OPHTHALMOLOGY

Raman MalhotraaZYXWVUTSRQPONMLKJIHGFEDCBA
M B C h B EDCBA

S e n io r H ouse O ffic e r ,

The W e s te r n E y e H o s p ita l, London

D a v id E a s ty M B C hB M D F R C O p h th

P r o fe s s o r ZYXWVUTSRQPONMLKJIHGFEDCBA
& H ead,
D e p a r tm e n t of O p h th a lm o lo g y , B r is to l U n iv e r s ity ,

and H onorary C o n s u lta n t

B r is to l E y e H o s p ita l, B r is to l

A m em ber o f th e H o d d e r H e a d lin e G ro u p

LONOON • SYDNEY· AUCKLAND

C c - p u b lis h e d in th e U S A b y O x f o r d U n iv e r s ity P r e s s , I n c ., N e w Y o r k
 ,\

\ Dedicated to Kavita

F ir s t p u b lis h e d in G r e a t B r ita in in 1 9 9 8 b y
A r n o ld , a m e m b e r o f th e H o d d e r H e a d lin e G r o u p ,
3 3 8 E u s to n R o a d , L o n d o n N W l 3 B H
•
h ttp ://w w w .a r n o ld p u b lis h e r s .c o m

C c - p u b lis h e d in th e U n ite d S ta te s o f A m e r ic a b y
O x fo rd U n iv e r s ity P r e s s , I n c .,
1 9 8 M a d is o n A v e n u e , N e w Y o r k , N Y 1 0 0 1 6
O x f o r d is a r e g is te r e d tr a d e m a r k o f O x f o r d U n iv e r s ity P r e s s

© 1 9 9 8 R a m a n M a lh o tr a ZYXWVUTSRQPONMLKJIHGFEDCBA
& D a v id E a s ty

A ll r ig h ts r e s e r v e d . N o p a r t o f th is p u b lic a tio n m y b e re p ro d u c e d or
tr a n s m itte d in a n y f o r m o r b y a n y m e a n s , e le c tr o n ic a lly o r m e c h a n ic a lly ,
in c lu d in g p h o to c o p y in g , r e c o r d in g o r a n y in f o r m a tio n s to r a g e o r r e tr ie v a l
s y s te m , w ith o u t e ith e r p r io r p e r m is s io n in w r itin g f r o m th e p u b lis h e r o r a
lic e n c e p e r m ittin g r e s tr ic te d c o p y in g . I n th e U n ite d K in g d o m s u c h lic e n c e s
a r e is s u e d b y th e C o p y r ig h t L ic e n s in g A g e n c y : 9 0 T o tte n h a m C o u rt R o a d ,
London W 1P 9H E.

W h ils t th e a d v ic e a n d in f o r m a tio n in th is b o o k is b e lie v e d to b e tr u e a n d

a c c u r a te a t th e d a te o f g o in g to p r e s s , n e ith e r th e a u th o r n o r th e p u b lis h e r
c a n a c c e p t a n y le g a l r e s p o n s ib ility o r lia b ilir y f o r a n y e r r o r s o r o m is s io n s
th a t m a y b e m a d e . EDCBA

B r itis h L ib r a r y C a ta lo g u in g in P u b lic a tio n D a ta

A c a ta lo g u e r e c o r d f o r th is b o o k is a v a ila b le f r o m th e B r itis h L ib r a r y

L ib r a r y of C ongress C a ta lo g in g -in -P u b lic a tio n D a ta

A c a ta lo g r e c o r d f o r th is b o o k is a v a ila b le f r o m th e L ib r a r y o f C o n g r e s s

IS B N 0 3 4 0 0 7 0 7 8 7

P u b lis h e r : G e o r g in a B e n d if f
P r o d u c tio n E d ito r : L iz G o o s te r
P r o d u c tio n C o n tr o lle r : S a r a h K e tt

T y p e s e t in 9 / 1 2 p t H e lv e tic a b y J & L C o m p o s itio n L td , F ile y , N o r th Y o r k s h ir e

P r in te d a n d b o u n d in G r e a t B r ita in b y J W A r r o w s m ith L r d , B r is to l
 ,\

\ Dedicated to Kavita

F ir s t p u b lis h e d in G r e a t B r ita in in 1 9 9 8 b y
A r n o ld , a m e m b e r o f th e H o d d e r H e a d lin e G r o u p ,
3 3 8 E u s to n R o a d , L o n d o n N W l 3 B H
•
h ttp ://w w w .a r n o ld p u b lis h e r s .c o m

C c - p u b lis h e d in th e U n ite d S ta te s o f A m e r ic a b y
O x fo rd U n iv e r s ity P r e s s , I n c .,
1 9 8 M a d is o n A v e n u e , N e w Y o r k , N Y 1 0 0 1 6
O x f o r d is a r e g is te r e d tr a d e m a r k o f O x f o r d U n iv e r s ity P r e s s

© 1 9 9 8 R a m a n M a lh o tr a ZYXWVUTSRQPONMLKJIHGFEDCBA
& D a v id E a s ty

A ll r ig h ts r e s e r v e d . N o p a r t o f th is p u b lic a tio n m y b e re p ro d u c e d or
tr a n s m itte d in a n y f o r m o r b y a n y m e a n s , e le c tr o n ic a lly o r m e c h a n ic a lly ,
in c lu d in g p h o to c o p y in g , r e c o r d in g o r a n y in f o r m a tio n s to r a g e o r r e tr ie v a l
s y s te m , w ith o u t e ith e r p r io r p e r m is s io n in w r itin g f r o m th e p u b lis h e r o r a
lic e n c e p e r m ittin g r e s tr ic te d c o p y in g . I n th e U n ite d K in g d o m s u c h lic e n c e s
a r e is s u e d b y th e C o p y r ig h t L ic e n s in g A g e n c y : 9 0 T o tte n h a m C o u rt R o a d ,
London W 1P 9H E.

W h ils t th e a d v ic e a n d in f o r m a tio n in th is b o o k is b e lie v e d to b e tr u e a n d

a c c u r a te a t th e d a te o f g o in g to p r e s s , n e ith e r th e a u th o r n o r th e p u b lis h e r
c a n a c c e p t a n y le g a l r e s p o n s ib ility o r lia b ilir y f o r a n y e r r o r s o r o m is s io n s
th a t m a y b e m a d e . EDCBA

B r itis h L ib r a r y C a ta lo g u in g in P u b lic a tio n D a ta

A c a ta lo g u e r e c o r d f o r th is b o o k is a v a ila b le f r o m th e B r itis h L ib r a r y

L ib r a r y of C ongress C a ta lo g in g -in -P u b lic a tio n D a ta

A c a ta lo g r e c o r d f o r th is b o o k is a v a ila b le f r o m th e L ib r a r y o f C o n g r e s s

IS B N 0 3 4 0 0 7 0 7 8 7

P u b lis h e r : G e o r g in a B e n d if f
P r o d u c tio n E d ito r : L iz G o o s te r
P r o d u c tio n C o n tr o lle r : S a r a h K e tt

T y p e s e t in 9 / 1 2 p t H e lv e tic a b y J & L C o m p o s itio n L td , F ile y , N o r th Y o r k s h ir e

P r in te d a n d b o u n d in G r e a t B r ita in b y J W A r r o w s m ith L r d , B r is to l
 PREFACEZYXWVUTSRQPONMLKJIHGFEDCBA

The e x a m in a tio n in b a s ic s c ie n c e s to w a r d s th e F e llo w s h ip o f th e R oyal C o lle g e of

O p h th a lm o lo g is ts dem ands a n in - d e p th k n o w le d g e o f o p h th a lm ic a n d g e n e ra l m e d ic a l

s u b je c ts in c lu d in g p h y s io lo g y , m ic r o b io lo g y , p h a r m a c o lo g y a n d a n a to m y . It is in e v ita -

b le th a t in th e c o u r s e o f p r e p a r a tio n c a n d id a te s w ill e n c o u n te r new o c u la r c o n c e p ts .

T h e r e a r e fe w b o o k s a v a ila b le w h ic h w e r e w r itte n s p e c ific a lly a s r e v is io n te x ts , in o th e r
w o rd s p r e s e n tin g ty p ic a l e x a m in a tio n q u e s tio n s , m odel a n s w e rs and c la r ific a tio n of
d iffic u lt o r im p o r ta n t to p ic s . T h is b o O k , th e r e fo r e , is a im e d a t m e e tin g th e s e o b je c tiv e s
fo r c a n d id a te s s ittin g th e fir s t p a r t e x a m in a tio n . It m a y a ls o b e u s e fu l to o th e r s w h o a re

p r e p a r in g fo r r e la te d exam s and w is h to r e fr e s h th e ir k n o w le d g e o f c e r ta in to p ic s .
T h e fir s t p a r t e x a m in a tio n is d iv id e d in to m u ltip le c h o ic e q u e s tio n p a p e rs (M C Q s ) a n d
essays. The MCQs cover a n in c r e d ib ly b ro a d ra n g e o f to p ic s and te s t k n o w le d g e in

q u ite fin e d e ta il. A n M C Q is m a d e aZYXWVUTSRQPONMLKJIHGFEDCBA

u p o f 5 s te m s , e a c h to b e a n s w e r e d
a s b e in g tr u e o r
fa ls e . A n in c o r r e c t answ er c a r r ie s th e p e n a lty o f a m a r k d e d u c te d fr o m th o s e a lr e a d y

s c o re d . T h e e s s a y s how ever te s t th e c a n d id a te 's a b ility to o ffe r a c o n c is e d e s c r ip tio n or

e x p la n a tio n o f a n is s u e w ith c la r ity o f th o u g h t a n d s tr u c tu r e . T h is m e th o d o f e x a m in a -

tio n c h a lle n g e s th e c a n d id a te to a c q u ir e a d e p th o f fin e d e ta ile d k n o w le d g e y e t a t th e

s a m e tim e m a in ta in a c le a r o v e r v ie w o f th e s u b je c t.
T h is b o o k c o n s is ts of M CQ s a n d d ia g r a m m a tic e s s a y s . It o c c a s io n a lly b u t d e lib e r a te ly

d e v ia te s fr o m th e e x a m in a tio n M C O fo r m a t o f 5 s te r n s b y in c lu d in g 6 o r e v e n 7 s te m s w ith
th e a im o f o ffe r in g p r a c tic e to th e r e a d e r . A lo n g w ith th e a n s w e rs a r e in c lu d e d s h o rt

e x p la n a to r y n o te s o n e a c h s u b je c t th a t m a y b e u s e fu l in p r e p a r in g s h o r t n o te s u m m a r ie s .

The essays a r e o f title s o r s u b je c ts th a t a r e b r o a d a n d o p e n -e n d e d , a n d th e ir fo r m a t

a llo w s th e ir b a s ic s tr u c tu r e to b e Id e n tifie d a t a g la n c e . N e c e s s a ry b a c k g ro u n d in fo r -
m a tio n is a ls o in c lu d e d e ith e r in th e s u m m a r y p a g e o r fu r th e r o n . E s s a y a n s w e r s r e q u ir e

a n a p p r e c ia tio n o f th e q u e s tio n a n d a n a w a re n e s s o f th e p r io r itie s . T o th is e n d w e h a v e

used a s y s te m o f 'tr a ffic lig h ts ' ( r e d , a m b e l' a n d g r e e n ) p r e s e n te d a s b la c k a n d w h ite
im a g e s in th e essays. These s e rv e a s u s e fu l b u lle ts b o th lis tin g and p r io r itis in g key
p o in ts . R e d id e n tifie s th e p o in t o r ta c t th a t is m o s t im p o r ta n t. Am ber is a tta c h e d to th e

second m o s t im p o r ta n t ta c t a n d g r e e n m a y s ig n ify e ith e r th e th ir d m ost im p o r ta n t fa c t

o r ( d e p e n d in g o n its c o n te x t) m ay in d ic a te a p o in t o r fe a tu r e o f le a s t im p o r ta n c e . The

'tr a ffic lig h t' s y s te m a llo w s fa c ts to b e g ro u p e d and th e n fu r th e r lis te d (p e rh a p s by

n u m b e r ) in e a c h g r o u p th e r e b y a v o id in g th e c o n fu s io n o f to o m a n y n u m b e re d p o in ts on

a p a g e . T h e s y s te m is fo r r e v is io n p u rp o s e s o n ly a n d h a s n o p la c e in e s s a y a n s w e rs . It

is n o t u n iv e r s a lly used and m ay p ro v e a m b ig u o u s to th e e x a m in e r .

W e hope th a t c a n d id a te s s ittin g th is exam w ill fin d th is book u s e fu l, a n d fo r th o s e

who m a y b e s ittin g th e ir e x a m once a g a in , d o n o t d e s p a ir , th is is a w e ll tr o d d e n p a th !

Raman Malhotra and David E a s ty

1997
 ACKNOWLEDGEMENTSZYXWVUTSRQPONMLKJIHGFEDCBA INTRODUCTION

U n iv e r s itie s a n d c o lle g e s s e t a s s e s s m e n ts to ju d g e a le v e l o f a c h ie v e m e n t, to m o n ito r

W e w o u ld lik e to th a n k th e fo llo w in g in d iv id u a ls fO l' th e ir h e lp in r e v ie w in g th e
p r o g r e s s , s o m e tim e s to m o tiv a te c a n d id a te s a n d s o m e tim e s to lic e n s e p r a c tic e w ith in
m a n u s c r ip t: a p r o fe s s io n . G o o d a s s e s s m e n ts n e e d to c o n s id e r th e m e n ta l a n d p r a c tic a l s k ills to b e
te s te d . In m e d ic in e th e te s ts s h o u ld b e v a lid a n d d e te n n in e le v e ls o f c o m p e te n c e in a
D r N e v ille G o o d m a n n u m b e r o f c o m p o n e n ts . F a c to r s th a t a r e im p o r ta n t in a s s e s s m e n t in m e d ic in e a r e r e c a ll
( C a r d io v a s c u la r a n d R e s p ir a to r y P h y s io lo g y ) , . o f in fo r m a tio n , in te r p r e ta tio n o f d a ta a n d p r o b le m - s o lv in g . E x a m in a tio n s s h o u ld e m u -
S e n io r L e c tu r e r , D e p a r tm e n t o f A n a e s th e s io lo g y , U n iv e r s ity o f B r is to l la te r e le v a n t v o c a tio n a l c o n d itio n s c lo s e ly .
A s s e s s m e n t m e th o d s v a r y fr o m th e th r e e - h o u r e s s a y e x a m in a tio n , th r o u g h p r e p a r e d
D r T e r r y H ill
e s s a y e x a m s , o p e n b o o k e s s a y s a n d s h o r t a n s w e r q u e s tio n s , to o b je c tiv e te s ts o f
( M ic r o b io lo g y )
v a r io u s k in d s in c lu d in g c o u r s e w o r k , p r a c tic a ls . s im u la te d ta s k s a n d o r a l s itu a tio n s
R e a d e r in M ic r o b io lo g y , D e p a r tm e n t o f P a th o lo g y a n d M ic r o b io lo g y , U n iv e r s ity o f B r is to l
s u c h a s viva voce e x a m s . In P a r t I o f th e M R C O p h th E x a m in a tio n , b a s ic s c ie n c e
D r G r a h a m H o ld e r r e le v a n t to v is io n a n d th e e y e is e v a lu a te d . T h e m e th o d s in v o lv e a th r e e - h o u r e s s a y
( E le c tr o p h y s io lo g y ) p a p e r a n d tw o m u ltip le c h o ic e p a p e r s . T h e fo r m e r r e q u ir e s g o o d k n o w le d g e o f in fo r -
D e p a r tm e n t o f E le c tr o d ia g n o s tic s , M o o r fie Id s H o s p ita l, L o n d o n m a tio n , w h ile th e la tte r r e q u ir e s th o u g h t a s w e ll a s in fo r m a tio n . T h e a d v a n ta g e s o f th e
m u ltip le c h o ic e p a p e r s a r e th a t th e r e is b r o a d c o v e r a g e o f th e s y lla b u s , m a r k in g is
O r S te p h e n L is n e y
o b je c tiv e a n d p r e c is e , a n d c o m p u te r m a r k in g is p o s s ib le .
( R e n a l, E n d o c r in e a n d N e u r o p h y s io lo g y )
W h a t is th e p r o b le m w ith th e s e m e d ic a l e x a m in a tio n s , a n d w h y d o c a n d id a te s fa il?
H e a d o f D e p a r tm e n t, D e p a r tm e n t o f P h y s io lo g y , U n iv e r s ity o f B r is to l
W h a t a r e th e c o m m o n e s t e r r o r s in a n s w e r in g w r itte n q u e s tio n s ? D o e s e v e r y b o d y p a s s
P r o fe s s o r G o r d o n R u s k e tl th e te s ts w h o s h o u ld p a s s , o r d o u n n e c e s s a r y fa ilu r e s o c c u r ? R e a s o n s fo r fa ilu r e a r e

( A n a to m y ) m a n y a n d v a r ie d . G iv e n th e m o tiv a tio n o f th o s e u n d e r ta k in g fu r th e r tr a in in g w ith in th e

D e p a r tm e n t o f O p to m e tr y a n d V is u a l S c ie n c e , C ity U n iv e r s ity m e d ic a l p r o fe s s io n , it is u n lik e ly th a t la c k o f a b ility 01' o f h a r d w o r k a r e fa c to r s . T h u s th e
u n s u c c e s s fu l c a n d id a te m a y h a v e o th e r p r o b le m s , s u c h a s s o c ia l is o la tio n , in a d e q u a te
D r E d w a r d S h e ffie ld
te a c h in g a n d th e p r e s s u r e o f m e d ic a l tr a in in g , to g e th e r w ith la c k o f tim e fO l' p r e p a r a tio n .
( P a th o lo g y ) O v e r s e a s s tu d e n ts m a y h a v e d iffIC u lty w ith la n g u a g e a n d e s s a y p r e s e n ta tio n ; w ith o u t
S e n io r L e c tu r e r . D e p a r tm e n t o f P a th o lo g y a n d M ic r o b io lo g y , U n iv e r s ity o f B r is to l
g o o d E n g lis h , it is d iffic u lt to w r ite a n a c c e p ta b le a n s w e r . T h e r e a r e m a n y w a y s in w h ic h

M r G a r y S h u ttle w o r th th e s e p r o b le m s c a n b e a lle v ia te d . S im p le s u g g e s tio n s to im p r o v e e x a m success

( O c u la r P h y s io lo g y a n d P h a r m a c o lo g y ) in c lu d e th e fo llo w in g . R e h e a r s e e s s a y p r e p a r a tio n q u e s tio n s b e fo r e th e e x a m s in c e

L e c tu r e r , D e p a r tm e n t o f O p h th a lm o lo g y , U n iv e r s ity o f B r is to l p r a c tic e im p r o v e s o u tc o m e . D o n o t ju s t c o p y o u t fa c ts fr o m te x t b o o k s . T r y to im ita te

e x a m in a tio n c o n d itio n s , a n d b e c o m e e x p e r t in p la n n in g q u e s tio n s , a n d th e n w r itin g

A s p e c ia l th a n k y o u to G a ll C la r e , S u e T e d d a n d A n n Y o u n g fo r ty p in g th e m a n u s c r ip t th e m o u t in a ' m e a s u r e d tim e in te r v a l. G e t a s e n io r c o lle a g u e to r e a d th r o u g h tr ia l

q u e s tio n s a n d in v ite h im 01' h e r to r e v ie w it c r itic a lly . E v e r y b o d y h a s th e ir o w n m e th o d
w ith s u c h i!') C r e d ib lep a tie n c e .
fo r p r e p a r a tio n , b u t r e m e m b e r th a t o v e r - p r e p a r a tio n c a n le a d to d is a s te r . D o n o t u s e
to o m a n y te x ts w ith in th e s a m e fie ld - s tic k w ith a r e a d a b le o n e , a n d d o n o t e x p a n d in to
r e fe r e n c e te x ts . M a k e s u r e th a t y o u u n d e r s ta n d th e s c ie n c e . In y o u r p r e p a r a tio n tr y to
g r a s p th e s c ie n c e o f p h y s io lo g y , p a th o lo g y , a n a to m y 01' b io c h e m is tr y . U n d e r s ta n d in g
h e lp s in m e m o r iz in g fa c ts , a n d in e x p la n a tio n s 01' d e s c r ip tio n s in a n s w e r s to q u e s tio n s .
W h a t is th e b e s t te c h n iq u e to u s e to p e r s u a d e e x a m in e r s to g iv e a p a s s m a r k ?
A d e q u a te p r e p a r a tio n is c r u c ia l. T h e p r e s s u r e to c o n tin u e q u ic k ly u p th e c a r e e r la d d e r
 ACKNOWLEDGEMENTSZYXWVUTSRQPONMLKJIHGFEDCBA INTRODUCTION

U n iv e r s itie s a n d c o lle g e s s e t a s s e s s m e n ts to ju d g e a le v e l o f a c h ie v e m e n t, to m o n ito r

