal edema, a 2+ anterior chamber reaction, and a mild hypopyon. There is no pain or conjunctival injection. What clinical entity should be distinguished from infectious endophthalmitis, and what is its typical timeline?

• AToxic Anterior Segment Syndrome (TASS); presents within 12 to 24 hours post-operatively
• BIrvine-Gass syndrome; presents 4 to 6 weeks post-operatively
• CUveitis-Glaucoma-Hyphema (UGH) syndrome; presents months after surgery
• DRebound iritis; presents 1 to 2 weeks after stopping steroid drops

During cataract surgery, the surgeon notes a sudden hardening of the globe, shallowing of the anterior chamber, loss of red reflex, and dark uveal tissue prolapsing into the wound. What is the diagnosis, and what is the immediate intraoperative management?

• ASuprachoroidal hemorrhage; close all incisions immediately to tamponade the bleeding
• BExpulsive choroidal effusion; perform immediate sclerotomies to drain the fluid
• CAqueous misdirection; inject cohesive OVD and perform a YAG hyaloidotomy
• DVitreous loss; increase infusion bottle height

According to the Infant Aphakia Treatment Study (IATS), which of the following is true regarding IOL implantation versus contact lens correction in infants undergoing unilateral cataract surgery before 7 months of age?

• AThere was no significant difference in visual acuity at age 5, but the IOL group had sign…
• BThe IOL group achieved significantly better visual acuity outcomes at age 5
• CThe contact lens group had a higher rate of secondary glaucoma
• DPrimary IOL placement is now the absolute standard of care for infants under 3 months

A 70-year-old male with an advanced hypermature cataract presents with acute, severe pain. IOP is 40 mmHg, and the anterior chamber shows heavy flare with large, protein-laden macrophages. The angle is open. What is the diagnosis?

• APhacolytic glaucoma
• BPhacomorphic glaucoma
• CLens particle glaucoma
• DPhacoanaphylactic endophthalmitis

A patient undergoes Nd:YAG laser posterior capsulotomy for symptomatic posterior capsule opacification (PCO). What is the most common post-procedure complication, and how is it managed?

• ATransient elevation of IOP; treated with prophylactic topical apraclonidine or brimonidine
• BRetinal detachment; managed with immediate vitrectomy
• CIOL subluxation; managed with surgical repositioning
• DCystoid macular edema; treated with oral acetazolamide

Based on the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT), what was the primary finding regarding ranibizumab versus bevacizumab for neovascular AMD?

• ARanibizumab and bevacizumab had equivalent effects on visual acuity when administered on…
• BRanibizumab was significantly superior to bevacizumab in improving visual acuity
• CMonthly dosing was equivalent to pro re nata (PRN) dosing in visual outcomes
• DBevacizumab was associated with a significantly higher rate of systemic stroke

According to the DRCR.net Protocol T trial, which anti-VEGF agent demonstrated superior visual acuity gains at 1 year in patients with diabetic macular edema (DME) who had a baseline visual acuity of 20/50 or worse?

• AAflibercept
• BRanibizumab
• CBevacizumab
• DAll three agents were equivalent regardless of baseline visual acuity

A 52-year-old diabetic patient presents with high-risk proliferative diabetic retinopathy (PDR). According to the DRCR.net Protocol S trial, what is a key clinical finding when comparing intravitreal ranibizumab with panretinal photocoagulation (PRP)?

• ARanibizumab was non-inferior to PRP for visual acuity at 2 years, with lower rates of per…
• BPRP achieved significantly better visual acuity outcomes than ranibizumab
• CRanibizumab was associated with a higher rate of tractional retinal detachment
• DPRP required significantly more follow-up visits than the ranibizumab group

A 65-year-old male presents with sudden, painless visual loss in his right eye. Fundoscopy reveals a pale retina with a cherry-red spot in the macula. An embolus is noted at a retinal artery bifurcation. What is the most common source and composition of a Hollenhorst plaque?

• ACholesterol embolus from the carotid artery
• BCalcium embolus from the cardiac valves
• CPlatelet-fibrin embolus from the carotid artery
• DTalc embolus from intravenous drug use

A 68-year-old patient presents with vision loss due to central retinal vein occlusion (CRVO). What clinical finding is most critical in defining the CRVO as ischemic rather than non-ischemic, and what is the associated risk of neovascularization?

• AArea of capillary non-perfusion >= 10 disc areas on fluorescein angiography; carries a hi…
• BPresence of any macular edema; carries a 100% risk of tractional retinal detachment
• CIOP > 30 mmHg; indicates a closed angle
• DThe presence of optociliary shunt vessels at the optic disc

A 45-year-old myopic male presents with sudden onset of flashes and floaters, followed by a dark curtain coming down in his superior field of vision. Dilated exam shows a rhegmatogenous retinal detachment (RRD) inferiorly. What is the pathophysiological sequence leading to this condition?

• ALiquefaction of the vitreous (synchysis), vitreous collapse (syneresis), posterior vitreo…
• BRetinal vascular occlusion, ischemia, release of VEGF, neovascularization, and tractional…
• CAccumulation of subretinal fluid due to retinal pigment epithelium (RPE) pump failure
• DExudation of protein-rich fluid from choroidal vessels due to inflammation

A 65-year-old female is diagnosed with a Stage 3 macular hole. Which of the following describes the anatomical characteristics of a Stage 3 hole according to the Gass classification?

• AFull-thickness macular hole > 400 microns with a posterior vitreous detachment from the m…
• BImpending macular hole with a yellow spot or ring in the fovea
• CFull-thickness macular hole < 400 microns with vitreoretinal traction
• DFull-thickness macular hole with a complete posterior vitreous detachment (PVD) from both…