W e w o u ld lik e to th a n k th e fo llo w in g in d iv id u a ls fO l' th e ir h e lp in r e v ie w in g th e
p r o g r e s s , s o m e tim e s to m o tiv a te c a n d id a te s a n d s o m e tim e s to lic e n s e p r a c tic e w ith in
m a n u s c r ip t: a p r o fe s s io n . G o o d a s s e s s m e n ts n e e d to c o n s id e r th e m e n ta l a n d p r a c tic a l s k ills to b e
te s te d . In m e d ic in e th e te s ts s h o u ld b e v a lid a n d d e te n n in e le v e ls o f c o m p e te n c e in a
D r N e v ille G o o d m a n n u m b e r o f c o m p o n e n ts . F a c to r s th a t a r e im p o r ta n t in a s s e s s m e n t in m e d ic in e a r e r e c a ll
( C a r d io v a s c u la r a n d R e s p ir a to r y P h y s io lo g y ) , . o f in fo r m a tio n , in te r p r e ta tio n o f d a ta a n d p r o b le m - s o lv in g . E x a m in a tio n s s h o u ld e m u -
S e n io r L e c tu r e r , D e p a r tm e n t o f A n a e s th e s io lo g y , U n iv e r s ity o f B r is to l la te r e le v a n t v o c a tio n a l c o n d itio n s c lo s e ly .
A s s e s s m e n t m e th o d s v a r y fr o m th e th r e e - h o u r e s s a y e x a m in a tio n , th r o u g h p r e p a r e d
D r T e r r y H ill
e s s a y e x a m s , o p e n b o o k e s s a y s a n d s h o r t a n s w e r q u e s tio n s , to o b je c tiv e te s ts o f
( M ic r o b io lo g y )
v a r io u s k in d s in c lu d in g c o u r s e w o r k , p r a c tic a ls . s im u la te d ta s k s a n d o r a l s itu a tio n s
R e a d e r in M ic r o b io lo g y , D e p a r tm e n t o f P a th o lo g y a n d M ic r o b io lo g y , U n iv e r s ity o f B r is to l
s u c h a s viva voce e x a m s . In P a r t I o f th e M R C O p h th E x a m in a tio n , b a s ic s c ie n c e
D r G r a h a m H o ld e r r e le v a n t to v is io n a n d th e e y e is e v a lu a te d . T h e m e th o d s in v o lv e a th r e e - h o u r e s s a y
( E le c tr o p h y s io lo g y ) p a p e r a n d tw o m u ltip le c h o ic e p a p e r s . T h e fo r m e r r e q u ir e s g o o d k n o w le d g e o f in fo r -
D e p a r tm e n t o f E le c tr o d ia g n o s tic s , M o o r fie Id s H o s p ita l, L o n d o n m a tio n , w h ile th e la tte r r e q u ir e s th o u g h t a s w e ll a s in fo r m a tio n . T h e a d v a n ta g e s o f th e
m u ltip le c h o ic e p a p e r s a r e th a t th e r e is b r o a d c o v e r a g e o f th e s y lla b u s , m a r k in g is
O r S te p h e n L is n e y
o b je c tiv e a n d p r e c is e , a n d c o m p u te r m a r k in g is p o s s ib le .
( R e n a l, E n d o c r in e a n d N e u r o p h y s io lo g y )
W h a t is th e p r o b le m w ith th e s e m e d ic a l e x a m in a tio n s , a n d w h y d o c a n d id a te s fa il?
H e a d o f D e p a r tm e n t, D e p a r tm e n t o f P h y s io lo g y , U n iv e r s ity o f B r is to l
W h a t a r e th e c o m m o n e s t e r r o r s in a n s w e r in g w r itte n q u e s tio n s ? D o e s e v e r y b o d y p a s s
P r o fe s s o r G o r d o n R u s k e tl th e te s ts w h o s h o u ld p a s s , o r d o u n n e c e s s a r y fa ilu r e s o c c u r ? R e a s o n s fo r fa ilu r e a r e

( A n a to m y ) m a n y a n d v a r ie d . G iv e n th e m o tiv a tio n o f th o s e u n d e r ta k in g fu r th e r tr a in in g w ith in th e

D e p a r tm e n t o f O p to m e tr y a n d V is u a l S c ie n c e , C ity U n iv e r s ity m e d ic a l p r o fe s s io n , it is u n lik e ly th a t la c k o f a b ility 01' o f h a r d w o r k a r e fa c to r s . T h u s th e
u n s u c c e s s fu l c a n d id a te m a y h a v e o th e r p r o b le m s , s u c h a s s o c ia l is o la tio n , in a d e q u a te
D r E d w a r d S h e ffie ld
te a c h in g a n d th e p r e s s u r e o f m e d ic a l tr a in in g , to g e th e r w ith la c k o f tim e fO l' p r e p a r a tio n .
( P a th o lo g y ) O v e r s e a s s tu d e n ts m a y h a v e d iffIC u lty w ith la n g u a g e a n d e s s a y p r e s e n ta tio n ; w ith o u t
S e n io r L e c tu r e r . D e p a r tm e n t o f P a th o lo g y a n d M ic r o b io lo g y , U n iv e r s ity o f B r is to l
g o o d E n g lis h , it is d iffic u lt to w r ite a n a c c e p ta b le a n s w e r . T h e r e a r e m a n y w a y s in w h ic h

M r G a r y S h u ttle w o r th th e s e p r o b le m s c a n b e a lle v ia te d . S im p le s u g g e s tio n s to im p r o v e e x a m success

( O c u la r P h y s io lo g y a n d P h a r m a c o lo g y ) in c lu d e th e fo llo w in g . R e h e a r s e e s s a y p r e p a r a tio n q u e s tio n s b e fo r e th e e x a m s in c e

L e c tu r e r , D e p a r tm e n t o f O p h th a lm o lo g y , U n iv e r s ity o f B r is to l p r a c tic e im p r o v e s o u tc o m e . D o n o t ju s t c o p y o u t fa c ts fr o m te x t b o o k s . T r y to im ita te

e x a m in a tio n c o n d itio n s , a n d b e c o m e e x p e r t in p la n n in g q u e s tio n s , a n d th e n w r itin g

A s p e c ia l th a n k y o u to G a ll C la r e , S u e T e d d a n d A n n Y o u n g fo r ty p in g th e m a n u s c r ip t th e m o u t in a ' m e a s u r e d tim e in te r v a l. G e t a s e n io r c o lle a g u e to r e a d th r o u g h tr ia l

q u e s tio n s a n d in v ite h im 01' h e r to r e v ie w it c r itic a lly . E v e r y b o d y h a s th e ir o w n m e th o d
w ith s u c h i!') C r e d ib lep a tie n c e .
fo r p r e p a r a tio n , b u t r e m e m b e r th a t o v e r - p r e p a r a tio n c a n le a d to d is a s te r . D o n o t u s e
to o m a n y te x ts w ith in th e s a m e fie ld - s tic k w ith a r e a d a b le o n e , a n d d o n o t e x p a n d in to
r e fe r e n c e te x ts . M a k e s u r e th a t y o u u n d e r s ta n d th e s c ie n c e . In y o u r p r e p a r a tio n tr y to
g r a s p th e s c ie n c e o f p h y s io lo g y , p a th o lo g y , a n a to m y 01' b io c h e m is tr y . U n d e r s ta n d in g
h e lp s in m e m o r iz in g fa c ts , a n d in e x p la n a tio n s 01' d e s c r ip tio n s in a n s w e r s to q u e s tio n s .
W h a t is th e b e s t te c h n iq u e to u s e to p e r s u a d e e x a m in e r s to g iv e a p a s s m a r k ?
A d e q u a te p r e p a r a tio n is c r u c ia l. T h e p r e s s u r e to c o n tin u e q u ic k ly u p th e c a r e e r la d d e r
 I n tr o d u c tio n I n tr o d u c tio n ZYXWVUTSRQPONMLKJIHGFEDCBA Xl
x

h a s a lw a y s b e e n c o n s id e r a b le a n d th e r e is o fte n a te n d e n c y to e n te r a e x a m to o e a r ly . • D o n o t fe e l th a t y o u m u s t a n s w e r a ll th e q u e s tio n s ; th e e x a m in e r s m a y u s e n e g a tiv e

P r e m a tu r e e n tr y w ith o u t a d e q u a te p r e p a r a tio n r a r e ly r e s u lts in a s u c c e s s fu l o u tc o m e . m a r k in g . i.e . a n in c o r r e c t a n s w e r w ill lo s e a m a r k .
C o v e r th e to ta l s u b je c t m a tte r d u r in g th is p e r io d . P r e s e n ta tio n o f e s s a y s is fu n d a m e n ta l
• B la n k s d o n o t lo s e m a r k s . P ic k o u t th e q u e s tio n s th a t y o u r e a lty k n o w fir s t, a n d th e n
fo r s u c c e s s . B e c a r e fu l to w r ite le g ib ly . a n d a v o id c lu m s y c o r r e c tio n s a n d c r o s s in g s o u t.
s e e h o w m u c h y o u h a v e a n s w e re d .
U s e h e a d in g s lib e r a lly . h ig h lig h tin g k e y w o r d s a n d im p o r ta n t fa c ts .

E x a m in a tio n s a r e r e g a r d e d b y s o m e a s a c o m p e titio n . to w h ic h c a n d id a te s r e a c t in a
Principles n u m b e r o f w a y s . T h u s s tu d y in g p a s t p a p e r s . d o in g p r a c tic e a n s w e rs as essays or
• T r y to r e la x b e fo r e th e e x a m in a tio n . T h e r e is little p o in t in a la s t m in u te s tr u g g le to
m u ltip le c h o ic e q u e s tio n s a n d s o o n a r e d is tin c t fr o m th e d is in te r e s te d p u r s u it o f th e
c o v e r a n e x te n s iv e fie ld . s u b je c t to b e s tu d ie d . F o r e x a m p le . e s s a y q u e s tio n s m a y s o m e tim e s c o n c e r n s u b je c ts
• R e a d th e in s tr u c tio n s h e e ts a n d q u e s tio n s e x tr e m e ly c a r e fu lly . A ll to o fr e q u e n tly
th a t h a v e b e e n d is c u s s e d a t a n a tio n a l m e e tin g . T o p ic a l is s u e s a r e g o o d s u b je c ts fo r
c a n d id a te s m is in te r p r e t a q u e s tio n . o r lo s e m a r k s b y n o t fo llo w in g in s tr u c tio n s . For
q u e s tio n s . H o w e v e r s o m e m a y fe e l th a t th is is n o t a r e a s o n a b le w a y to p r o c e e d . a n d
e x a m p le . c a n d id a te s a s k e d to a n s w e r th r e e o u t o f fo u r s h o r t n o te q u e s tio n s . m a y
th e r e fo r e ig n o r e th is o n p d n c ip le . O th e r s w ill d e p e n d o n h a r d w o r k a lo n e . T h e g r e a te s t
a n s w e r o n ly o n e . T h is is u n fo r tu n a te . b u t w ill lo s e m a r k s .
• W o r k o u t th e tim e y o u m u s t a llo c a te to e a c h q u e s tio n . P r e p a r e a p la n In a b o u t 1 0 s u c c e s s c o m e s fr o m c u e - c o n s c io u s n e s s a n d h a r d w o r k . W e h o p e th a t th e e x a m p le s o f
m in u te s a t th e b e g in n in g . M a k e a s k e le to n a n s w e r w ith a s e r ie s o f h e a d in g s . A v o id e s s a y q u e s tio n s and M CQ s in th is b o o k w ill h e lp c a n d id a te s to w a r d s a s u c c e s s fu l

r e p e titio n . T r y to c o n v e y a Io g ic a l'tr a in o f th o u g h t. o u tc o m e .
• D o n o t fe e l th a t y o u h a v e to c o m m it e v e r y th in g y o u k n o w to p a p e r - th is w ill p r o b a b ly
ta k e fa r to o lo n g . a n d y o u w ill n o t h a v e tim e to a n s w e r th e o th e r q u e s tio n s p r o p e r ly .

• W r ite le g ib ly . D o n o t r u s h s o th a t y o u r s c r ip t is in d e c ip h e r a b le . A s h o r t a n s w e r th a t is

r e a d a b le is b e tte r th a n a lo n g a n s w e r in a n ille g ib le s c r a w l.
• T r y to b e g r a m m a tic a lly C O fl'8 C t.D o n o t w r ite in n o te fo r m u n le s s th is Is r e q u e s te d .
W r ite in s e n te n c e s . It is u s e fu l to ite m iz e p o in ts . o r r e la te d p a r a g r a p h s a s it d e m o n -
s tr a te s a w e ll- o r g a n iz e d a p p r o a c h . It m a y b e u s e fu l to th e e x a m in e r s to u n d e r lin e in

c o lo u r im p o r ta n t p o in ts th a t y o u w is h to h ig h lig h t.
• Illu s tr a tio n s a r e r e g a r d e d a s h e lp fu l. b u t b e c a r e fu l - e r r o r s c a n b e c o s tly . If y o u a r e
n o t c e r ta in o f th e fa c ts . u s e d e s c r ip tio n . If y o u d e c id e to u s e a d ia g r a m . th e n ta k e
c a r e a n d k e e p it n e a t a n d tid y . C a s u a l th u m b - n a il s k e tc h e s d o n o t h e lp v e r y m u c h .
• F lo w d ia g r a m s . o n th e o th e r h a n d . m a y s h o r te n th e te x t a n d p r o v id e th e e x a m in e r s

w ith a n id e a o f y o u r tr a in o f th o u g h t.

• A v o id ta b le s .
• A v o id a b b r e v ia tio n s w ith o u t e x p la n a tio n . U se th e m o n ly a fte r th e y have been
e x p la in e d . e .g . v is u a l e v o k e d r e s p o n s e ( \IE R ) . V e r y c o m m o n a b b r e v ia tio n s a re p e r-
m is s ib le . s u c h a s lO P ~ n tr a - o c u la r p r e s s u r e ) . If th e r e is a n y d o u b t. w r ite it o u t in fu ll.
• M a k e th e e s s a y in te r e s tin g . D o n o t m a k e th in g s u p . D o n o t w a ffle . S h o r t s e n te n c e s

a r e b e tte r th a n lo n g o n e s .
• G iv e y o u r s e lf tim e to r e a d th r o u g h th e e n tir e s c r ip t a t th e e n d . s o th a t e r r o r s c a n b e

c o r r e c te d .
• F in a lly . tr y to b e n e a t a n d tid y . C r o s s in g o u t a n d s lo p p y p r e s e n ta tio n d o e s n o t s c o re

p o in ts . T h e n e a te s t w r ite r s s c o r e th e m o s t p o in ts in th e e n d .

O u r a im in th is b o o k is to p r o v id e h e lp o n th e b e s t w a y to a n s w e r a n e s s a y q u e s tio n . It
a ls o p r o v id e s a s e r ie s o f m u ltip le c h o ic e q u e s tio n s ( M C a s ) s o th a t p o te n tia l c a n d id a te s

c a n g a in e x p e r ie n c e in th is m e th o d o f te s tin g .

• R e m e m b e r th a t if th e a n s w e r to an M ea is n o t k n o w n . d o n o t tr y to g u e s s th e

a n s w e r.
 I n tr o d u c tio n I n tr o d u c tio n ZYXWVUTSRQPONMLKJIHGFEDCBA Xl
x

h a s a lw a y s b e e n c o n s id e r a b le a n d th e r e is o fte n a te n d e n c y to e n te r a e x a m to o e a r ly . • D o n o t fe e l th a t y o u m u s t a n s w e r a ll th e q u e s tio n s ; th e e x a m in e r s m a y u s e n e g a tiv e

P r e m a tu r e e n tr y w ith o u t a d e q u a te p r e p a r a tio n r a r e ly r e s u lts in a s u c c e s s fu l o u tc o m e . m a r k in g . i.e . a n in c o r r e c t a n s w e r w ill lo s e a m a r k .
C o v e r th e to ta l s u b je c t m a tte r d u r in g th is p e r io d . P r e s e n ta tio n o f e s s a y s is fu n d a m e n ta l
• B la n k s d o n o t lo s e m a r k s . P ic k o u t th e q u e s tio n s th a t y o u r e a lty k n o w fir s t, a n d th e n
fo r s u c c e s s . B e c a r e fu l to w r ite le g ib ly . a n d a v o id c lu m s y c o r r e c tio n s a n d c r o s s in g s o u t.
s e e h o w m u c h y o u h a v e a n s w e re d .
U s e h e a d in g s lib e r a lly . h ig h lig h tin g k e y w o r d s a n d im p o r ta n t fa c ts .

E x a m in a tio n s a r e r e g a r d e d b y s o m e a s a c o m p e titio n . to w h ic h c a n d id a te s r e a c t in a
Principles n u m b e r o f w a y s . T h u s s tu d y in g p a s t p a p e r s . d o in g p r a c tic e a n s w e rs as essays or
• T r y to r e la x b e fo r e th e e x a m in a tio n . T h e r e is little p o in t in a la s t m in u te s tr u g g le to
m u ltip le c h o ic e q u e s tio n s a n d s o o n a r e d is tin c t fr o m th e d is in te r e s te d p u r s u it o f th e
c o v e r a n e x te n s iv e fie ld . s u b je c t to b e s tu d ie d . F o r e x a m p le . e s s a y q u e s tio n s m a y s o m e tim e s c o n c e r n s u b je c ts
• R e a d th e in s tr u c tio n s h e e ts a n d q u e s tio n s e x tr e m e ly c a r e fu lly . A ll to o fr e q u e n tly
th a t h a v e b e e n d is c u s s e d a t a n a tio n a l m e e tin g . T o p ic a l is s u e s a r e g o o d s u b je c ts fo r
c a n d id a te s m is in te r p r e t a q u e s tio n . o r lo s e m a r k s b y n o t fo llo w in g in s tr u c tio n s . For
q u e s tio n s . H o w e v e r s o m e m a y fe e l th a t th is is n o t a r e a s o n a b le w a y to p r o c e e d . a n d
e x a m p le . c a n d id a te s a s k e d to a n s w e r th r e e o u t o f fo u r s h o r t n o te q u e s tio n s . m a y
th e r e fo r e ig n o r e th is o n p d n c ip le . O th e r s w ill d e p e n d o n h a r d w o r k a lo n e . T h e g r e a te s t
a n s w e r o n ly o n e . T h is is u n fo r tu n a te . b u t w ill lo s e m a r k s .
• W o r k o u t th e tim e y o u m u s t a llo c a te to e a c h q u e s tio n . P r e p a r e a p la n In a b o u t 1 0 s u c c e s s c o m e s fr o m c u e - c o n s c io u s n e s s a n d h a r d w o r k . W e h o p e th a t th e e x a m p le s o f
m in u te s a t th e b e g in n in g . M a k e a s k e le to n a n s w e r w ith a s e r ie s o f h e a d in g s . A v o id e s s a y q u e s tio n s and M CQ s in th is b o o k w ill h e lp c a n d id a te s to w a r d s a s u c c e s s fu l

r e p e titio n . T r y to c o n v e y a Io g ic a l'tr a in o f th o u g h t. o u tc o m e .
• D o n o t fe e l th a t y o u h a v e to c o m m it e v e r y th in g y o u k n o w to p a p e r - th is w ill p r o b a b ly
ta k e fa r to o lo n g . a n d y o u w ill n o t h a v e tim e to a n s w e r th e o th e r q u e s tio n s p r o p e r ly .

• W r ite le g ib ly . D o n o t r u s h s o th a t y o u r s c r ip t is in d e c ip h e r a b le . A s h o r t a n s w e r th a t is

r e a d a b le is b e tte r th a n a lo n g a n s w e r in a n ille g ib le s c r a w l.
• T r y to b e g r a m m a tic a lly C O fl'8 C t.D o n o t w r ite in n o te fo r m u n le s s th is Is r e q u e s te d .
W r ite in s e n te n c e s . It is u s e fu l to ite m iz e p o in ts . o r r e la te d p a r a g r a p h s a s it d e m o n -
s tr a te s a w e ll- o r g a n iz e d a p p r o a c h . It m a y b e u s e fu l to th e e x a m in e r s to u n d e r lin e in

c o lo u r im p o r ta n t p o in ts th a t y o u w is h to h ig h lig h t.
• Illu s tr a tio n s a r e r e g a r d e d a s h e lp fu l. b u t b e c a r e fu l - e r r o r s c a n b e c o s tly . If y o u a r e
n o t c e r ta in o f th e fa c ts . u s e d e s c r ip tio n . If y o u d e c id e to u s e a d ia g r a m . th e n ta k e
c a r e a n d k e e p it n e a t a n d tid y . C a s u a l th u m b - n a il s k e tc h e s d o n o t h e lp v e r y m u c h .
• F lo w d ia g r a m s . o n th e o th e r h a n d . m a y s h o r te n th e te x t a n d p r o v id e th e e x a m in e r s

w ith a n id e a o f y o u r tr a in o f th o u g h t.

• A v o id ta b le s .
• A v o id a b b r e v ia tio n s w ith o u t e x p la n a tio n . U se th e m o n ly a fte r th e y have been
e x p la in e d . e .g . v is u a l e v o k e d r e s p o n s e ( \IE R ) . V e r y c o m m o n a b b r e v ia tio n s a re p e r-
m is s ib le . s u c h a s lO P ~ n tr a - o c u la r p r e s s u r e ) . If th e r e is a n y d o u b t. w r ite it o u t in fu ll.
• M a k e th e e s s a y in te r e s tin g . D o n o t m a k e th in g s u p . D o n o t w a ffle . S h o r t s e n te n c e s

a r e b e tte r th a n lo n g o n e s .
• G iv e y o u r s e lf tim e to r e a d th r o u g h th e e n tir e s c r ip t a t th e e n d . s o th a t e r r o r s c a n b e

c o r r e c te d .
• F in a lly . tr y to b e n e a t a n d tid y . C r o s s in g o u t a n d s lo p p y p r e s e n ta tio n d o e s n o t s c o re

p o in ts . T h e n e a te s t w r ite r s s c o r e th e m o s t p o in ts in th e e n d .

O u r a im in th is b o o k is to p r o v id e h e lp o n th e b e s t w a y to a n s w e r a n e s s a y q u e s tio n . It
a ls o p r o v id e s a s e r ie s o f m u ltip le c h o ic e q u e s tio n s ( M C a s ) s o th a t p o te n tia l c a n d id a te s

c a n g a in e x p e r ie n c e in th is m e th o d o f te s tin g .

• R e m e m b e r th a t if th e a n s w e r to an M ea is n o t k n o w n . d o n o t tr y to g u e s s th e

a n s w e r.
 ANATOMY
QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIH

1 In the orbital cavity,

A the lateral wall of the cavity is directly related to the temporal fossa
B the lateral wall of the orbit is made up of the zygomatic bone and the greater wing
of the sphenoid only
C the roof of the orbit is made up of the orbital plate of the frontal bone and the
greater and lesser wings of the sphenoid
D the frontal nerve is directly related to the entire length of the roof of the orbit
E the medial wall of the orbit is made up by the frontal process of the maxilla, the
lacrimal bone, the orbital plate of the ethmoid and the orbital process of the
palatine bone

2 Which of the following statements regarding the orbital cavity are true?

A Direct relations of the medial wall of the orbit include the sphenoid sinus, medial
rectus and lacrimal sac.
B The floor of the orbit is directly related to the inferior rectus.
C The superior orbital fissure is closed laterally by the frontal bone.
D The superior orbital fissure connects the orbital cavity with the pterygopalatine
fossa.
E The optic canal lies in the body of the sphenoid.
F The optic canal is directed forwards, laterally and downwards.

3 The periorbita is firmly attached to the

A orbital margins
B orbital surface of the maxilla
C sutures
o lacrimal fossa
E superior orbital fissure

4 Regarding the paranasal sinuses,

A the maxillary sinus lies above the anterior five teeth

B the maxillary sinus drains into the bulla ethmoidal is
 Anatom y Questions 3
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
2
o The subtarsal sulcus lies half way between the anterior and posterior edge of the
C the frontal sinus drains into the hiatus semilunaris lid margin.
o the lymphatic drainage of the posterior ethmoidal sinus is to the submandibular E The grey line mat1<san avascular plane separating the tarsal plate from the
lymph nodes conjunctiva.
E the frontal sinuses are the only sinuses not present at birth
F the sphenoidal sinus is related postariorly to the pons
9 Regarding the conjunctiva,

5 Which of the following statements about the eyelids are true? A the superior fornix of the conjunctiva lies 10 mm from the limbus
B the lateral conjunctival fomix lies 5 mm from the limbus
A The nerves to the eyelids lie anterior to orbicularis. e the anterior conjunctival artery arises mainly from the palpebral arterial arches
B The lower tarsal plate is 5 mm in height at the middle and 1 mm thick. o the conjunctiva fuses with Tenon's capsule 3 mm behind the limbus
e The medial palpebral ligament is attached to the posterior lacrimal crest. E goblet cells are most concentrated in the upper temporal conjunctival fornix
D The lateral palpebral ligament is attached to the marginal tubercle 11 mm below F the superior peripheral arterial arch supplies blood to the largest area of con-
junctiva
the frontozygomatic suture.
E The lateral palpebral ligament lies anterior to the lateral palpebral raphe.

10 In the lacrimal system

6 The orbital septum A the lacrimal gland is situated superomedial to the globe
B basal tear flow is mainly drained by the nasolacrimal duct
A marks the junction between periosteum and periorbita
e the orbital portion of the lacrimal gland is three times larger than the palpebral
B lies behind the lateral palpebral ligament
portion
e attaches behind the posterior lacrimal crest o the orbital portion of the lacrimal gland is related inferiorly to the conjunctiva and
o lies anterior to the medial palpebral ligament globe
E is pierced by an extension of the inferior rectus sheath
E the palpebral portion of the lacrimal gland is related anteriorly to the orbital septum
F is pierced by the lacrimal. supraorbital. supratrochlear and inlraorbital nerves

11 Which of the following statements about the lacrimal gland are true?
7 Regarding the eyelids.
A The lacrimal gland is surrounded by a capsule.
A the meibomian glands lie between the tarsal plate and the conjunctivae
B Excision of the palpebral portion of the lacrimal gland stops tear secretion almost
B the glands of Moll are more numerous in the upper lid completely.
e there are approximately two glands of Zeis to each cilium C The lacrimal vein joins the ophthalmic vein.
o the arterial arches run anterior to orbicularis o The lymphatic drainage of the lacrimal gland is to the preauricular nodes.
E the marginal arterial arch runs 1 mm from the free margin ef the eyelids
E Preganglionic parasympathetic innervation is via the lesser petrosal nerve.
F the Iymphatics of the upper eyelid drain to the preauricular nodes and the lower lid
to the submandibular nodes
12 In the lacrimal system,

8 Which of the following statements about the eyelids are true? A the lower lacrimal punctum Is 6.5 mm from the medial canthus
B the superior lac:nmai canalicull;ls is shorter than the Inferior canaliculus
A The orbital portion of orbicularis arises from the bony orbital margin medial to the C the canaliculi pierce the lacrimal sac 5 mm below the apex of the lacrimal sac
supraorbital notch and the inlraorbital foramen. o the normal diameter of the lacrimal canaliculus is 0.5 mm
B The skin of the eyelid is separated from the palpebral portion of orbicularis by fat.
E the lacrimal canaliculi are lined by stratified squamous epithelium
e The lacrimal portion of orbicularis arises from the posterior lacrimal crest.
 Anatom y Questions 3
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
2
o The subtarsal sulcus lies half way between the anterior and posterior edge of the
C the frontal sinus drains into the hiatus semilunaris lid margin.
o the lymphatic drainage of the posterior ethmoidal sinus is to the submandibular E The grey line mat1<san avascular plane separating the tarsal plate from the
lymph nodes conjunctiva.
E the frontal sinuses are the only sinuses not present at birth
F the sphenoidal sinus is related postariorly to the pons
9 Regarding the conjunctiva,

5 Which of the following statements about the eyelids are true? A the superior fornix of the conjunctiva lies 10 mm from the limbus
B the lateral conjunctival fomix lies 5 mm from the limbus
A The nerves to the eyelids lie anterior to orbicularis. e the anterior conjunctival artery arises mainly from the palpebral arterial arches
B The lower tarsal plate is 5 mm in height at the middle and 1 mm thick. o the conjunctiva fuses with Tenon's capsule 3 mm behind the limbus
e The medial palpebral ligament is attached to the posterior lacrimal crest. E goblet cells are most concentrated in the upper temporal conjunctival fornix
D The lateral palpebral ligament is attached to the marginal tubercle 11 mm below F the superior peripheral arterial arch supplies blood to the largest area of con-
junctiva
the frontozygomatic suture.
E The lateral palpebral ligament lies anterior to the lateral palpebral raphe.

10 In the lacrimal system

6 The orbital septum A the lacrimal gland is situated superomedial to the globe
B basal tear flow is mainly drained by the nasolacrimal duct
A marks the junction between periosteum and periorbita
e the orbital portion of the lacrimal gland is three times larger than the palpebral
B lies behind the lateral palpebral ligament
portion
e attaches behind the posterior lacrimal crest o the orbital portion of the lacrimal gland is related inferiorly to the conjunctiva and
o lies anterior to the medial palpebral ligament globe
E is pierced by an extension of the inferior rectus sheath
E the palpebral portion of the lacrimal gland is related anteriorly to the orbital septum
F is pierced by the lacrimal. supraorbital. supratrochlear and inlraorbital nerves

11 Which of the following statements about the lacrimal gland are true?
7 Regarding the eyelids.
A The lacrimal gland is surrounded by a capsule.
A the meibomian glands lie between the tarsal plate and the conjunctivae
B Excision of the palpebral portion of the lacrimal gland stops tear secretion almost
B the glands of Moll are more numerous in the upper lid completely.
e there are approximately two glands of Zeis to each cilium C The lacrimal vein joins the ophthalmic vein.
o the arterial arches run anterior to orbicularis o The lymphatic drainage of the lacrimal gland is to the preauricular nodes.
E the marginal arterial arch runs 1 mm from the free margin ef the eyelids
E Preganglionic parasympathetic innervation is via the lesser petrosal nerve.
F the Iymphatics of the upper eyelid drain to the preauricular nodes and the lower lid
to the submandibular nodes
12 In the lacrimal system,

8 Which of the following statements about the eyelids are true? A the lower lacrimal punctum Is 6.5 mm from the medial canthus
B the superior lac:nmai canalicull;ls is shorter than the Inferior canaliculus
A The orbital portion of orbicularis arises from the bony orbital margin medial to the C the canaliculi pierce the lacrimal sac 5 mm below the apex of the lacrimal sac
supraorbital notch and the inlraorbital foramen. o the normal diameter of the lacrimal canaliculus is 0.5 mm
B The skin of the eyelid is separated from the palpebral portion of orbicularis by fat.
E the lacrimal canaliculi are lined by stratified squamous epithelium
e The lacrimal portion of orbicularis arises from the posterior lacrimal crest.
 Anatom y Questions
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 5
4
D the endothelial layer of the cornea stops abruptly at the limbus
13 With regard to the lacrimal system, E the comeal endothelium is a bilayer of flat, hexagonal-shaped cells

A the lacrimal sac Is related medially to the anterior ethmoidal air cells and middle
meatus of the nose 18 The sclera
B the angular vein crosses the medial palpebral ligament 8 mm from the medial

canthus A is 0.6 mm thick at the equator

e the medial palpebral ligament lies over the lower two-thirds of the lacrimal sac
B is 0.3 mm thick just behind the insertion of the recti
D the nasolacrimal duct is 12 mm long , e has four middle apertures found 4 mm in front of the equator
E the nasolacrimal duct passes downwards, forwards and laterally
D has posterior apertures which transmit the long and short ciliary nerves and
F the nasolacrimal duct is lined by stratified squamous epithelium
vessels
E contains an endothelial canal called the canal of Schlemm

14 Concerning the anatomy of the eyeball, which of the following are true?
19 Which of the following statements about the sclera are true?
A The normal anteroposterior diameter of the adult globe is 24 mm.
B The vertical diameter is greatat' than the horizontal diameter of the globe.
A The scleral fibres anterior to the equator are directed longitudinally.
e The globe lies inferolaterally in the orbital cavity. B The episclera is a highly vascular zone of loose connected tissue that becomes
D One-third of the globe lies in front of the plane between the medial and lateral
thinner towards the back of the eye.
orbital margins. e The lamina cribrosa is the weakest part of the sclera.
E The anteroposterior axis of the globe passes through the optic disc.
D The sclera has a rich sensory innervation.
E Type rv collagen is found mainly at the lamina cribrosa.

15 In the cornea,
20 Regarding the sclera, which of the following are true?
A the posterior radius of curvature is 7.5 mm
B the peripheral comea is more curved than the central cornea
A the sclera is one-third water and two-thirds protein.
e the refractive power is mainly due to the curvature of the posterior surface B Bruch's membrane forms the Inner layer of the sclera.
D the refractive index is 1.33 e the long posterior ciliary arteries enter the sclera 3.6 mm and 3.9 mm nasal and
E the periphery is 1 mm thick temporal to the optic nerve.
D the optic nerve pierces the sclera 3 mm medial to the mid-line and 1 mm above
the horizontal meridian.
16 Which of the following statements about the cornea are correct? E The sclera increases in thickness with age.

A The epithelium is 10% of the corneal thickness.

B The superficial layer of cells is not more than one cell thick.
21 The ciliary body
e The basal layer consists of a single layer of tall columnar stem cells.
D Bowman's membrane is 15-20 urn thick. A is larger on the nasal side than the temporal side
E Bowman's membrane does not contain fibroblasts. B on the nasal side has a posterior border that lies 5 mm behind the comeoscleral
limbus
C begins 1.5 mm behind the comeoscieral limbus in the vertical metidian
17 In the cornea, D contains the pars plicata which has an anteroposterior length of between 3.5 and
4mm
A Descemet's membrane is the endothelial basement membrane E includes the pars plicata, which is made up of 20--30 folds, forming the ciliary
B the posterior layer of Descemet's membrane increases thickness throughout life
process '
e Bowman's membrane continues beyond the limbus as Schwalbe's line
 Anatom y Questions
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 5
4
D the endothelial layer of the cornea stops abruptly at the limbus
13 With regard to the lacrimal system, E the comeal endothelium is a bilayer of flat, hexagonal-shaped cells

A the lacrimal sac Is related medially to the anterior ethmoidal air cells and middle
meatus of the nose 18 The sclera
B the angular vein crosses the medial palpebral ligament 8 mm from the medial

canthus A is 0.6 mm thick at the equator

e the medial palpebral ligament lies over the lower two-thirds of the lacrimal sac
B is 0.3 mm thick just behind the insertion of the recti
D the nasolacrimal duct is 12 mm long , e has four middle apertures found 4 mm in front of the equator
E the nasolacrimal duct passes downwards, forwards and laterally
D has posterior apertures which transmit the long and short ciliary nerves and
F the nasolacrimal duct is lined by stratified squamous epithelium
vessels
E contains an endothelial canal called the canal of Schlemm

14 Concerning the anatomy of the eyeball, which of the following are true?
19 Which of the following statements about the sclera are true?
A The normal anteroposterior diameter of the adult globe is 24 mm.
B The vertical diameter is greatat' than the horizontal diameter of the globe.
A The scleral fibres anterior to the equator are directed longitudinally.
e The globe lies inferolaterally in the orbital cavity. B The episclera is a highly vascular zone of loose connected tissue that becomes
D One-third of the globe lies in front of the plane between the medial and lateral
thinner towards the back of the eye.
orbital margins. e The lamina cribrosa is the weakest part of the sclera.
E The anteroposterior axis of the globe passes through the optic disc.
D The sclera has a rich sensory innervation.
E Type rv collagen is found mainly at the lamina cribrosa.

15 In the cornea,
20 Regarding the sclera, which of the following are true?
A the posterior radius of curvature is 7.5 mm
B the peripheral comea is more curved than the central cornea
A the sclera is one-third water and two-thirds protein.
e the refractive power is mainly due to the curvature of the posterior surface B Bruch's membrane forms the Inner layer of the sclera.
D the refractive index is 1.33 e the long posterior ciliary arteries enter the sclera 3.6 mm and 3.9 mm nasal and
E the periphery is 1 mm thick temporal to the optic nerve.
D the optic nerve pierces the sclera 3 mm medial to the mid-line and 1 mm above
the horizontal meridian.
16 Which of the following statements about the cornea are correct? E The sclera increases in thickness with age.

A The epithelium is 10% of the corneal thickness.

B The superficial layer of cells is not more than one cell thick.
21 The ciliary body
e The basal layer consists of a single layer of tall columnar stem cells.
D Bowman's membrane is 15-20 urn thick. A is larger on the nasal side than the temporal side
E Bowman's membrane does not contain fibroblasts. B on the nasal side has a posterior border that lies 5 mm behind the comeoscleral
limbus
C begins 1.5 mm behind the comeoscieral limbus in the vertical metidian
17 In the cornea, D contains the pars plicata which has an anteroposterior length of between 3.5 and
4mm
A Descemet's membrane is the endothelial basement membrane E includes the pars plicata, which is made up of 20--30 folds, forming the ciliary
B the posterior layer of Descemet's membrane increases thickness throughout life
process '
e Bowman's membrane continues beyond the limbus as Schwalbe's line
6 Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Questions 7

22 In the ciliary body, 26 In the iris,

A both pigmented and non-pigmented ciliary epitllelia are cuboidal in the young A the sphincter pupillae muscle is 1 mm wide
a the blood aqueous barrier is formed by tight junctions at the basoIateral surface a the sphincter pupillae muscle is only found at the pupillary zone
of the non-pigmented epithelial cells C the dilator pupillae is made up of striated muscle fibres
e The pigmented epithelium forms the inner layer of the ciliary epithelium o the dilator pupillae lies between the pupillary zone and the periphery of the uls
o at gap junctions, the non-pigmented epithfllial cells are separated by 2 mm clefts E the posterior pigment epithelium of the iris gives rise to the dilator pupillae
E the greatest number of ciliary epithelial gap jmctlons occur between the pig- muscle
mented and non-pigmented epithelia

27 With regard to the epithelium of the iris, which of the following are true?
23 Which of the following statements about the ciliary body are true?
A The posterior pigment epithelium is continuous with the non-pigmented epithe-
A Zonulae occludentes are not found between adjacent ciliary pigmented epithelial lium of the ciliary body.

cells.
a The anterior epithelial cells are larger than the posterior epithelial cells.
a The pigmented epithelial cells contain fewer mitochondria than the noo-pigmen- e The posterior epithelial cells are more pigmented than the anterior epithelial cells.

ted epithelial cells.

o The posterior epithelial cells are columnar when the pupil is dilated.
e The pigmented epithelial cells contain a greater degree of rough endoplasmic E The pigmented epithelial cells oppose each other base-to-apex.
reticulum than the non-pigmented epithelial cells.
o The non-pigmented epithelial basement membrane is continuous with the inter-
nal limiting membrane of the retina. 28 The lens
E Capillaries in the ciliary stroma have discontinuous walls.
A has a radius of curvature at the posterior surface of 6 mm
B anterior surface lies 3 mm from the posterior surface of the cornea
e diameter is 10 mm
24 In the ciliary body,
o is 3 mm thick in the adult
E has an epithelium made up of a bilayer of cells
A the oblique ciliary muscle fibres make up the outermost fibres of the ciliary
muscle
a ciliary muscle contains more extensive mitochondria and endoplasmic reticulum
29 Which of the following statements about the lens are true?
than normal smooth muscle
C the blood supply is derived from the continuation of the choriocapillaris
A The anterior lens capsule is thicker than the posterior capsule.
o venous drainage body is mainly by the anterior ciliary vessels
B The epithelial cells of the lens are columnar.
E parasympathetic, sympathetic and sensory innervation is received
C The foetal nucleus is made up of 'V-shaped' sutures.
o The anterior radius of curvature becomes smaller with age.
E Zonular fibres of the lens attach the capsule at the lens equator to the ciliary
25 Which of the following statements regarding the iris are true? processes of the pars phcata as well as the pars plana.

A The iris and pupillary diameters measured through the cornea are magnified by
12% . 30 In the choroid.
a The iris is thickest at the ciliary margin.
e The anterior surface of the iris is made up of a thin endothelial cell layer. A the arterial blood supply is by the anterior as well as the long and short posterior
o The stroma contains mast cells. ciliary arteries
E The stroma is rich in collagen and elastic fibres. B the short posterior ciliary arteries pierce the sclera within a 2.5 mm radius of the
F The fenestrated arterial vessels of the iris run in the stroma. optic disc
6 Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Questions 7

22 In the ciliary body, 26 In the iris,

A both pigmented and non-pigmented ciliary epitllelia are cuboidal in the young A the sphincter pupillae muscle is 1 mm wide
a the blood aqueous barrier is formed by tight junctions at the basoIateral surface a the sphincter pupillae muscle is only found at the pupillary zone
of the non-pigmented epithelial cells C the dilator pupillae is made up of striated muscle fibres
e The pigmented epithelium forms the inner layer of the ciliary epithelium o the dilator pupillae lies between the pupillary zone and the periphery of the uls
o at gap junctions, the non-pigmented epithfllial cells are separated by 2 mm clefts E the posterior pigment epithelium of the iris gives rise to the dilator pupillae
E the greatest number of ciliary epithelial gap jmctlons occur between the pig- muscle
mented and non-pigmented epithelia

27 With regard to the epithelium of the iris, which of the following are true?
23 Which of the following statements about the ciliary body are true?
A The posterior pigment epithelium is continuous with the non-pigmented epithe-
A Zonulae occludentes are not found between adjacent ciliary pigmented epithelial lium of the ciliary body.

cells.
a The anterior epithelial cells are larger than the posterior epithelial cells.
a The pigmented epithelial cells contain fewer mitochondria than the noo-pigmen- e The posterior epithelial cells are more pigmented than the anterior epithelial cells.

ted epithelial cells.

o The posterior epithelial cells are columnar when the pupil is dilated.
e The pigmented epithelial cells contain a greater degree of rough endoplasmic E The pigmented epithelial cells oppose each other base-to-apex.
reticulum than the non-pigmented epithelial cells.
o The non-pigmented epithelial basement membrane is continuous with the inter-
nal limiting membrane of the retina. 28 The lens
E Capillaries in the ciliary stroma have discontinuous walls.
A has a radius of curvature at the posterior surface of 6 mm
B anterior surface lies 3 mm from the posterior surface of the cornea
e diameter is 10 mm
24 In the ciliary body,
o is 3 mm thick in the adult
E has an epithelium made up of a bilayer of cells
A the oblique ciliary muscle fibres make up the outermost fibres of the ciliary
muscle
a ciliary muscle contains more extensive mitochondria and endoplasmic reticulum
29 Which of the following statements about the lens are true?
than normal smooth muscle
C the blood supply is derived from the continuation of the choriocapillaris
A The anterior lens capsule is thicker than the posterior capsule.
o venous drainage body is mainly by the anterior ciliary vessels
B The epithelial cells of the lens are columnar.
E parasympathetic, sympathetic and sensory innervation is received
C The foetal nucleus is made up of 'V-shaped' sutures.
o The anterior radius of curvature becomes smaller with age.
E Zonular fibres of the lens attach the capsule at the lens equator to the ciliary
25 Which of the following statements regarding the iris are true? processes of the pars phcata as well as the pars plana.

A The iris and pupillary diameters measured through the cornea are magnified by
12% . 30 In the choroid.
a The iris is thickest at the ciliary margin.
e The anterior surface of the iris is made up of a thin endothelial cell layer. A the arterial blood supply is by the anterior as well as the long and short posterior
o The stroma contains mast cells. ciliary arteries
E The stroma is rich in collagen and elastic fibres. B the short posterior ciliary arteries pierce the sclera within a 2.5 mm radius of the
F The fenestrated arterial vessels of the iris run in the stroma. optic disc
 Anatom y Questions 9
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
8
35 Which of the following statements about the retina are true?
C innervation is by the long and short ciliary nerves only
D parasyrnpathetic innervation from the facial nerve is seen A The ellipsoid is the outer portion of the photoreceptor inner segment.
E the suprachoroidal space is greatest seen at the macula B The ellipsoid is predominantly rich in rough endoplasmic reticulum.
C The outer nuclear layer lies between the external limiting membrane and the outer
plexiform layer.
D The external limiting membrane is made of up of a continuous row of zonulae
31 Regarding the choroid, which of the following are true?
occludentes.
E The outer plexiform layer lies between the outer nuclear layer and the externai
A The choroid is thickest at the equator.
limiting membrane.
B Melanocytes are most densely found in the inner layers of the choroid.
C Veins form the majority of vessels in the choroid.
D Choroidal veins are most concentrated at the macula.
E The choriocaplllaris lies sclerae! to Bruch's membrane. 36 With regard to the retina,

A ganglion cells do not exist at the !ovea or optic disc

B Muller cells extend from the external limiting lamina to the internal limiting lamina
32 In the choroid, C the internal limiting lamina is formed by a continuous row of zonulae adherentes
between Muller cell processes
A the endothelium of the arteries and arterioles is continuous D the retinal arteries are only found in the nerve fibre layer
B the choriocapillaris is lined by a single layer of smooth muscle cells E the central retinal vein lies medial to the central retinal art(l(Y at the optic disc
C Bruch's membrane forms the inner layer of the choroid F the retinal capillaries do not pass towards the sclera beyond the inner nuclear
D Bruch's membrane is continuous with the basement membrane of the retinal
layer
pigment epithelium
E Bruch's membrane is thickest anterior to the equator

37 Which of the following statements about the retina are true?

33 Regarding the retina, A Retinal capillaries consist of non-fenestrated endothelium and pericytes outside
the endothelium.
A the foveola is 3 mm from the temporal margin of the optic disc and 0.8 mm B Retinal pigment epithelial cells at the macula are taller and contain more melanin
superior to its centre than those in the retinal periphery.
B the fovea has the same diameter as the optic disc C The basement membrane of the retinal pigment epithelium is continuous with
C the retina is thinnest at the fovea that of the ciliary pigment epithelium.
D the retina is thickest at the perifoveal region D Retinal pigment epithelial cells are attached to each other at their basolateral
E rods are absent within a radius of 2.8 mm from the centre of the foveola surfaces by zonulae occludentes and zonulae adherentes.
E Retinal arteries are two-thirds to three-quarters the diameter of retinal veins.

34 In the retina,
38 The extraocular muscles: regarding the rectus muscles,
A the fovea contains one-sixtieth of the entire retinal cones
B there are approximately 120 000 000 rods A the superior rectus is the longest rectus muscle
C the cones at the foveola are not separated from each other by Muller cells B the inferior rectus is the shortest rectus muscle
D regarding the cone photoreceptor, the outer membrane of the outer segment Is C the lateral rectus has the longest tendon length
discontinuous with the discs D the medial rectus inserts into the sclera closest to the limbus
E the connecting stalk of the photoreceptor contains 10 pairs of microtubules and E the rectus muscles are each approximately 40 mm in length
no central pair
 Anatom y Questions 9
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
8
35 Which of the following statements about the retina are true?
C innervation is by the long and short ciliary nerves only
D parasyrnpathetic innervation from the facial nerve is seen A The ellipsoid is the outer portion of the photoreceptor inner segment.
E the suprachoroidal space is greatest seen at the macula B The ellipsoid is predominantly rich in rough endoplasmic reticulum.
C The outer nuclear layer lies between the external limiting membrane and the outer
plexiform layer.
D The external limiting membrane is made of up of a continuous row of zonulae
31 Regarding the choroid, which of the following are true?
occludentes.
E The outer plexiform layer lies between the outer nuclear layer and the externai
A The choroid is thickest at the equator.
limiting membrane.
B Melanocytes are most densely found in the inner layers of the choroid.
C Veins form the majority of vessels in the choroid.
D Choroidal veins are most concentrated at the macula.
E The choriocaplllaris lies sclerae! to Bruch's membrane. 36 With regard to the retina,

A ganglion cells do not exist at the !ovea or optic disc

B Muller cells extend from the external limiting lamina to the internal limiting lamina
32 In the choroid, C the internal limiting lamina is formed by a continuous row of zonulae adherentes
between Muller cell processes
A the endothelium of the arteries and arterioles is continuous D the retinal arteries are only found in the nerve fibre layer
B the choriocapillaris is lined by a single layer of smooth muscle cells E the central retinal vein lies medial to the central retinal art(l(Y at the optic disc
C Bruch's membrane forms the inner layer of the choroid F the retinal capillaries do not pass towards the sclera beyond the inner nuclear
D Bruch's membrane is continuous with the basement membrane of the retinal
layer
pigment epithelium
E Bruch's membrane is thickest anterior to the equator

37 Which of the following statements about the retina are true?

33 Regarding the retina, A Retinal capillaries consist of non-fenestrated endothelium and pericytes outside
the endothelium.
A the foveola is 3 mm from the temporal margin of the optic disc and 0.8 mm B Retinal pigment epithelial cells at the macula are taller and contain more melanin
superior to its centre than those in the retinal periphery.
B the fovea has the same diameter as the optic disc C The basement membrane of the retinal pigment epithelium is continuous with
C the retina is thinnest at the fovea that of the ciliary pigment epithelium.
D the retina is thickest at the perifoveal region D Retinal pigment epithelial cells are attached to each other at their basolateral
E rods are absent within a radius of 2.8 mm from the centre of the foveola surfaces by zonulae occludentes and zonulae adherentes.
E Retinal arteries are two-thirds to three-quarters the diameter of retinal veins.

34 In the retina,
38 The extraocular muscles: regarding the rectus muscles,
A the fovea contains one-sixtieth of the entire retinal cones
B there are approximately 120 000 000 rods A the superior rectus is the longest rectus muscle
C the cones at the foveola are not separated from each other by Muller cells B the inferior rectus is the shortest rectus muscle
D regarding the cone photoreceptor, the outer membrane of the outer segment Is C the lateral rectus has the longest tendon length
discontinuous with the discs D the medial rectus inserts into the sclera closest to the limbus
E the connecting stalk of the photoreceptor contains 10 pairs of microtubules and E the rectus muscles are each approximately 40 mm in length
no central pair
 Anatomy Questions 11
Questions
10 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatomy

43 The tributaries of the cavernous sinus include

39 Which of the following statements about the extraocular muscles are true?
A the superior ophthalmic vein
A The tendon of the superior oblique hooks through the trochlea and inserts into B the central retinal vein
the sclera 54° to the sagittal plane. C the sphenoparietal sinus
B The superior oblique passes above the superior rectus. o the pterygoid plexus
e The inferior oblique passes above the inferior rectus. E the superior petrosal sinus
o The inferior rectus sheath also inserts into the lower lid.
E The medial rectus is innervated by the superior division of the oculomotor nerve.
44 Regarding the veins,

40 With regard to the arteries and nerves serving the extraocular muscles.
A the cavernous sinus extends from the superior orbital fissure to the apex of the
petrous temporal bone
B the central retinal veln leaves the optic nerve 12.5 mm from the eyeball
A the lacrimal artery lies inferior to the lateral rectus
C the superior ophthalmic vein receives blood from the central retinal vein
B the ophthalmic artery lies superior to the medial rectus
o the inferior ophthalmic vein lies aOove the inferior rectus and communicates with
e the ophthalmic artery passes below the superior rectus
the pterygoid plexus
o the superior division of the oculomotor nerve pierces levator before terminating In
E the cavernous sinus lies medial to the trigeminal ganglion
the superior rectus
E the trochlea nerve pierces the superior oblique close to its insertion
45 Which of the following statements about the visual pathway are correct?

41 The orbital blood vessels: the ophthalmic artery A The intraorbital optic nerve is up to 30 mm long.
B The optic chiasma commonly lies 10 mm directly above the dorsum sellae.
A arises medial to the anterior clinoid process and below the optic nerve C Fibres of the inferior nasal retina are related to the posterior portion of the optic
B lies within the dural sheath throughout its course in the optic canal chiasma.
e lies medial to the ciliary ganglion in the orbital cavity o The arterial blood supply to the intracranial portion of the optic nerve is by the
o divides terminally into the medial palpable artery and the dorsal nasal artery superior hypophyseal and ophthalmic arteries.
E arises from the internal carotid artery and lies in the subdural space before E Ventromedial fibres of the optic tract correspond to the superior contraJateral
visual field.
reaching the optic canal
F Macular fibres of the retina correspond to the ventromedial fibres of the optic
F occasionally enters the orbital cavity through the superior orbital fissure
tract.

42 Which of the following statements about the orbital blood vessels are true?
46 Regarding the visual pathway.

A The central retinal artery enters the inferomedial surface of the optic nerve.
A superior retinal fibres correspond to medial cells at the lateral geniculate nucleus
B The lacrimal artery follows the lacrimal nerve in the orbital cavity above the lateral B ipsilateral temporal retinal fibres synapse in layers 2. 4 and 5 of the lateral
rectus. geniculate nucleus
e The anterior ethmoidal artery supplies the dura of the anterior fossa, anterior and C macular fibres of the retina correspond to the most medial portion of the lateral
middle ethmoidal sinuses and the frontal sinus. geniculate nucleus
o The posterlor ethmoidal artery is a branch of the naSOciliary artery. D superior retinal fibres correspond to fibres in the superior lip of the calcarine
E Anterior ciliary arteries arise from the muscular arteries. sulcus
E fibres of the optic radiation relating to the Inferior retinal quadrants are related
inferolaterally to the anterior tip of the temporal horn of the lateral ventricle
 Anatomy Questions 11
Questions
10 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatomy

43 The tributaries of the cavernous sinus include

39 Which of the following statements about the extraocular muscles are true?
A the superior ophthalmic vein
A The tendon of the superior oblique hooks through the trochlea and inserts into B the central retinal vein
the sclera 54° to the sagittal plane. C the sphenoparietal sinus
B The superior oblique passes above the superior rectus. o the pterygoid plexus
e The inferior oblique passes above the inferior rectus. E the superior petrosal sinus
o The inferior rectus sheath also inserts into the lower lid.
E The medial rectus is innervated by the superior division of the oculomotor nerve.
44 Regarding the veins,

40 With regard to the arteries and nerves serving the extraocular muscles.
A the cavernous sinus extends from the superior orbital fissure to the apex of the
petrous temporal bone
B the central retinal veln leaves the optic nerve 12.5 mm from the eyeball
A the lacrimal artery lies inferior to the lateral rectus
C the superior ophthalmic vein receives blood from the central retinal vein
B the ophthalmic artery lies superior to the medial rectus
o the inferior ophthalmic vein lies aOove the inferior rectus and communicates with
e the ophthalmic artery passes below the superior rectus
the pterygoid plexus
o the superior division of the oculomotor nerve pierces levator before terminating In
E the cavernous sinus lies medial to the trigeminal ganglion
the superior rectus
E the trochlea nerve pierces the superior oblique close to its insertion
45 Which of the following statements about the visual pathway are correct?

41 The orbital blood vessels: the ophthalmic artery A The intraorbital optic nerve is up to 30 mm long.
B The optic chiasma commonly lies 10 mm directly above the dorsum sellae.
A arises medial to the anterior clinoid process and below the optic nerve C Fibres of the inferior nasal retina are related to the posterior portion of the optic
B lies within the dural sheath throughout its course in the optic canal chiasma.
e lies medial to the ciliary ganglion in the orbital cavity o The arterial blood supply to the intracranial portion of the optic nerve is by the
o divides terminally into the medial palpable artery and the dorsal nasal artery superior hypophyseal and ophthalmic arteries.
E arises from the internal carotid artery and lies in the subdural space before E Ventromedial fibres of the optic tract correspond to the superior contraJateral
visual field.
reaching the optic canal
F Macular fibres of the retina correspond to the ventromedial fibres of the optic
F occasionally enters the orbital cavity through the superior orbital fissure
tract.

42 Which of the following statements about the orbital blood vessels are true?
46 Regarding the visual pathway.

A The central retinal artery enters the inferomedial surface of the optic nerve.
A superior retinal fibres correspond to medial cells at the lateral geniculate nucleus
B The lacrimal artery follows the lacrimal nerve in the orbital cavity above the lateral B ipsilateral temporal retinal fibres synapse in layers 2. 4 and 5 of the lateral
rectus. geniculate nucleus
e The anterior ethmoidal artery supplies the dura of the anterior fossa, anterior and C macular fibres of the retina correspond to the most medial portion of the lateral
middle ethmoidal sinuses and the frontal sinus. geniculate nucleus
o The posterlor ethmoidal artery is a branch of the naSOciliary artery. D superior retinal fibres correspond to fibres in the superior lip of the calcarine
E Anterior ciliary arteries arise from the muscular arteries. sulcus
E fibres of the optic radiation relating to the Inferior retinal quadrants are related
inferolaterally to the anterior tip of the temporal horn of the lateral ventricle
12 Anatom y QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Questions 13

47 With regard to the ventricles. o The maxillary division supplies sensory innervation to the face via the infraorbital
zygomaticofacial and zygomaticotemporal nerves only.
A the lateral wall of the third ventricle is formed by the thalamus E The buccal nerve carries sensory innervation to the cheek and is a branch of the
B the aqueduct of Sylvius is a communication between the third ventricle and each maxillary division.
lateral ventricle F The auriculotemporal nerve supplies sensory innervation to the parotid fascia.
C the only ports of exit for cerebrospinal fluid in the ventricles are the foramina of
Magendie and Luschka
D the roof of the anterior hom of the lateral ventricle is formed by the corpus 51 The abducent nerve
callosum
E the thalamus forms the medial wall of the body of the lateral ventricle A carries parasympathetic fibres
F the optic radiation! lie in the lateral wall of the posterior horn of the lateral B innervates the ipsilateral lateral rectus
ventricle C runs lateral to and parallel with the internal carotid artery in the cavernous sinus
o receives sympathetic fibres in the cavemous sinus from the internal carotid
plexus. which then leave to join the ophthalmic division of the trigeminal nerve
48 Which of the following statements about the oculomotor nerve are true? E leaves the brainstem at the lower border of the mid-brain

A The oculomotor nerve emerges from the mid-brain lateral to the cerebral
peduncles. 52 Which of the following statements about the facial nerve are true?
B Section of the third nerve causes lacrimation.
C The ciliary ganglion is enclosed in dura. A The chorda tympani carries somatic afferent innervation to the anterior two-thirds
D The oculomotor complex innervates the ipsilateral inferior rectus. medial rectus to the tongue.
and superior rectus. D The facial nerve supplies motor innervation to stapedius distal to the geniculate
E The nerve to the inferior oblique muscle is responsible for supplying myelinated ganglion.
preganglionic parasympathetic fibres to the ciliary ganglion. C The posterior auricular nerve is a branch of the facial nerve.
D The chorda tympani supplies preganglionic parasympathetic fibres to the sub-
mandibular ganglion.
E The greater petrosal nerve leaves the main facial nerve at the geniculate
49 The trochlear nerve
ganglion.
F The greater petrosal nerve carries taste fibres from both the hard and soft
A is the thinnest cranial nerve
palates.
B lies dorsomedial to the medial longitudinal fasciculus
C the IV nucleus is connected by the medial longitudinal fasciculus to the Ill. V and
VIII nuclei
53 In the face and scalp.
D supplies the contralateral superior oblique muscle
E enters the orbital cavity outside the common tendinous ring
F passes medially below levator in the orbital cavity to pierce the superior oblique A the pterygomandibular raphe consists of interdigitating fibres of buccinator and
middle constrictor
muscle
B buccinator is a muscle of mastication innervated by the mandibular division of
the trigeminal nerve
C the intemal and extemal carotid arteries anastomose at the junction of the fore-
50 Which of the following statements about the trigeminal nerve are true?
head and the temple
D terminal branches of the superficial temporal artery enter the orbit through the
A Fibres from the ophthalmic root lie ventrolaterally in the spinal tract of the
inferior orbital fissure
trigeminal nerve.
E blood vessels of the scalp run in the loose areolar tissue between the aponeuro-
B The frontal nerve is the largest branch of the ophthalmic division.
sis and the pericranium
C The trigeminal nerve is responsible for the oculocardiac reflex.
F temporalis and medial pterygoid retract the mandible
12 Anatom y QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Questions 13

47 With regard to the ventricles. o The maxillary division supplies sensory innervation to the face via the infraorbital
zygomaticofacial and zygomaticotemporal nerves only.
A the lateral wall of the third ventricle is formed by the thalamus E The buccal nerve carries sensory innervation to the cheek and is a branch of the
B the aqueduct of Sylvius is a communication between the third ventricle and each maxillary division.
lateral ventricle F The auriculotemporal nerve supplies sensory innervation to the parotid fascia.
C the only ports of exit for cerebrospinal fluid in the ventricles are the foramina of
Magendie and Luschka
D the roof of the anterior hom of the lateral ventricle is formed by the corpus 51 The abducent nerve
callosum
E the thalamus forms the medial wall of the body of the lateral ventricle A carries parasympathetic fibres
F the optic radiation! lie in the lateral wall of the posterior horn of the lateral B innervates the ipsilateral lateral rectus
ventricle C runs lateral to and parallel with the internal carotid artery in the cavernous sinus
o receives sympathetic fibres in the cavemous sinus from the internal carotid
plexus. which then leave to join the ophthalmic division of the trigeminal nerve
48 Which of the following statements about the oculomotor nerve are true? E leaves the brainstem at the lower border of the mid-brain

A The oculomotor nerve emerges from the mid-brain lateral to the cerebral
peduncles. 52 Which of the following statements about the facial nerve are true?
B Section of the third nerve causes lacrimation.
C The ciliary ganglion is enclosed in dura. A The chorda tympani carries somatic afferent innervation to the anterior two-thirds
D The oculomotor complex innervates the ipsilateral inferior rectus. medial rectus to the tongue.
and superior rectus. D The facial nerve supplies motor innervation to stapedius distal to the geniculate
E The nerve to the inferior oblique muscle is responsible for supplying myelinated ganglion.
preganglionic parasympathetic fibres to the ciliary ganglion. C The posterior auricular nerve is a branch of the facial nerve.
D The chorda tympani supplies preganglionic parasympathetic fibres to the sub-
mandibular ganglion.
E The greater petrosal nerve leaves the main facial nerve at the geniculate
49 The trochlear nerve
ganglion.
F The greater petrosal nerve carries taste fibres from both the hard and soft
A is the thinnest cranial nerve
palates.
B lies dorsomedial to the medial longitudinal fasciculus
C the IV nucleus is connected by the medial longitudinal fasciculus to the Ill. V and
VIII nuclei
53 In the face and scalp.
D supplies the contralateral superior oblique muscle
E enters the orbital cavity outside the common tendinous ring
F passes medially below levator in the orbital cavity to pierce the superior oblique A the pterygomandibular raphe consists of interdigitating fibres of buccinator and
middle constrictor
muscle
B buccinator is a muscle of mastication innervated by the mandibular division of
the trigeminal nerve
C the intemal and extemal carotid arteries anastomose at the junction of the fore-
50 Which of the following statements about the trigeminal nerve are true?
head and the temple
D terminal branches of the superficial temporal artery enter the orbit through the
A Fibres from the ophthalmic root lie ventrolaterally in the spinal tract of the
inferior orbital fissure
trigeminal nerve.
E blood vessels of the scalp run in the loose areolar tissue between the aponeuro-
B The frontal nerve is the largest branch of the ophthalmic division.
sis and the pericranium
C The trigeminal nerve is responsible for the oculocardiac reflex.
F temporalis and medial pterygoid retract the mandible
 Anatom y Questions 15
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
14
F the parotid duct pierces masseter and buccinator to open into the cheek
54 Which of the following statements about the thyroid gland are COIT9Ct? G the parotid duct opens opposite the second upper premolar tooth

A The thyroid gland lies behind the pretracheal fascia.

B The isthmus lies in front of the second, third and fourth tracheal rings.
C The inferior thyroid artery arises from the branch of the first part of subclavian
58 With regard to the cerebral vessels, which of the following statements are true? ••
artery.
D The arterial blood supplies to the upper and lower parathyroid glands are by the A The posterior cerebral artery is a branch of the internal carotid artery.
inferior thyroid artery. B The anterior communicating artery supplies the optic chiasma.
e The venous drainage of the thyroid gland is to the internal jugular vein. C The anterior cerebral artery supplies arterial blood to motor and sensory areas of
the contralateral leg, the perineum, micturition and defaecation centres.
o The circle of Willis is formed by the internal carotid and basilar arteries only.
55 The cervical sympathetic trunk E Occlusion of the middle cerebral artery may result in a contralateral weakness of
the lower portion of the face.
A lies anterior to the neck of the first rib
B runs medial to the vertebral artery in the root of the neck
C lies behind prevertebral fascia
D lies medial to the carotid sheath 59 Regarding the cerebral vessels,
E lies lateral to the vagus nerve
F section results in exophthalmos A the anterior cerebral artery passes above the optic nerve and runs in the long-
G ends at the superior cervical ganglion, which lies anterior to the lateral mass of
itudinal fissure
the atlas and axis B the posterior cerebral artery runs beneath the tentorium cerebelli
H carries preganglionic sympathetic fibres to synapse at the middle cervical gang-
C the middle cerebral artery supplies 90% of the visual cortex
lion, which lies anterior to the vertebral artery at the level of C6 vertebra.
o the posterior communicating artery is the main supply to the anterior third of the
optic radiation
56 Which of the following statements about cervical sympathetic innervation are true? E occlusion of the basilar artery results in bilateral paralysis

A Postganglionic fibres from the superior cervical ganglion are distributed to C1-4.
B Postganglionic fibres from the inferior cervical ganglion are distributed to the 60 In the cerebral vessels,
vertebral artery.
C Only the middle cervical ganglion supplies fibres to the cardiac plexus.
A the posterior cerebral artery supplies the posterior portion of the optic radiation
D The inferior and middle cervical ganglia supply fibres to the hand.
B occlusion of the posterior cerebral artery produces a contralateral homonymous
e The trachea receives sympathetiC innervation from the middle cervical ganglion.
hemianopia
C the anterior choroidal and posterior communicating arteries are the main source
57 In the parotid region, of arterial supply to the optic tract
o The middle cerebral artery is the largest branch of the intemal carotid artery
A the parotid gland is supplied by the VII nerve E The middle cerebral artery runs in the lateral sulcus
B the marginal mandibular artery emerges at the lower border of the mandible
anterior to the insertion of masseter
C the capsule of the parotid gland is derived from the investing layer of deep
cervical fascia
D the parotid duct arises from the gland deep to the branches of the facial nerve
E preauricular lymph nodes exist deep to the parotid capsule and within the parotid
gland
 Anatom y Questions 15
Anatom y Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
14
F the parotid duct pierces masseter and buccinator to open into the cheek
54 Which of the following statements about the thyroid gland are COIT9Ct? G the parotid duct opens opposite the second upper premolar tooth

A The thyroid gland lies behind the pretracheal fascia.

B The isthmus lies in front of the second, third and fourth tracheal rings.
C The inferior thyroid artery arises from the branch of the first part of subclavian
58 With regard to the cerebral vessels, which of the following statements are true? ••
artery.
D The arterial blood supplies to the upper and lower parathyroid glands are by the A The posterior cerebral artery is a branch of the internal carotid artery.
inferior thyroid artery. B The anterior communicating artery supplies the optic chiasma.
e The venous drainage of the thyroid gland is to the internal jugular vein. C The anterior cerebral artery supplies arterial blood to motor and sensory areas of
the contralateral leg, the perineum, micturition and defaecation centres.
o The circle of Willis is formed by the internal carotid and basilar arteries only.
55 The cervical sympathetic trunk E Occlusion of the middle cerebral artery may result in a contralateral weakness of
the lower portion of the face.
A lies anterior to the neck of the first rib
B runs medial to the vertebral artery in the root of the neck
C lies behind prevertebral fascia
D lies medial to the carotid sheath 59 Regarding the cerebral vessels,
E lies lateral to the vagus nerve
F section results in exophthalmos A the anterior cerebral artery passes above the optic nerve and runs in the long-
G ends at the superior cervical ganglion, which lies anterior to the lateral mass of
itudinal fissure
the atlas and axis B the posterior cerebral artery runs beneath the tentorium cerebelli
H carries preganglionic sympathetic fibres to synapse at the middle cervical gang-
C the middle cerebral artery supplies 90% of the visual cortex
lion, which lies anterior to the vertebral artery at the level of C6 vertebra.
o the posterior communicating artery is the main supply to the anterior third of the
optic radiation
56 Which of the following statements about cervical sympathetic innervation are true? E occlusion of the basilar artery results in bilateral paralysis

A Postganglionic fibres from the superior cervical ganglion are distributed to C1-4.
B Postganglionic fibres from the inferior cervical ganglion are distributed to the 60 In the cerebral vessels,
vertebral artery.
C Only the middle cervical ganglion supplies fibres to the cardiac plexus.
A the posterior cerebral artery supplies the posterior portion of the optic radiation
D The inferior and middle cervical ganglia supply fibres to the hand.
B occlusion of the posterior cerebral artery produces a contralateral homonymous
e The trachea receives sympathetiC innervation from the middle cervical ganglion.
hemianopia
C the anterior choroidal and posterior communicating arteries are the main source
57 In the parotid region, of arterial supply to the optic tract
o The middle cerebral artery is the largest branch of the intemal carotid artery
A the parotid gland is supplied by the VII nerve E The middle cerebral artery runs in the lateral sulcus
B the marginal mandibular artery emerges at the lower border of the mandible
anterior to the insertion of masseter
C the capsule of the parotid gland is derived from the investing layer of deep
cervical fascia
D the parotid duct arises from the gland deep to the branches of the facial nerve
E preauricular lymph nodes exist deep to the parotid capsule and within the parotid
gland
 Anatomy Answers 17
ANATOMY 4 A = False B = False C = True D = False E = True F = True

AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
The maxillary sinus of Highmore (seventeenth-century physician of Sherbome) lies
above the posterior five teeth (two premolars, three molars). The roots of these teeth
often protrude into the sinus. The ostium of the sinus opens into the middle meatus in
the hiatus semilunaris. The frontal sinsus drains by the infundibulum into the hiatus
1 A gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
= True B = True C = False 0 = True E = False
semilunaris of the middle meatus. The sphenoidal sinus and posterior ethmoidal sinus
lymphatic drainage is to the retropharyngeallymph nodes. The remaining sinuses drain
The lateral wall of the orbit is made up of the zygomatic bone, including the marginal to the submandibular nodes.
tubercle of Whitnall (Professor of Anatomy at McGiII University in Montreal and Bristol The paranasal sinuses arise as outbuddings of the nasal mucosa. The frontal sinus is
University) and the greater wing of the sphenoid. Anteriorty it is directly related to the the only sinus not present at birth. It may be thought of as an anterior ethmoidal air cell
temporal fossa and further back, to the middle cranial fossa. that has migrated forwards. It appears in the second year and does not reach full size
The roof of the orbit is a triangular plate consisting of the orbital part of the frontal until approximately 25 years of age. The sphenoidal sinus is related anteriorty to the
bone and the lesser wing of the sphenoid. Throughout its length, the roof is directly ethmoidal sinus and the nose, laterally to the cavernous sinus, internal carotid artery
related to the frontal nerve. The medial wall is the thinnest wall of the orbit Oess than and abducent nerve, posteriorty to the posterior cranial fossa and the pons, superiorly
0.4 mm). It consists of the frontal process of the maxilla, the lacrimal bone, the orbital
to the pituitary gland, optic nerve and chiasma and inferiorly to the pterygoid canal and
nasopharynx.
plate of the ethmoid and the body of the sphenoid.

2 A = True B = True C = True 0 = False E = False F = True 5 A = False B = True C = False D = True E = True

The direct medial relation of the medial wall of the orbit includes the nasal cavity, The main nerves to the eyelid lie with the blood vessels posterior to orbicularis in front
of the tarsal plate and orbital septum. The upper tarsal plate is between 10 and 11 mm
ethmoid sinuses and sphenoid sinus. It is posteriorly related to the optic canal. The
in height in the middle. Its lateral edge is 7 mm from the marginal tubercle of Whitnall
medial wall is also directly related to the medial rectus, superior oblique, anterior and
and the medial end is approximately 9 mm from the anterior lacrimal crest. The lower
posterior ethmoidal nerves, infratrochlear nerve and the termination of the ophthalmic
tarsal plate is 5 mm in height at the middle. Both tarsal plates are approximately 13 mm
artery. It is related anteriorly to the lacrimal sac OYingin the lacrimal fossa). The apex of wide and 1 mm thick.
the floor of the orbit is directly related above to the inferior rectus muscles. Further The medial palpebral ligament is a triangular ligament attached to the frontal process
forward the two are separated by inferior oblique as well as orbital fat. of the maxilla at the anterior lacrimal crest. It lies anterior to the lacrimal sac.
The superior orbital fissure is formed by the greater and lesser wings of the sphenoid The lateral palpebral ligament lies behind the palpebral raphe of orbicularis and
and is closed laterally by the frontal bone. It lies between the roof and the lateral wall of anterior to a lobule of the lacrimal gland and lateral check ligament.
the orbit and connects the orbital cavity with the middle cranial fossa.
The inferior orbital fissure is bounded by the greater wing of the sphenoid posteriorly,
and by the maxilla and orbital processes of the palatine bone and anterioriy. It connects 6 A = True B = False C = True D = False E = True F = True
the orbital cavity with the pterygopalatine fossa and thus the infratemporal fossa.
The optic canal lies in the lesser wing of the sphenoid and is directed forward, The orbital septum is attached along the orbital margin and marks the junction between
laterally and downwardS. periosteum and periorbita. It is continuous with the tarsal plate except where it is
pierced by fibres of levator or an extension of the inferior rectus sheath inserting into
the skin of the eyelid and border of the tarsal plate. The lateral side is superficial and
medial side deep. It lies anterior to the lateral palpebral ligament, bridges the supraor-
3 A = True B = False C = True 0 = True E = True
bital notch forming the foramen, passes anterior to the trochlea, leaves the bone briefly
and reattaches behind the posterior lacrimal crest, lacrimal sac and medial palpebral
The periorbita, or orbital periosteum, lines the orbital cavity. It is firmly attached to the
ligament but anterior to the medial check ligament.
orbital margins, sutures, fssures and foramina and the lacrimal fossa. It is loosely
The orbital septum is pierced by the lacrimal, supraorbital and supratrochlear vessels
attached to the bony surface.
 Anatomy Answers 17
ANATOMY 4 A = False B = False C = True D = False E = True F = True

AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
The maxillary sinus of Highmore (seventeenth-century physician of Sherbome) lies
above the posterior five teeth (two premolars, three molars). The roots of these teeth
often protrude into the sinus. The ostium of the sinus opens into the middle meatus in
the hiatus semilunaris. The frontal sinsus drains by the infundibulum into the hiatus
1 A gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
= True B = True C = False 0 = True E = False
semilunaris of the middle meatus. The sphenoidal sinus and posterior ethmoidal sinus
lymphatic drainage is to the retropharyngeallymph nodes. The remaining sinuses drain
The lateral wall of the orbit is made up of the zygomatic bone, including the marginal to the submandibular nodes.
tubercle of Whitnall (Professor of Anatomy at McGiII University in Montreal and Bristol The paranasal sinuses arise as outbuddings of the nasal mucosa. The frontal sinus is
University) and the greater wing of the sphenoid. Anteriorty it is directly related to the the only sinus not present at birth. It may be thought of as an anterior ethmoidal air cell
temporal fossa and further back, to the middle cranial fossa. that has migrated forwards. It appears in the second year and does not reach full size
The roof of the orbit is a triangular plate consisting of the orbital part of the frontal until approximately 25 years of age. The sphenoidal sinus is related anteriorty to the
bone and the lesser wing of the sphenoid. Throughout its length, the roof is directly ethmoidal sinus and the nose, laterally to the cavernous sinus, internal carotid artery
related to the frontal nerve. The medial wall is the thinnest wall of the orbit Oess than and abducent nerve, posteriorty to the posterior cranial fossa and the pons, superiorly
0.4 mm). It consists of the frontal process of the maxilla, the lacrimal bone, the orbital
to the pituitary gland, optic nerve and chiasma and inferiorly to the pterygoid canal and
nasopharynx.
plate of the ethmoid and the body of the sphenoid.

2 A = True B = True C = True 0 = False E = False F = True 5 A = False B = True C = False D = True E = True

The direct medial relation of the medial wall of the orbit includes the nasal cavity, The main nerves to the eyelid lie with the blood vessels posterior to orbicularis in front
of the tarsal plate and orbital septum. The upper tarsal plate is between 10 and 11 mm
ethmoid sinuses and sphenoid sinus. It is posteriorly related to the optic canal. The
in height in the middle. Its lateral edge is 7 mm from the marginal tubercle of Whitnall
medial wall is also directly related to the medial rectus, superior oblique, anterior and
and the medial end is approximately 9 mm from the anterior lacrimal crest. The lower
posterior ethmoidal nerves, infratrochlear nerve and the termination of the ophthalmic
tarsal plate is 5 mm in height at the middle. Both tarsal plates are approximately 13 mm
artery. It is related anteriorly to the lacrimal sac OYingin the lacrimal fossa). The apex of wide and 1 mm thick.
the floor of the orbit is directly related above to the inferior rectus muscles. Further The medial palpebral ligament is a triangular ligament attached to the frontal process
forward the two are separated by inferior oblique as well as orbital fat. of the maxilla at the anterior lacrimal crest. It lies anterior to the lacrimal sac.
The superior orbital fissure is formed by the greater and lesser wings of the sphenoid The lateral palpebral ligament lies behind the palpebral raphe of orbicularis and
and is closed laterally by the frontal bone. It lies between the roof and the lateral wall of anterior to a lobule of the lacrimal gland and lateral check ligament.
the orbit and connects the orbital cavity with the middle cranial fossa.
The inferior orbital fissure is bounded by the greater wing of the sphenoid posteriorly,
and by the maxilla and orbital processes of the palatine bone and anterioriy. It connects 6 A = True B = False C = True D = False E = True F = True
the orbital cavity with the pterygopalatine fossa and thus the infratemporal fossa.
The optic canal lies in the lesser wing of the sphenoid and is directed forward, The orbital septum is attached along the orbital margin and marks the junction between
laterally and downwardS. periosteum and periorbita. It is continuous with the tarsal plate except where it is
pierced by fibres of levator or an extension of the inferior rectus sheath inserting into
the skin of the eyelid and border of the tarsal plate. The lateral side is superficial and
medial side deep. It lies anterior to the lateral palpebral ligament, bridges the supraor-
3 A = True B = False C = True 0 = True E = True
bital notch forming the foramen, passes anterior to the trochlea, leaves the bone briefly
and reattaches behind the posterior lacrimal crest, lacrimal sac and medial palpebral
The periorbita, or orbital periosteum, lines the orbital cavity. It is firmly attached to the
ligament but anterior to the medial check ligament.
orbital margins, sutures, fssures and foramina and the lacrimal fossa. It is loosely
The orbital septum is pierced by the lacrimal, supraorbital and supratrochlear vessels
attached to the bony surface.
18gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers
19

and nerves, the infratrochlear nerve, the anastomosis of the angular vein and the sulcus, a shallow groove providing an entry for perforating vessels from the eyelid as
ophthalmic vein, medial palpebral arteries. fibres of levator and inferior rectus sheath. well as a trap for foreign particles.
On eversion of the eyelid, it is important to examine the sulcus in the search for
foreign bodies. Approximately half way between the anterior and posterior edges of the
lid margin is found the grey line that marks an avascular plane separating the tarsal
7 A = False B = False C = True D = False E = False F = False
plate from orbicularis. The lid may be split in this plane.

The meibomian glands lie actually in the tarsal plate but may be seen as yellow streaks
through the conjunctivae of an everted eyelid. The glands of Moll (ciliary glands) are
modified sweat glands that open either into a follicle. between two lashes or into a
9 A = True B = False C = False D = True E = False F = True
gland of leis duct. They are more numerous in the lower lid than upper. The glands of
The conjunctiva consists of a palpebral part, an orbital part and a fomix. The palpebral
Zeis are modified sebaceous glands attached to ciliary follicles. Each cilium has two
glands. Their oily secretions prevent desiccation of lashes and contribute to the tear conjunctiva is firmly adherent to the entire width of the superior tarsal plate and half the
film. lower tarsal plate. The conjunctival fomix has a superior, inferior, lateral and medial
The blood supply to the eyelids is via the medial and lateral palpebral arteries portion. The superior fornix is found 10 mm from the limbus. The inferior fornix lies
(ophthalmic and lacrimal arteries). lhese form marginal and peripheral arches that 8 mm from the limbus. The lateral fomix lies 14 mm from the limbus (extending just
run behind orbicularis and in front of the tarsal plate and pierce both orbicularis to behind the equator of the globe). The medial fornix is essentially absent due to the
presence of the caruncle and plica semilunaris.
supply structures anteriorly. and the tarsal plates to supply the palpebral conjunctiva.
The marginal arterial arch runs 3 mm from the free margin of the eyelids. The bulbar conjunctiva is separated from Tenon's capsule up to 3 mm from the
The Iymphatics of the medial third of the upper and lower eyelids (including con- timbus by loose areolar tissue. Subconjunctival vessels may be found in this space.
The conjunctiva fuses with Tenon's capsule 3 mm from the limbus.
junctiva) follow the facial vein and drain to the submandibular nodes, whereas the
lateral two-thirds drain to the preauricular and parotid nodes. The blood supply to the conjunctiva is from the palpebral arteries and the anterior
ciliary arteries (continuations of the muscular arteries). The palpebral arteries form the
marginal and peripheral arterial arches. The peripheral arterial arch of the upper lid
supplies the largest area of conjunctiva, Including the palpebral conjunctiva. the super-
8 A = True B = False C = True D = False E = False . Ior fomix and the bulbar conjunctiva up to approximately 4 mm from the limbus. The
, Inferior peripheral arterial arch is often absent. The arterial arches give rise to the
Orbicularis has three portions: an orbital, a palpebral, and a lacrimal portion. The posterior conjunctival artery. The anterior ciliary artery gives rise to the anterior con-
palpebral portion may be divided into a pretarsal muscle ~n front of the tarsal plate) junctival artery. These two anastomose at around 4 mm from the limbus. Goblet cells
and a preseptal muscle (in front of the orbital seplum). The pretarsai muscle arises from are found all over the conjunctiva and deep in the epithelium. They are most concen-
the lateral palpebral ligament and sweeps medially to insert into the medial palpebral trated inferonasally at the bulbar conjunctiva and least concentrated supra temporally in
ligament. The preseptal muscle arises from the lateral palpebral ligament and also the fornix. They are absent at the nasal and temporal bulbar conjunctiva near the
inserts into the medial palpebral ligament. Deep fibres insert into the lacrimal fascia limbus.
of the lateral wall of the lacrimal sac. These fibres are thought to be responsible for the
lacrimal sac 'vacuum effect'. The orbital portion arises from the medial orbital margin
between the supraorbital notch (superiorly) down to the margin medial to the infraorbital 10 A = False B = False C = True D = False E = False
foramen as well as the medial palpebral ligament.
Areolar tissue intervenes between the palpebral portion of orbicularis and the skin, as The lacrimal system comprises the lacrimal gland superolateral to the globe producing
well as the tarsal plate. No fat exists here. The situation reverses with regards to the tears, the lacrimal canaliculi. the lacrimal sac and nasolacrimal duct.
orbital portion of orbicularis where fat (and no areolar tissue) lies between the skin and Under basal conditions of tear production. tears are removed mainly by evaporation
the muscle. The lacrimal portion (Homer'S muscle) is in the form of a thin layer of and virtually none passes down the nasolacrimal duct which exists along with the
muscle arising from behind the lacrimal sac from the posterior lacrimal crest passing nasolacrimal sac to remove excess tears. The lacrimal gland is made up ota large
forward and lateral to the lacrimal sac before dividing into an upper and lower portion orbital portion and a smaller palpebral portion. The orbital portion rests in the lacrimal
terminating at the medial margins of the upper and lower lids. It is often thought of as a fossa and is related superiorly to the fossa (frontal bone), inferiorly to levator, its tendon
deep portion of the pretarsal muscle, part of the palpebral portion of the orbicularis. expansion and the lateral rectus, anteriorly to the orbital septum and posteriorly to the
Approximately 2 mm from the posterior edge of the lid margin lies the subtarsal orbital fat.
18gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers
19

and nerves, the infratrochlear nerve, the anastomosis of the angular vein and the sulcus, a shallow groove providing an entry for perforating vessels from the eyelid as
ophthalmic vein, medial palpebral arteries. fibres of levator and inferior rectus sheath. well as a trap for foreign particles.
On eversion of the eyelid, it is important to examine the sulcus in the search for
foreign bodies. Approximately half way between the anterior and posterior edges of the
lid margin is found the grey line that marks an avascular plane separating the tarsal
7 A = False B = False C = True D = False E = False F = False
plate from orbicularis. The lid may be split in this plane.

The meibomian glands lie actually in the tarsal plate but may be seen as yellow streaks
through the conjunctivae of an everted eyelid. The glands of Moll (ciliary glands) are
modified sweat glands that open either into a follicle. between two lashes or into a
9 A = True B = False C = False D = True E = False F = True
gland of leis duct. They are more numerous in the lower lid than upper. The glands of
The conjunctiva consists of a palpebral part, an orbital part and a fomix. The palpebral
Zeis are modified sebaceous glands attached to ciliary follicles. Each cilium has two
glands. Their oily secretions prevent desiccation of lashes and contribute to the tear conjunctiva is firmly adherent to the entire width of the superior tarsal plate and half the
film. lower tarsal plate. The conjunctival fomix has a superior, inferior, lateral and medial
The blood supply to the eyelids is via the medial and lateral palpebral arteries portion. The superior fornix is found 10 mm from the limbus. The inferior fornix lies
(ophthalmic and lacrimal arteries). lhese form marginal and peripheral arches that 8 mm from the limbus. The lateral fomix lies 14 mm from the limbus (extending just
run behind orbicularis and in front of the tarsal plate and pierce both orbicularis to behind the equator of the globe). The medial fornix is essentially absent due to the
presence of the caruncle and plica semilunaris.
supply structures anteriorly. and the tarsal plates to supply the palpebral conjunctiva.
The marginal arterial arch runs 3 mm from the free margin of the eyelids. The bulbar conjunctiva is separated from Tenon's capsule up to 3 mm from the
The Iymphatics of the medial third of the upper and lower eyelids (including con- timbus by loose areolar tissue. Subconjunctival vessels may be found in this space.
The conjunctiva fuses with Tenon's capsule 3 mm from the limbus.
junctiva) follow the facial vein and drain to the submandibular nodes, whereas the
lateral two-thirds drain to the preauricular and parotid nodes. The blood supply to the conjunctiva is from the palpebral arteries and the anterior
ciliary arteries (continuations of the muscular arteries). The palpebral arteries form the
marginal and peripheral arterial arches. The peripheral arterial arch of the upper lid
supplies the largest area of conjunctiva, Including the palpebral conjunctiva. the super-
8 A = True B = False C = True D = False E = False . Ior fomix and the bulbar conjunctiva up to approximately 4 mm from the limbus. The
, Inferior peripheral arterial arch is often absent. The arterial arches give rise to the
Orbicularis has three portions: an orbital, a palpebral, and a lacrimal portion. The posterior conjunctival artery. The anterior ciliary artery gives rise to the anterior con-
palpebral portion may be divided into a pretarsal muscle ~n front of the tarsal plate) junctival artery. These two anastomose at around 4 mm from the limbus. Goblet cells
and a preseptal muscle (in front of the orbital seplum). The pretarsai muscle arises from are found all over the conjunctiva and deep in the epithelium. They are most concen-
the lateral palpebral ligament and sweeps medially to insert into the medial palpebral trated inferonasally at the bulbar conjunctiva and least concentrated supra temporally in
ligament. The preseptal muscle arises from the lateral palpebral ligament and also the fornix. They are absent at the nasal and temporal bulbar conjunctiva near the
inserts into the medial palpebral ligament. Deep fibres insert into the lacrimal fascia limbus.
of the lateral wall of the lacrimal sac. These fibres are thought to be responsible for the
lacrimal sac 'vacuum effect'. The orbital portion arises from the medial orbital margin
between the supraorbital notch (superiorly) down to the margin medial to the infraorbital 10 A = False B = False C = True D = False E = False
foramen as well as the medial palpebral ligament.
Areolar tissue intervenes between the palpebral portion of orbicularis and the skin, as The lacrimal system comprises the lacrimal gland superolateral to the globe producing
well as the tarsal plate. No fat exists here. The situation reverses with regards to the tears, the lacrimal canaliculi. the lacrimal sac and nasolacrimal duct.
orbital portion of orbicularis where fat (and no areolar tissue) lies between the skin and Under basal conditions of tear production. tears are removed mainly by evaporation
the muscle. The lacrimal portion (Homer'S muscle) is in the form of a thin layer of and virtually none passes down the nasolacrimal duct which exists along with the
muscle arising from behind the lacrimal sac from the posterior lacrimal crest passing nasolacrimal sac to remove excess tears. The lacrimal gland is made up ota large
forward and lateral to the lacrimal sac before dividing into an upper and lower portion orbital portion and a smaller palpebral portion. The orbital portion rests in the lacrimal
terminating at the medial margins of the upper and lower lids. It is often thought of as a fossa and is related superiorly to the fossa (frontal bone), inferiorly to levator, its tendon
deep portion of the pretarsal muscle, part of the palpebral portion of the orbicularis. expansion and the lateral rectus, anteriorly to the orbital septum and posteriorly to the
Approximately 2 mm from the posterior edge of the lid margin lies the subtarsal orbital fat.
 Anatom y Answers 21
20gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

The small palpebral portion lies superolateral to the superior conjunctival fornix. It is lacrimal sac separately approximately 2.5 mm below the apex of the lacrimal sac. The
separated from the orbital portion above by levator. nonnal diameter of the canaliculus is 0.5 mm; however, it can be stretched to up to
three times its nonnal diameter.
The lacrimal canaliculi are lined by stratified squamous epithelium.
•
11 A = True B = True C = True 0 = True E = False

The lacrimal gland is surrounded by a capsule. Its masses of lobules are often sepa- 13 A = True B = True C = False 0 = False E = False F = False
rated by the surrounding orbital fat.
Approximately five ducts pass from the orbital portion through the palpebral portion
The lacrimal sac is 12 mm long and lined (as with the nasolacrimal duct) by two layers
and about six in number drain to the superior conjunctival fomix. Due to this arrange-
of columnar epithelium, the deeper being slightly flatter. It is related medially to the
ment it is seen that excision of the palpebral portion of the lacrimal gland will reduce
anterior ethmoidal air cells above and the middle meatus of the nose below. Anteriorty,
tear secretion to almost zero.
Arterial supply is mainly by the lacrimal artery but occasionally also by the infraorbital the medial palpebral ligament is related to its upper half. With regards to the surgical
artery. Venous drainage is by the corresponding vein which drains into the ophthalmic approach to the lacrimal sac, care must be taken not to approach more than 3 mm
vein. Lymphatic drainage is via the conjunctival Iymphatics to the preauricular and medial to the medial canthus as the angular vein crosses the medial palpebral ligament
parotid nodes. . approximately 8 mm medial to the medial canthus, and occasionally angular vein
The lacrimal gland receives both parasympathetic and sympathetic as well as sen- tributaries may also be found between the vein and the canthus.
sory innervation. Parasympathetic innervation arises as preganglionic fibres from the The nasolacrimal duct is 18 mm long and passes downwards, backwards and lat-
superior salivatory nucleus via the nervus intermediate and from the geniculate gang- erally. It lies lateral to the middle meatus and makes an indentation into the medial wall
lion to continue as the greater petrosal nerve passing through the petrous temporal
of the maxillary sinus.
bone and then entering a groove on its surface beneath the dura of the middle cranial
fossa and the trigeminal ganglion. Running across the foramen lacerum it is joined by
the postganglionic sympathetic fibres of the intemal carotid plexus known as the deep
petrosal nerve, and becomes the nerve of the pterygoid canal (Vidian's nerve). This
14 A = True B = False C = False 0 = True E = False

nerve passes through the pterygoid canal to reach the pterygopalatine fossa and the
preganglionic fibres synapse at the pterygopalatine ganglion. Postganglionic fibres are The eyeball lies superolaterally in the orbital cavity and anterior1y, so that one-third of
thought to either 'hitch-hike' via the zygomatic nerve zygomaticotemporal and lacrimal the globe lies in front of an imaginary plane between the medial and lateral orbital
nerve, or, as described by Ruskell, probably reach directly by a retro-orbital plexus margins. The globe consists of an anterior segment and a posterior segment. Its
through the inferior orbital fissure to the lacrimal gland. anteroposterior diameter is 24 mm and the axis passes through a point in between
Sensory innervation is by the lacrimal nerve, a branch of the ophthalmic division of the optic disc and the fovea. It may be as high as 29 mm in myopes or as low as 20 mm
the trigeminal nerve. The lesser petrosal nerve carries preganglionic parasympathetic in hypermetropes. The vertical diameter is 23 mm and is less than the horizontal
secretomotor fibres from the inferior salivary nucleus and the timpanic branch of the diameter of 23.5 mm.
glossopharyngeal nerve. It is formed at the medial wall of the middle ear and leaves by
passing up through the petrous temporal bone into the middle cranial fossa. It runs
forward beneath the dura and leaves through the foramen ovale to synapse to the otic
ganglion in the infratemporal fossa. Postganglionic parasympathetic fibres innervate
15 A = False B = False C = False 0 = False E = True

the parotid gland.

Corneal diameters are approximately 11.7 mm horizontally and 10.6 mm vertically. The
cornea has a thickness of approximately 0.5-0.6 mm in its central portion and 1 mm
12 A = True B = True C = False 0 = True E = True peripherally. The radius of curvature of the anterior surfaces is 7.8 mm and the posterior
surface 6.5 mm. The cornea is usually more curved in the vertical axis than in the
Each lacrimal punctum lies on a raised papilla; the lower punctum lies 6.5 mm from the horizontal axis. It is more curved in the central third portion and flatter peripherally. The
medial canthus and the superior punctum slightly medial at 6 mm from the medial refractive index of the comea is 1.36 and the anterior surface is largely responsible for
canthus. The lacrimal canaliculi begin at the puncta and consist of a 2 mm vertical and the power of refraction.
8 mm (upper canaliculus being slightly shorter) horizontal component. They pierce the
 Anatom y Answers 21
20gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

The small palpebral portion lies superolateral to the superior conjunctival fornix. It is lacrimal sac separately approximately 2.5 mm below the apex of the lacrimal sac. The
separated from the orbital portion above by levator. nonnal diameter of the canaliculus is 0.5 mm; however, it can be stretched to up to
three times its nonnal diameter.
The lacrimal canaliculi are lined by stratified squamous epithelium.
•
11 A = True B = True C = True 0 = True E = False

The lacrimal gland is surrounded by a capsule. Its masses of lobules are often sepa- 13 A = True B = True C = False 0 = False E = False F = False
rated by the surrounding orbital fat.
Approximately five ducts pass from the orbital portion through the palpebral portion
The lacrimal sac is 12 mm long and lined (as with the nasolacrimal duct) by two layers
and about six in number drain to the superior conjunctival fomix. Due to this arrange-
of columnar epithelium, the deeper being slightly flatter. It is related medially to the
ment it is seen that excision of the palpebral portion of the lacrimal gland will reduce
anterior ethmoidal air cells above and the middle meatus of the nose below. Anteriorty,
tear secretion to almost zero.
Arterial supply is mainly by the lacrimal artery but occasionally also by the infraorbital the medial palpebral ligament is related to its upper half. With regards to the surgical
artery. Venous drainage is by the corresponding vein which drains into the ophthalmic approach to the lacrimal sac, care must be taken not to approach more than 3 mm
vein. Lymphatic drainage is via the conjunctival Iymphatics to the preauricular and medial to the medial canthus as the angular vein crosses the medial palpebral ligament
parotid nodes. . approximately 8 mm medial to the medial canthus, and occasionally angular vein
The lacrimal gland receives both parasympathetic and sympathetic as well as sen- tributaries may also be found between the vein and the canthus.
sory innervation. Parasympathetic innervation arises as preganglionic fibres from the The nasolacrimal duct is 18 mm long and passes downwards, backwards and lat-
superior salivatory nucleus via the nervus intermediate and from the geniculate gang- erally. It lies lateral to the middle meatus and makes an indentation into the medial wall
lion to continue as the greater petrosal nerve passing through the petrous temporal
of the maxillary sinus.
bone and then entering a groove on its surface beneath the dura of the middle cranial
fossa and the trigeminal ganglion. Running across the foramen lacerum it is joined by
the postganglionic sympathetic fibres of the intemal carotid plexus known as the deep
petrosal nerve, and becomes the nerve of the pterygoid canal (Vidian's nerve). This
14 A = True B = False C = False 0 = True E = False

nerve passes through the pterygoid canal to reach the pterygopalatine fossa and the
preganglionic fibres synapse at the pterygopalatine ganglion. Postganglionic fibres are The eyeball lies superolaterally in the orbital cavity and anterior1y, so that one-third of
thought to either 'hitch-hike' via the zygomatic nerve zygomaticotemporal and lacrimal the globe lies in front of an imaginary plane between the medial and lateral orbital
nerve, or, as described by Ruskell, probably reach directly by a retro-orbital plexus margins. The globe consists of an anterior segment and a posterior segment. Its
through the inferior orbital fissure to the lacrimal gland. anteroposterior diameter is 24 mm and the axis passes through a point in between
Sensory innervation is by the lacrimal nerve, a branch of the ophthalmic division of the optic disc and the fovea. It may be as high as 29 mm in myopes or as low as 20 mm
the trigeminal nerve. The lesser petrosal nerve carries preganglionic parasympathetic in hypermetropes. The vertical diameter is 23 mm and is less than the horizontal
secretomotor fibres from the inferior salivary nucleus and the timpanic branch of the diameter of 23.5 mm.
glossopharyngeal nerve. It is formed at the medial wall of the middle ear and leaves by
passing up through the petrous temporal bone into the middle cranial fossa. It runs
forward beneath the dura and leaves through the foramen ovale to synapse to the otic
ganglion in the infratemporal fossa. Postganglionic parasympathetic fibres innervate
15 A = False B = False C = False 0 = False E = True

the parotid gland.

Corneal diameters are approximately 11.7 mm horizontally and 10.6 mm vertically. The
cornea has a thickness of approximately 0.5-0.6 mm in its central portion and 1 mm
12 A = True B = True C = False 0 = True E = True peripherally. The radius of curvature of the anterior surfaces is 7.8 mm and the posterior
surface 6.5 mm. The cornea is usually more curved in the vertical axis than in the
Each lacrimal punctum lies on a raised papilla; the lower punctum lies 6.5 mm from the horizontal axis. It is more curved in the central third portion and flatter peripherally. The
medial canthus and the superior punctum slightly medial at 6 mm from the medial refractive index of the comea is 1.36 and the anterior surface is largely responsible for
canthus. The lacrimal canaliculi begin at the puncta and consist of a 2 mm vertical and the power of refraction.
8 mm (upper canaliculus being slightly shorter) horizontal component. They pierce the
 22 Anatom y Answers 23
Anatom y Answers
16 A = TrueB = False C = False 0 = False E = True
yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA cribrosa. Elsewhere, they are arranged in a net-like fashion with a circular arrangement
anterior to the equator so that the recti interact at right-angles with the fibres at their
The epithelium is 5<Hl0 EDCBA
J .lm thick and is 10% of the corneal thickness. It is made up of a insertion. The scleral collagen is mainly of type I and type Ill. Type N collagen Is found in
stratified non-keratinized epithelium, five cell layers centrally and thickening to up to 12 the lamina cribrosa. The lamina cribrosa is the weakest part of the sclera. The sclera is
cells at the limbus. It is made up of three layers: a flat superficial layer of approximately relatively avascular and poorly innervated. The episclera, however is a highly vascular
three cells thick, attached to each other by desmosomes, a second layer of polyhedral (receiving supply from the anterior ciliary arteries) zone of loose connective tissue that
'wing' -shaped cells, and a basal layer made up of a single layer of tall columnar cells is thick anteriorly and becomes thinner towards the back of the eye.
interdigitating with one another and attached by desmosomes and hemidesmosomes
to the underlying basement membrane. It is important to note that the comea does not
possess epithelial stem cells and regeneration depends on centripetal migration from 20 A = False B = False C = True 0 = False E = False
the mitotic limbal stem cells.
Bowman's membrane is an acellular layer approximately 10 J .lm thick containing a The sclera is made up of approximately 68% water and remains opaque with values
matrix of collagen fibrils. Unlike the stroma. there are no fibroblasts in Bowman's between 40% and 80% . It becomes transparent with levels less than 40% or greater
membrane. than 80% . The inner layer of the sclera is formed by the lamina fusca formed by a thin
irregular coating of melanocytes separating the sclera from the perichoroidal space.
The long posterior ciliary arteries and nerves pierce the sclera nasally and temporarily at
17 A = True B = True C = False 0 = False E = False 3.6 mm and 3.9 mm from the optic nerve respectively. The optic nerve pierces the
sclera 3 mm medial to the mid-line and 1 mm below the horizontal meridian of the
Descemet's membrane is regarded as the endothelial basement membrane. It is globe.
between 6 and 1 0 ~Imthick and increases in thickness throughout life. It has an anterior The sclera decreases in thickness with age.
fibrillar layer and a posterior granular layer where the main growth occurs. At the limbus,
Descemet's membrane appears to be continuous with the line of Schwalbe. The
endothelial is a single layer of flat. hexagonal-shaped cells, interdigitating and also 21 A = False B = False C = True 0 = False E = False
connected with one another by tight junctions. It continues beyond the limbus as
endothelium lining the spaces of the angle. The ciliary body is continuous with the choroid and iris. It begins 1.5 mm behind the
comeosclerallimbus in the vertical meridian only (at the scleral spu" and ends 7.5-
8 mm behind the limbus on the temporal side and 6.5-7 mm behind the limbus on the
18 A = True B = True C = False 0 = True E = True nasal side. It is thus seen to be larger on the temporal side. The pars plicata has an
anteroposterior length of 2 mm and the wider pars plana has an anteroposterior length
The sclera (derived from the Greek word s k le r o s , meaning 'hard') is 1 mm thick poster- of 3.5 mm (nasally) and 4 mm (temporally).
iorty, 0.6 mm thick at the equator and 0.3 mm behind the insertions of the recti (the The pars plicata is made up of 70-80 foldS forming the ciliary process.
thickness of the tendon and muscles result in the sclera being 0.6 mm thick at the
insertion) and 0.8 mm thick near the corneoscleral limbus. The sclera is pierced by
three groups of apertures: the posterior apertures around the optic nerve transmit the 22 A = True B = False C = False 0 = False E = True
long and short ciliary nerves and vessels; the middle apertures located 4 mm behind
the equator transmit the exiting vortex veins leaving from the choroid; the anterior Both the inner non-pigmented and outer pigmented ciliary epithelia are cuboidal in the
apertures at the insertions of the recti transmit the anterior Ciliary arteries (seven in young. however. with age the non-pigmented epithelial cells become columnar. The
total). The canal of Schlemm lies within the sclera deep to the limbus and is lined by non-pigmented epithelia are attached to one another basolaterally by desmosomes
endothelium. and apicolaterally by zonulae occludentes ('tight junctions1, zonulae adherentes and
gap junctions (2 nm clefts). The apicolateral tight junctions form an important compo-
nent of the blood-aqueous barrier.
19 A = False B = True C = True 0 = False E = True The greatest number of gap junctions in the ciliary epithelium are found between
pigmented and non-pigmented cells. This allows them to function in close cooperation.
The dense, hard, fibrous sclera is made up of collagen fibrils and Irregularly arranged Other junctions between pigmented and non-pigmented epithelial cells include desmo-
elastic fibres. The fibres are arranged circumferentialy around the optic disc and lamina somes and 'modified focal zonulae adherentes' known as puncta adherentes.
 22 Anatom y Answers 23
Anatom y Answers
16 A = TrueB = False C = False 0 = False E = True
yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA cribrosa. Elsewhere, they are arranged in a net-like fashion with a circular arrangement
anterior to the equator so that the recti interact at right-angles with the fibres at their
The epithelium is 5<Hl0 EDCBA
J .lm thick and is 10% of the corneal thickness. It is made up of a insertion. The scleral collagen is mainly of type I and type Ill. Type N collagen Is found in
stratified non-keratinized epithelium, five cell layers centrally and thickening to up to 12 the lamina cribrosa. The lamina cribrosa is the weakest part of the sclera. The sclera is
cells at the limbus. It is made up of three layers: a flat superficial layer of approximately relatively avascular and poorly innervated. The episclera, however is a highly vascular
three cells thick, attached to each other by desmosomes, a second layer of polyhedral (receiving supply from the anterior ciliary arteries) zone of loose connective tissue that
'wing' -shaped cells, and a basal layer made up of a single layer of tall columnar cells is thick anteriorly and becomes thinner towards the back of the eye.
interdigitating with one another and attached by desmosomes and hemidesmosomes
to the underlying basement membrane. It is important to note that the comea does not
possess epithelial stem cells and regeneration depends on centripetal migration from 20 A = False B = False C = True 0 = False E = False
the mitotic limbal stem cells.
Bowman's membrane is an acellular layer approximately 10 J .lm thick containing a The sclera is made up of approximately 68% water and remains opaque with values
matrix of collagen fibrils. Unlike the stroma. there are no fibroblasts in Bowman's between 40% and 80% . It becomes transparent with levels less than 40% or greater
membrane. than 80% . The inner layer of the sclera is formed by the lamina fusca formed by a thin
irregular coating of melanocytes separating the sclera from the perichoroidal space.
The long posterior ciliary arteries and nerves pierce the sclera nasally and temporarily at
17 A = True B = True C = False 0 = False E = False 3.6 mm and 3.9 mm from the optic nerve respectively. The optic nerve pierces the
sclera 3 mm medial to the mid-line and 1 mm below the horizontal meridian of the
Descemet's membrane is regarded as the endothelial basement membrane. It is globe.
between 6 and 1 0 ~Imthick and increases in thickness throughout life. It has an anterior The sclera decreases in thickness with age.
fibrillar layer and a posterior granular layer where the main growth occurs. At the limbus,
Descemet's membrane appears to be continuous with the line of Schwalbe. The
endothelial is a single layer of flat. hexagonal-shaped cells, interdigitating and also 21 A = False B = False C = True 0 = False E = False
connected with one another by tight junctions. It continues beyond the limbus as
endothelium lining the spaces of the angle. The ciliary body is continuous with the choroid and iris. It begins 1.5 mm behind the
comeosclerallimbus in the vertical meridian only (at the scleral spu" and ends 7.5-
8 mm behind the limbus on the temporal side and 6.5-7 mm behind the limbus on the
18 A = True B = True C = False 0 = True E = True nasal side. It is thus seen to be larger on the temporal side. The pars plicata has an
anteroposterior length of 2 mm and the wider pars plana has an anteroposterior length
The sclera (derived from the Greek word s k le r o s , meaning 'hard') is 1 mm thick poster- of 3.5 mm (nasally) and 4 mm (temporally).
iorty, 0.6 mm thick at the equator and 0.3 mm behind the insertions of the recti (the The pars plicata is made up of 70-80 foldS forming the ciliary process.
thickness of the tendon and muscles result in the sclera being 0.6 mm thick at the
insertion) and 0.8 mm thick near the corneoscleral limbus. The sclera is pierced by
three groups of apertures: the posterior apertures around the optic nerve transmit the 22 A = True B = False C = False 0 = False E = True
long and short ciliary nerves and vessels; the middle apertures located 4 mm behind
the equator transmit the exiting vortex veins leaving from the choroid; the anterior Both the inner non-pigmented and outer pigmented ciliary epithelia are cuboidal in the
apertures at the insertions of the recti transmit the anterior Ciliary arteries (seven in young. however. with age the non-pigmented epithelial cells become columnar. The
total). The canal of Schlemm lies within the sclera deep to the limbus and is lined by non-pigmented epithelia are attached to one another basolaterally by desmosomes
endothelium. and apicolaterally by zonulae occludentes ('tight junctions1, zonulae adherentes and
gap junctions (2 nm clefts). The apicolateral tight junctions form an important compo-
nent of the blood-aqueous barrier.
19 A = False B = True C = True 0 = False E = True The greatest number of gap junctions in the ciliary epithelium are found between
pigmented and non-pigmented cells. This allows them to function in close cooperation.
The dense, hard, fibrous sclera is made up of collagen fibrils and Irregularly arranged Other junctions between pigmented and non-pigmented epithelial cells include desmo-
elastic fibres. The fibres are arranged circumferentialy around the optic disc and lamina somes and 'modified focal zonulae adherentes' known as puncta adherentes.
24gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers 2S

23 A = True B = True C = False D = True E = False 26 A = True B = True C = False 0 = True E = False

The cuboidal pigmented ciliary epithelial cells are attached to one another by gap
See notes to Anatomy Question 27.
junctions, desmosomes and puncta adherentes. No zonulae occludentes are present
and this is consistent with a lack of blood-aqueous barrier function here. Pigmented
ciliary epithelial cells contain fewer mitochondria, less rough endoplasmic reticulum
and less regular Golgi apparatus than the adjacent non-pigmented epithelial cells. Both 27 A = True B = False C = True 0 = True E = False
layers of epithelial cells have a basement membrane. The outer layer basement mem-
brane Is continuous with the basement membrane of the outer retinal layers, and the The iris (after the Greek word meaning 'rainbow'] has a diameter of 21 mm. It is divided
inner layer basement membrane is continuous with the intemal limiting membrane of by the colarette (the thickest part of the iris 2 mm from the inner pupillary margin) into
the retina. the pupillary zone and a thinner peripheral ciliary zone. The iris is made up of three
The capillary walls in the ciliary stroma are fenestrated. layers: an anterior surface, the stroma and sphincter pupillae muscle, and a posterior
layer.
The a n te r io r surface is made up of a dense compact and discontinuous arrangement
24 A = False B = True C = False D = False E = True
of fibroblasts, melanocytes and collagen. Because of its density, this layer is distinct
from the underlying stroma. The human iris does not contain an endothelial layer.
The ciliary muscle fibres form the bulk of the ciliary body and are comprised of an
The stroma contains pigmented and rion-pigmented cells including fibroblasts, mel-
outermost longitudinalEDCBA
( o r meridional) component, a middle oblique (or radiaQ compo-
nent and an inner circular or (sphincteric) part. The fibre bundles are surrounded by a anocytes, clump cells, mast cells, macrophages, Iymphocytes and extracellular matrix
sheath of fibroblasts (as opposed to collagen) and contain more abundant mitochon- of loosely arranged collagen (diameter 4()-50 nm, periodicity 50-£0 nm), protooglycans
dria and endoplasmic reticulum then normal smooth muscle. The Golgi apparatus is as well as blood vessels and nerves. The stroma does not contain elastic fibres. All
better developed. With age, dense collagen and granular material accumulates. Upo- arterial vessels, including capillaries, of the stroma have non-fenestrated endothelium.
fuscin is seen to deposit after the age of 50. The s p h in c te r p u p illa e is a flat ring of smooth muscle approximately 1 mm wide and is
The blood supply to the ciliary body is from the two long posterior Ciliary arteries and
found at the pupillary zone around the circumference of the pupil. It is surrounded by
the seven anterior ciliary arteries. These anastamose at the major arterial circle of the
collagen that also attaches it to the pupillary end of dilator pupillae.
iris behind the root of the iris and in front of the radial portion of the ciliary muscle to
The p o s te r io r la y e r is formed by the pigment epithelial cells and dilator pupillae
supply a rich plexus to the ciliary processes. Recurrent branches of the long posterior
ciliary arteries as well as 10-12 recurrent branches from the anterior ciliary arteries pass muscle. The dilator pupillae is a thin layer of myoepithelium made up of smooth muscle
back to the choroid. The ciliary body also receives muscular branches from the major and derived from the anterior pigment epithelium of the iris. It lies from the pupillary
arterial circle. zone to the periphery of the iris. The pigment epithelium of the iris is made up of a
Venous drainage is mainly by the vortex veins, but also to a small degree by the bilayer of epithelial cells lying apex-to-apex behind the stroma. The anterior pigment
anterior ciliary vessels. epithelium is continuous with the pigment epithelium of the ciliary body and lies poster-
The ciliary body contains myelinated and non-myelinated nerve fibres carrying para- ior to the stroma. The posterior epithelial cells are cuboidal and larger than the anterior
sympathetic, sympathetic and sensory innervation. The ciliary muscle and ciliary body epithelial cells. They become columnar when the pupil is dilated. They are more
receive postganglionic parasympathetic innervation from the ciliary ganglion (Via the
pigmented and contain a greater number of melanin granUles.
Edinger-Westphal nucleus and oculomotor nerve). Sympathetic fibres from both the
long ciliary nerves as well as accompanying fibres of the ciliary arteries are found
mainly in the ciliary processes as well as the ciliary muscle. The role of these is
uncertain. The role of the sensory innervation to the ciliary body is also uncertain. 28 A = True B = True C = True 0 = False E = False

The lens has an equatorial diameter of 10 mm and a thickness of 4-5 mm; however, the
latter increases with accommodation. The anterior surface lies 3 mm from the posterior
25 A = True B = False C = False D = True E = False F = False surface of the comea. The lens is made up of a capsule, epithelium, lens fibres and
zonules. The epithelium is a monolayer of cells just behind the capsule on the anterior
See notes to Anatomy Question 27.
surface of the lens.
24gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers 2S

23 A = True B = True C = False D = True E = False 26 A = True B = True C = False 0 = True E = False

The cuboidal pigmented ciliary epithelial cells are attached to one another by gap
See notes to Anatomy Question 27.
junctions, desmosomes and puncta adherentes. No zonulae occludentes are present
and this is consistent with a lack of blood-aqueous barrier function here. Pigmented
ciliary epithelial cells contain fewer mitochondria, less rough endoplasmic reticulum
and less regular Golgi apparatus than the adjacent non-pigmented epithelial cells. Both 27 A = True B = False C = True 0 = True E = False
layers of epithelial cells have a basement membrane. The outer layer basement mem-
brane Is continuous with the basement membrane of the outer retinal layers, and the The iris (after the Greek word meaning 'rainbow'] has a diameter of 21 mm. It is divided
inner layer basement membrane is continuous with the intemal limiting membrane of by the colarette (the thickest part of the iris 2 mm from the inner pupillary margin) into
the retina. the pupillary zone and a thinner peripheral ciliary zone. The iris is made up of three
The capillary walls in the ciliary stroma are fenestrated. layers: an anterior surface, the stroma and sphincter pupillae muscle, and a posterior
layer.
The a n te r io r surface is made up of a dense compact and discontinuous arrangement
24 A = False B = True C = False D = False E = True
of fibroblasts, melanocytes and collagen. Because of its density, this layer is distinct
from the underlying stroma. The human iris does not contain an endothelial layer.
The ciliary muscle fibres form the bulk of the ciliary body and are comprised of an
The stroma contains pigmented and rion-pigmented cells including fibroblasts, mel-
outermost longitudinalEDCBA
( o r meridional) component, a middle oblique (or radiaQ compo-
nent and an inner circular or (sphincteric) part. The fibre bundles are surrounded by a anocytes, clump cells, mast cells, macrophages, Iymphocytes and extracellular matrix
sheath of fibroblasts (as opposed to collagen) and contain more abundant mitochon- of loosely arranged collagen (diameter 4()-50 nm, periodicity 50-£0 nm), protooglycans
dria and endoplasmic reticulum then normal smooth muscle. The Golgi apparatus is as well as blood vessels and nerves. The stroma does not contain elastic fibres. All
better developed. With age, dense collagen and granular material accumulates. Upo- arterial vessels, including capillaries, of the stroma have non-fenestrated endothelium.
fuscin is seen to deposit after the age of 50. The s p h in c te r p u p illa e is a flat ring of smooth muscle approximately 1 mm wide and is
The blood supply to the ciliary body is from the two long posterior Ciliary arteries and
found at the pupillary zone around the circumference of the pupil. It is surrounded by
the seven anterior ciliary arteries. These anastamose at the major arterial circle of the
collagen that also attaches it to the pupillary end of dilator pupillae.
iris behind the root of the iris and in front of the radial portion of the ciliary muscle to
The p o s te r io r la y e r is formed by the pigment epithelial cells and dilator pupillae
supply a rich plexus to the ciliary processes. Recurrent branches of the long posterior
ciliary arteries as well as 10-12 recurrent branches from the anterior ciliary arteries pass muscle. The dilator pupillae is a thin layer of myoepithelium made up of smooth muscle
back to the choroid. The ciliary body also receives muscular branches from the major and derived from the anterior pigment epithelium of the iris. It lies from the pupillary
arterial circle. zone to the periphery of the iris. The pigment epithelium of the iris is made up of a
Venous drainage is mainly by the vortex veins, but also to a small degree by the bilayer of epithelial cells lying apex-to-apex behind the stroma. The anterior pigment
anterior ciliary vessels. epithelium is continuous with the pigment epithelium of the ciliary body and lies poster-
The ciliary body contains myelinated and non-myelinated nerve fibres carrying para- ior to the stroma. The posterior epithelial cells are cuboidal and larger than the anterior
sympathetic, sympathetic and sensory innervation. The ciliary muscle and ciliary body epithelial cells. They become columnar when the pupil is dilated. They are more
receive postganglionic parasympathetic innervation from the ciliary ganglion (Via the
pigmented and contain a greater number of melanin granUles.
Edinger-Westphal nucleus and oculomotor nerve). Sympathetic fibres from both the
long ciliary nerves as well as accompanying fibres of the ciliary arteries are found
mainly in the ciliary processes as well as the ciliary muscle. The role of these is
uncertain. The role of the sensory innervation to the ciliary body is also uncertain. 28 A = True B = True C = True 0 = False E = False

The lens has an equatorial diameter of 10 mm and a thickness of 4-5 mm; however, the
latter increases with accommodation. The anterior surface lies 3 mm from the posterior
25 A = True B = False C = False D = True E = False F = False surface of the comea. The lens is made up of a capsule, epithelium, lens fibres and
zonules. The epithelium is a monolayer of cells just behind the capsule on the anterior
See notes to Anatomy Question 27.
surface of the lens.
26gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers
27

29 A = TNe B = False C = TNe D = TNe E = TNe choroidal veins mainly drain into the four vortex veins and the anterior ciliary veins. The
choriocapillaris lies vitread to the layer of arteries and veins and sclerad to Bruch's
The lens capsule is an homogeneous basement membrane structure, It is thickest just in membrane.
front of and behind the equator and thinnest at the posterior pole (approximately 3 pm).
The anterior capsule is up to three times thicker than the posterior capsule.
The epithelium of the lens is made up of a monolayer of cubodial cells. 32 A = TNe B = False C = TNe D = False E = False
The lens fibres are 12 mm long, U-shaped fibres tightly packed and attached to each
other by interdigitating 'ball and socket' and 'tongue and groove' jolnts in the cortex continuous endothelial lining Is found in the arteries, arterioles and veins of the choroid.
and nucleus respectively. They form an innermost compact embryonic nucleus, fol- The choriocapillaris has fenestrated endothelial cells surrounded by basement mem-
lowed by a foetal nucleus (with V-Shaped sutures), both of which remain constant in brane and no smooth muscle. The stroma does not form a definite layer in the choroid
size after birth. Outside this lies the adult nucleus (increasing in size throughout life) and but serves as a supporting structure of connective tissue surrounding the vessels
the cortex of young enucleated fibres. (which take up the greatest volume of the choroid).
Electron microscopy has shown that zonular fibres of the lens attach the capsule at BNCh's membrane is the innermost layer of the choroid. It is said to have up to five
and around the equator to the ciliary processes of the pars plicata as well as further layers and its inner basement membrane is separated from the retinal pigment epithe-
posterioriy to a small aspect of the pars plana. lium cell membrane by a radiolucent ~one. Bruch's membrane is thickest posteriorly
The radii of curvature of both anterior and posterior surfaces decrease with age. near the disc (approximately 3 pm) and becomes thinner anteriorly (1 pm).

30 A = True B = True C = False D = TNe E = False

33 A = False B = TNe C = TNe D = TNe E = TNe
The choroid is described as having four layers: (1) suprachoroid, (2) vessel layer, (3)
The foveola lies 3 mm (two disc margins) temporal to the temporal margin of the optic
choriocapillaris layer and (4) BNch's membrane. It is made up of melanocytes, stroma
disc and 0.8 mm below the meridional plane of the centre of the optic disc. It is a
mucinous fluid, vessels and nerves.
depression containing cones only found in the centre of the fovea (1.5 mm or one disc
The arterial blood supply to the choroid is by the anterior as well as the long and
in diameter). The retina is thinnest at the fovea (0.1 mm) and thickest at the perifoveal
short posterior ciliary arteries. The 20 or so short posterior ciliary arteries pierce the
region (0.23 mm). It then gradually thins out towards the ora serrata (0.11 mm), stabiliz-
sclera mainly in the longitudinal plane more so on the temporal side within a 2.5 mm
ing at the equator.
radius of the optic disc.
The foveola is a rod-free zone and rods remain absent within a 2.8 mm radius from
The choroid is innervated by the long and short ciliary nerves and fibres from the
the centre of the foveola.
facial nerve. The long Ciliary nerves supply sensory, sympathetic and some parasym-
pathetic fibres to dilator pupillae. The short ciliary nerve also carries sensory, para-
sympathetic and some sympathetic fibres. Parasympathetic fibres in the choroid are
mainly from the Edinger-Westphal nucleus and oculomotor nerve, however, vasomotor 34 A = TNe B = TNe C = False D = False E = False
fibres from the facial nerve and pterygopalatine ganglion have also been found in the
The retina contains approximately 6.5 million cones, 100 000 of which are present in
choroid.
The suprachoroidal space is the outer layer of the choroid and is approximately the fovea, and approximately 120000 000 rods, most concentrated at the perifovea
and outside the fovea and parafovea. Cones are most concentrated in number at the
30 ~Im thick. It is least seen at the macula due the density of vessels and nerves
foveola (approximately 2500) and are packed perpendicular to the retinal surface. The
here passing from the sclera to choroid.
inner segments are separated from each other by the supporting Muller cells forming
the external limiting membrane.
One of the main differences between rods and cones is the fact that the outer
31 A = False B = False C = TNe D = False E = TNe
membrane of the rod outer segment is discontinuous with the stack of 600-1000
discs enclosed. The outer membrane of the cone outer segment is continuous with
The choroid is at its thickest at the posterior pole (0.2-{).3 mm) becoming thinner
peripherally (0.1 mm). Melanocytes are most densely found in the outer choroidal layers the discs.
The photoreceptor is made up of an outer segment and an inner segment, an outer
and decrease in density towards the inner layer. Except for the macula and adjacent
fibre separated from an inner fibre by a cell body and finally a spherule (rod) or pedicle
area to the optic disc, the majority of the vessels seen in the choroid are veins. These
26gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers
27

29 A = TNe B = False C = TNe D = TNe E = TNe choroidal veins mainly drain into the four vortex veins and the anterior ciliary veins. The
choriocapillaris lies vitread to the layer of arteries and veins and sclerad to Bruch's
The lens capsule is an homogeneous basement membrane structure, It is thickest just in membrane.
front of and behind the equator and thinnest at the posterior pole (approximately 3 pm).
The anterior capsule is up to three times thicker than the posterior capsule.
The epithelium of the lens is made up of a monolayer of cubodial cells. 32 A = TNe B = False C = TNe D = False E = False
The lens fibres are 12 mm long, U-shaped fibres tightly packed and attached to each
other by interdigitating 'ball and socket' and 'tongue and groove' jolnts in the cortex continuous endothelial lining Is found in the arteries, arterioles and veins of the choroid.
and nucleus respectively. They form an innermost compact embryonic nucleus, fol- The choriocapillaris has fenestrated endothelial cells surrounded by basement mem-
lowed by a foetal nucleus (with V-Shaped sutures), both of which remain constant in brane and no smooth muscle. The stroma does not form a definite layer in the choroid
size after birth. Outside this lies the adult nucleus (increasing in size throughout life) and but serves as a supporting structure of connective tissue surrounding the vessels
the cortex of young enucleated fibres. (which take up the greatest volume of the choroid).
Electron microscopy has shown that zonular fibres of the lens attach the capsule at BNCh's membrane is the innermost layer of the choroid. It is said to have up to five
and around the equator to the ciliary processes of the pars plicata as well as further layers and its inner basement membrane is separated from the retinal pigment epithe-
posterioriy to a small aspect of the pars plana. lium cell membrane by a radiolucent ~one. Bruch's membrane is thickest posteriorly
The radii of curvature of both anterior and posterior surfaces decrease with age. near the disc (approximately 3 pm) and becomes thinner anteriorly (1 pm).

30 A = True B = True C = False D = TNe E = False

33 A = False B = TNe C = TNe D = TNe E = TNe
The choroid is described as having four layers: (1) suprachoroid, (2) vessel layer, (3)
The foveola lies 3 mm (two disc margins) temporal to the temporal margin of the optic
choriocapillaris layer and (4) BNch's membrane. It is made up of melanocytes, stroma
disc and 0.8 mm below the meridional plane of the centre of the optic disc. It is a
mucinous fluid, vessels and nerves.
depression containing cones only found in the centre of the fovea (1.5 mm or one disc
The arterial blood supply to the choroid is by the anterior as well as the long and
in diameter). The retina is thinnest at the fovea (0.1 mm) and thickest at the perifoveal
short posterior ciliary arteries. The 20 or so short posterior ciliary arteries pierce the
region (0.23 mm). It then gradually thins out towards the ora serrata (0.11 mm), stabiliz-
sclera mainly in the longitudinal plane more so on the temporal side within a 2.5 mm
ing at the equator.
radius of the optic disc.
The foveola is a rod-free zone and rods remain absent within a 2.8 mm radius from
The choroid is innervated by the long and short ciliary nerves and fibres from the
the centre of the foveola.
facial nerve. The long Ciliary nerves supply sensory, sympathetic and some parasym-
pathetic fibres to dilator pupillae. The short ciliary nerve also carries sensory, para-
sympathetic and some sympathetic fibres. Parasympathetic fibres in the choroid are
mainly from the Edinger-Westphal nucleus and oculomotor nerve, however, vasomotor 34 A = TNe B = TNe C = False D = False E = False
fibres from the facial nerve and pterygopalatine ganglion have also been found in the
The retina contains approximately 6.5 million cones, 100 000 of which are present in
choroid.
The suprachoroidal space is the outer layer of the choroid and is approximately the fovea, and approximately 120000 000 rods, most concentrated at the perifovea
and outside the fovea and parafovea. Cones are most concentrated in number at the
30 ~Im thick. It is least seen at the macula due the density of vessels and nerves
foveola (approximately 2500) and are packed perpendicular to the retinal surface. The
here passing from the sclera to choroid.
inner segments are separated from each other by the supporting Muller cells forming
the external limiting membrane.
One of the main differences between rods and cones is the fact that the outer
31 A = False B = False C = TNe D = False E = TNe
membrane of the rod outer segment is discontinuous with the stack of 600-1000
discs enclosed. The outer membrane of the cone outer segment is continuous with
The choroid is at its thickest at the posterior pole (0.2-{).3 mm) becoming thinner
peripherally (0.1 mm). Melanocytes are most densely found in the outer choroidal layers the discs.
The photoreceptor is made up of an outer segment and an inner segment, an outer
and decrease in density towards the inner layer. Except for the macula and adjacent
fibre separated from an inner fibre by a cell body and finally a spherule (rod) or pedicle
area to the optic disc, the majority of the vessels seen in the choroid are veins. These
28 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatomy Answers 29
Anatomy Answers
(cone). The connecting stalk is an eccentrically placed 0.2 !Jm diameter modified cilium
consisting of nine pairs of microtubules with no central paIr. plexiform layer (Henle's fibre layer) and these phenomena probably account for the
darker appearance of the macula.
The basement membrane of the retinal pigment epithelium is continuous with that of •
35 A = True B = False C = True 0 = False E = False
the ciliary pigment epithelium and stops at the optic disc.
The retinal pigment epithelial cells are attached to each other at their apicolateral
The inner segment of the photoreceptor consists of an outer portion named the
surfaces by zonulae occludentes and zonulae adherentes, forming a complex that
'ellipsoid', richEDCBA
in mitochondria and an inner portion, the 'myoid', rich in components
encircles a\l apicolateral surfaces playing an important role in the blood-retinal barrier.
for protein synthesis such as rough endoplasmic reticulum, ribosomes and G o lg i
They are attached to each other at their basolateral surfaces by desmosome-like
apparatus.
Although not strictly 'layers', the retina is described as having ten layers (from attachments. Desmosomes (maculae adherentes) appear at intervals on the lateral
vitreous to sclera): (1) internal limited membrane, (2) nerve fibre layer, (3) ganglion cell surfaces of adjacent cells and form point attachments. They may be identified by their
layer, (4) in n e r plexiform layer, (5) inner nuclear layer, (6) outer plexiform layer, (7) outer characteristic electron-dense intercellular plates and tonofilarnents passing into the
nuclear layer, (8) external limited membrane, (9) photoreceptor layer (rods and cones), retinal pigment epithelium cytoplasm.
and (10) retinal pigment epithelium. Retinal arteries are two-thirds to three-quarters the diameter of retinal veins.
The outer nuclear layer of the retina' lies between the external limiting membrane and
the outer plexiform layer and consists mainly of rod and cone cell bodies as well as
in n e r and outer fibres. The external limiting membrane is a layer formed by the attach-
38 A = True B = True C = True D ='True E = True
ment of modified MUlier cell membrane with rod and cone membranes and zonulae
adherentes c r e a tin g a dense visible line without gaps. The outer plexiforril layer is
The four rectus muscles arise from the tendinous ring (of Zinn). They are each approxi-
formed by rod and cone inner fibres, synapses between photoreceptors, bipolar and
horizontal cells and also by MOller cell processes. The outer plexiform layer lies mately 40 mm in length. The superior rectus has the longest muscle length, followed by
between the inner and outer nuclear layers. the medial rectus then the lateral rectus and lastly, the inferior rectus. They run close to
the orbital wall and beyond the equator form tendons that insert into the sclera. The
lateral rectus has the longest tendon length (8.8 mm) followed by the superior rectus
36 A = True B = True C = False 0 = False E = False F = True (5.8 mm) then the inferior rectus (5.5 mm) and lastly the medial rectus (3.7 mm). The
medial rectus inserts into the sclera closest to the limbus (5.5 mm), followed by the
Ganglion cells do not exist at the fovea or optic disc. Muller cells extend from the inferior rectus (6.5 mm) then the lateral rectus (6.9 mm) and last, the superior rectus
external limiting lamina to the intemal limiting lamina. They provide intercellular sup-
port. The internal limiting lamina is formed by end feet of the MOller cells and astrocytes [1.7 mm).
and is a basement membrane covering the inner retinal surface with interactions with
vitreous body collagen fibrils.
The central retinal vein lies temporal (or latera~ to the central retinal artery at the optic 39 A = True B = False C = False D = True E = False
disc. The retinal arteries lie either vitread or sclerad to retinal veins beneath the internal
limiting membrane in either the nerve fibre layer or the ganglion cell layer. They branch The superior oblique arises above and medial to the optic canal and after a muscle
into arterioles and then capillaries that are distributed to all layers up to the inner length of approximately 32 mm becomes a tendon. One centimetre further, it hooks
nuclear layer. around the trochlea and turns back at an angle of 54° to the sagittal plane to insert into
the sclera after passing beneath the superior rectus.
The inferior oblique arises from the orbital plate at the maxilla behind the lower orbital
37 A = True B = True C = True 0 = False E = True margin and lateral to the nasolacrimal duct. It passes back at an angle of 51° to the
sagittal plane, beneath the inferior rectus to insert into the sclera.
Retinal capillaries are made of up of non-fenestrated endothelium, basement mem-
As a simple rule: the obliques pass beneath the recti.
brane and pericytes lining outside the endothelium.
A thickening of the inferior rectus sheath passes forward to insert into the lower lid
Retinal pigment epithelial cells at the macula are taller and contain more melanin than
in the retinal periphery. Xanthophyll pigment is also found at the macula In the outer and is known as the lower lid retractor.
The medial rectus is innervated by the inferior division of the oculomotor nerve.
28 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatomy Answers 29
Anatomy Answers
(cone). The connecting stalk is an eccentrically placed 0.2 !Jm diameter modified cilium
consisting of nine pairs of microtubules with no central paIr. plexiform layer (Henle's fibre layer) and these phenomena probably account for the
darker appearance of the macula.
The basement membrane of the retinal pigment epithelium is continuous with that of •
35 A = True B = False C = True 0 = False E = False
the ciliary pigment epithelium and stops at the optic disc.
The retinal pigment epithelial cells are attached to each other at their apicolateral
The inner segment of the photoreceptor consists of an outer portion named the
surfaces by zonulae occludentes and zonulae adherentes, forming a complex that
'ellipsoid', richEDCBA
in mitochondria and an inner portion, the 'myoid', rich in components
encircles a\l apicolateral surfaces playing an important role in the blood-retinal barrier.
for protein synthesis such as rough endoplasmic reticulum, ribosomes and G o lg i
They are attached to each other at their basolateral surfaces by desmosome-like
apparatus.
Although not strictly 'layers', the retina is described as having ten layers (from attachments. Desmosomes (maculae adherentes) appear at intervals on the lateral
vitreous to sclera): (1) internal limited membrane, (2) nerve fibre layer, (3) ganglion cell surfaces of adjacent cells and form point attachments. They may be identified by their
layer, (4) in n e r plexiform layer, (5) inner nuclear layer, (6) outer plexiform layer, (7) outer characteristic electron-dense intercellular plates and tonofilarnents passing into the
nuclear layer, (8) external limited membrane, (9) photoreceptor layer (rods and cones), retinal pigment epithelium cytoplasm.
and (10) retinal pigment epithelium. Retinal arteries are two-thirds to three-quarters the diameter of retinal veins.
The outer nuclear layer of the retina' lies between the external limiting membrane and
the outer plexiform layer and consists mainly of rod and cone cell bodies as well as
in n e r and outer fibres. The external limiting membrane is a layer formed by the attach-
38 A = True B = True C = True D ='True E = True
ment of modified MUlier cell membrane with rod and cone membranes and zonulae
adherentes c r e a tin g a dense visible line without gaps. The outer plexiforril layer is
The four rectus muscles arise from the tendinous ring (of Zinn). They are each approxi-
formed by rod and cone inner fibres, synapses between photoreceptors, bipolar and
horizontal cells and also by MOller cell processes. The outer plexiform layer lies mately 40 mm in length. The superior rectus has the longest muscle length, followed by
between the inner and outer nuclear layers. the medial rectus then the lateral rectus and lastly, the inferior rectus. They run close to
the orbital wall and beyond the equator form tendons that insert into the sclera. The
lateral rectus has the longest tendon length (8.8 mm) followed by the superior rectus
36 A = True B = True C = False 0 = False E = False F = True (5.8 mm) then the inferior rectus (5.5 mm) and lastly the medial rectus (3.7 mm). The
medial rectus inserts into the sclera closest to the limbus (5.5 mm), followed by the
Ganglion cells do not exist at the fovea or optic disc. Muller cells extend from the inferior rectus (6.5 mm) then the lateral rectus (6.9 mm) and last, the superior rectus
external limiting lamina to the intemal limiting lamina. They provide intercellular sup-
port. The internal limiting lamina is formed by end feet of the MOller cells and astrocytes [1.7 mm).
and is a basement membrane covering the inner retinal surface with interactions with
vitreous body collagen fibrils.
The central retinal vein lies temporal (or latera~ to the central retinal artery at the optic 39 A = True B = False C = False D = True E = False
disc. The retinal arteries lie either vitread or sclerad to retinal veins beneath the internal
limiting membrane in either the nerve fibre layer or the ganglion cell layer. They branch The superior oblique arises above and medial to the optic canal and after a muscle
into arterioles and then capillaries that are distributed to all layers up to the inner length of approximately 32 mm becomes a tendon. One centimetre further, it hooks
nuclear layer. around the trochlea and turns back at an angle of 54° to the sagittal plane to insert into
the sclera after passing beneath the superior rectus.
The inferior oblique arises from the orbital plate at the maxilla behind the lower orbital
37 A = True B = True C = True 0 = False E = True margin and lateral to the nasolacrimal duct. It passes back at an angle of 51° to the
sagittal plane, beneath the inferior rectus to insert into the sclera.
Retinal capillaries are made of up of non-fenestrated endothelium, basement mem-
As a simple rule: the obliques pass beneath the recti.
brane and pericytes lining outside the endothelium.
A thickening of the inferior rectus sheath passes forward to insert into the lower lid
Retinal pigment epithelial cells at the macula are taller and contain more melanin than
in the retinal periphery. Xanthophyll pigment is also found at the macula In the outer and is known as the lower lid retractor.
The medial rectus is innervated by the inferior division of the oculomotor nerve.
 Anatom y Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 31
30 Anatom y Answers

40 A = False B = True C = True D = False E = False the sphenoparietal sinus. It drains to the transverse sinus via the superior petrosal
sinus, the intemal jugular vein via the inferior petrosal sinus and the pterygoid plexus
The lacrimal nerve and artery lie above the lateral rectus. The ophthalmic artery passes via emissary veins passing through foramen ovale. By communication with the superior
below the superior rectus to either cross over (or under) the optic nerve. It then passes
ophthalmic vein it may also drain to the facial vein.
medial to the globe above the medial rectus. •
The superior division of the oculomotor nerve pierces (and innervates) the superior
rectus before terminating in levator. The trochlea nerve emerges from the superior
orbital fissure within the common tendinous ring and enters the superior surface of
44 A = True B = False C == True D == True E == False

the superior oblique muscle soon after, fairly close to the muscle origin (not insertion).
The cavernous sinus extends between the superior orbital fissure and the apex of the
petrous temporal bone. It is approximately 2 cm long and 1 cm wide and lies beside the

41 A = True B = True C = True D == False E = False F = True bodY of the sphenoid bone. It lies lateral to the sphenoidal sinus and hypophysis
cerebri and medial to the uncus. The trigeminal cave and ganglion lie inferoposterior
The ophthalmic artery arises from the internal carotid artery after it passes from the to the cavemous sinus.
cavernous sinus and lies medial to the anterior clinoid process and below the optic The superior ophthalmic vein receives blood from the central retinal vein. The central
nerve. It lies in the subarachnoid space and passes laterally and forwards within the retinal vein leaves the optic nerve 10 mm from the eyeball and lies in the subarachnoid
dural sheath throughout its course in the optic canal. Early on in the orbital cavity it lies space before either joining the superior ophthalmiC vein or the cavemous sinus directly.
medial to the ciliary ganglion before passing over the optic nerve (15% pass under) The inferior ophthalmic vein passes back in the orbital cavity and may be found lying
towards the medial wall 01 the orbit. It then passes forwards and divides terminally into
above the inferior rectus. It communicates via the inferior orbital fissure with the
the dorsal nasal artery and the supratrochlear artery.
pterygoid venous plexus and often communicates with the cavernous sinus via the
superior orbital fissure.
42 A = True B = True C == True D = False E == True

The central retinal artery arises from the ophthalmic artery inferolaterally to the optic neMl. 45 A = True B = True C = False 0 == True E = False F = False
It pierces the dural sheath 12.5 mm from the eyeball and crosses the subarachnoid space
below the optic nerve before piercing the Inferomedial surface of the optic nerve. The optic nerve is made up of an intraocular part (10 mm), a tortuous intraorbital part
The lacrimal artery usually arises once the ophthalmic artery leaves the optic canal. It (25-30 mm) and an intracanalicular part (5 mm) and an intracranial part (10 mm). The
runs with the lacrimal nerve on the upper border of the lateral rectus. optic chiasma measures 8 mm anteroposteriorly, 12 mm wide and 4 mm thick. It
The anterior and posterior ethmoidal arteries are branches of the ophthalmic artery.
usually lies 'post-fixed' 10 mm directly above the dorsum sellae (although may lie
The anterior ethmoidal artery (larger than the posterior ethmoidal artery) passes throUgtl
'pre-fixed' directly above the sella turcica itself).
the anterior ethmoidal canal, anterior cranial fossa and cribriform plate before passing
Nasal retinal fibres decussate at the optic chiasma. The fibres corresponding to the
beneath the nasal bone to emerge between the bone and the lateral nasal cartilage and
supply an area of the tip of the nose. It supplies the frontal sinus and anterior and inferonasal retina are related to the anterior portion of the optic chiasma. Superonasal
medial ethmoidal sinuses. Whilst In the anterior fossa it also gives off a meningeal retinal fibres are related to the posterior portion of the optic chiasma.
branch to supply the dura of the anterior cranial fossa. The arterial blood supply to the intracranial portion of the optic nerve is by its pial
The anterior ciliary arteries arise from the muscular branches of the ophthalmic artery. plexus which is supplied by the superior hypophyseal artery (from the internal carotid
Eltcept for the lateral rectus, which gives rise to one anterior ciliary artery, each rectus artery) and the ophthalmiC artery. It also receives a few branches from the anterior
muscle gives rise to two anterior ciliary arteries. cerebral artery.
The optic tract fibres correspond to the ipsilateral temporal retina and contralateral
nasal retina. These relate to the contralateral field. Inferior retinal fibres correspond to
43 A = True B = True C = True D = False E = False lateral fibres of the optic tract and superior retinal fibres correspond to medial fibres of
the optic tract. Macular fibres lie centrally and towards the lateral geniculate nucleus
The cavemous sinus receives blood from the superior and inferior ophthalmic veins, the
central retinal vein, the superficial middle cerebral vein, the inferior cerabral veins and adopt a more dorsolateral position in cross-section.
 Anatom y Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 31
30 Anatom y Answers

40 A = False B = True C = True D = False E = False the sphenoparietal sinus. It drains to the transverse sinus via the superior petrosal
sinus, the intemal jugular vein via the inferior petrosal sinus and the pterygoid plexus
The lacrimal nerve and artery lie above the lateral rectus. The ophthalmic artery passes via emissary veins passing through foramen ovale. By communication with the superior
below the superior rectus to either cross over (or under) the optic nerve. It then passes
ophthalmic vein it may also drain to the facial vein.
medial to the globe above the medial rectus. •
The superior division of the oculomotor nerve pierces (and innervates) the superior
rectus before terminating in levator. The trochlea nerve emerges from the superior
orbital fissure within the common tendinous ring and enters the superior surface of
44 A = True B = False C == True D == True E == False

the superior oblique muscle soon after, fairly close to the muscle origin (not insertion).
The cavernous sinus extends between the superior orbital fissure and the apex of the
petrous temporal bone. It is approximately 2 cm long and 1 cm wide and lies beside the

41 A = True B = True C = True D == False E = False F = True bodY of the sphenoid bone. It lies lateral to the sphenoidal sinus and hypophysis
cerebri and medial to the uncus. The trigeminal cave and ganglion lie inferoposterior
The ophthalmic artery arises from the internal carotid artery after it passes from the to the cavemous sinus.
cavernous sinus and lies medial to the anterior clinoid process and below the optic The superior ophthalmic vein receives blood from the central retinal vein. The central
nerve. It lies in the subarachnoid space and passes laterally and forwards within the retinal vein leaves the optic nerve 10 mm from the eyeball and lies in the subarachnoid
dural sheath throughout its course in the optic canal. Early on in the orbital cavity it lies space before either joining the superior ophthalmiC vein or the cavemous sinus directly.
medial to the ciliary ganglion before passing over the optic nerve (15% pass under) The inferior ophthalmic vein passes back in the orbital cavity and may be found lying
towards the medial wall 01 the orbit. It then passes forwards and divides terminally into
above the inferior rectus. It communicates via the inferior orbital fissure with the
the dorsal nasal artery and the supratrochlear artery.
pterygoid venous plexus and often communicates with the cavernous sinus via the
superior orbital fissure.
42 A = True B = True C == True D = False E == True

The central retinal artery arises from the ophthalmic artery inferolaterally to the optic neMl. 45 A = True B = True C = False 0 == True E = False F = False
It pierces the dural sheath 12.5 mm from the eyeball and crosses the subarachnoid space
below the optic nerve before piercing the Inferomedial surface of the optic nerve. The optic nerve is made up of an intraocular part (10 mm), a tortuous intraorbital part
The lacrimal artery usually arises once the ophthalmic artery leaves the optic canal. It (25-30 mm) and an intracanalicular part (5 mm) and an intracranial part (10 mm). The
runs with the lacrimal nerve on the upper border of the lateral rectus. optic chiasma measures 8 mm anteroposteriorly, 12 mm wide and 4 mm thick. It
The anterior and posterior ethmoidal arteries are branches of the ophthalmic artery.
usually lies 'post-fixed' 10 mm directly above the dorsum sellae (although may lie
The anterior ethmoidal artery (larger than the posterior ethmoidal artery) passes throUgtl
'pre-fixed' directly above the sella turcica itself).
the anterior ethmoidal canal, anterior cranial fossa and cribriform plate before passing
Nasal retinal fibres decussate at the optic chiasma. The fibres corresponding to the
beneath the nasal bone to emerge between the bone and the lateral nasal cartilage and
supply an area of the tip of the nose. It supplies the frontal sinus and anterior and inferonasal retina are related to the anterior portion of the optic chiasma. Superonasal
medial ethmoidal sinuses. Whilst In the anterior fossa it also gives off a meningeal retinal fibres are related to the posterior portion of the optic chiasma.
branch to supply the dura of the anterior cranial fossa. The arterial blood supply to the intracranial portion of the optic nerve is by its pial
The anterior ciliary arteries arise from the muscular branches of the ophthalmic artery. plexus which is supplied by the superior hypophyseal artery (from the internal carotid
Eltcept for the lateral rectus, which gives rise to one anterior ciliary artery, each rectus artery) and the ophthalmiC artery. It also receives a few branches from the anterior
muscle gives rise to two anterior ciliary arteries. cerebral artery.
The optic tract fibres correspond to the ipsilateral temporal retina and contralateral
nasal retina. These relate to the contralateral field. Inferior retinal fibres correspond to
43 A = True B = True C = True D = False E = False lateral fibres of the optic tract and superior retinal fibres correspond to medial fibres of
the optic tract. Macular fibres lie centrally and towards the lateral geniculate nucleus
The cavemous sinus receives blood from the superior and inferior ophthalmic veins, the
central retinal vein, the superficial middle cerebral vein, the inferior cerabral veins and adopt a more dorsolateral position in cross-section.
32 yxwvutsrqponmlkjihgfed omy Answers Anat Anatomy Answers
cbaZYXWVUTSRQPONM LKJIHGFEDCBA 33
46 A '" True nlc parasyrnpathetic fibres from
B '" False C = False D '" True E '" True the nerve to the inferior obliq
ue (a branch of the
oculomotor nerve).
Fibres of the ipsilateral temp The oculomotor nerve does not
oral retina synapse in layers supply the lacrim al gland and
geniculate nucleus and fibres 2. 3 and 5 of the lateral therefore section does
of the contralateral nasal retina not result in increased lacrim ation
synapse in \ayers 1. 4 .
and 6. Superior retinal fibres
correspond to the ventromed
geniculate nucleus and inferior ial portion of the lateral
retinal fibres correspond to the
dorsolateral portion.
Macular fibres correspond to a
wedge-like area in the most dorsa 49 A = True B = True C = False D = True
l portion of the lateral E = True F = False
geniculate nucleus.
The loop of Meyer refers to the The trochlear nerve is the thinn
fibres of the optic radiation (corr est cranial nerve. It enters the
esponding to the superior orbital fissure outside orbital cavity through the
inferior retinal quadrants) that the comm on tendinous ring medi
swing out furthest before tumin al to the frontal nerve.
lower lip of the calcarine sulcus. g medially to reach the In the orbital cavity the troch
As these fibres bend out. they lea nerve passes medially abov
are relatad inferolaterally superior oblique. It is the only e levator to pierce the
to the anterior tip of the temp cranial nerve to emerge from
oral hom of the lateral ventricle. the brainstem from its
It explains the superior
quadrantanopia defect seen in dorsal aspect.
temporal lobe lesions.
The IV nucleus lies in the floor
of the aqueduct (of Sylvius) in
medial to the medial longitudin the mid-brain and also
al fasciculus. Connections inclu
nucleus of the medial longitudin de the rostral interstitial
47 A = True B = False C = True al fasciculus and the medial
D '" True E = False F = True itself. connecting it to the Ill. VI longitudinal fasciculus
and VIII nuclei. Fibres from the
they pass posterioriy before emer IV nucleus decussate as
The third ventricle is a slit-like ging from the dorsal aspect of
cavity whose lateral walls are the mid-brain. The IV
receives a comm unication from formed by the thalamus. It nucleus innervates the contralate
the two lateral ventricles via ral superior oblique.
amina (of Monro) and continues the interventricular for-
caudally through the mid-brain
as the narrow aqueduct
of Sylvius. eventually arriving
at the fourth ventricle.
The fourth ventricle lies in the 50 A = True B =
pons and upper medulla. It has
a mid-line slit-like
True C = True D = True E = False F = False
aperture (the foram en of Mage
ndie) and two lateral apertures
(foramina of Luschka). These that open anterioriy Sensory fibres of the trigem inal
form the only ports of exit of nerve carrying pain and temp
cerebrosP inal fluid from somatotopically organized in erature sensation are
the ventricles. the spinal tract. Fibres from
ventrolaterally. follow ed by those the ophthalmic division lie
The lateral ventricle is described of the maxillary division and finall
as a C-shaped cavity lying in y the fibres from the
sphere. It is lined by ependyma the cerebral hemi- mandibular division lie dorsomedi
l cells and is made up of an ally. General visceral afferents
anterior. posterior and yngeal. vagus and facial nerve from the glossophar-
inferior horn as well as a body. s form a colum n adjacent and
The anterior hom is enclosed by dorsal to the spinal tract.
its roof. the fibres of the The frontal nerve is the large
st branch of the ophthalmic
corpus callosum. interm ediate sized nasociliary division follow ed by the
Inferomedially. a small aperture. nerve and lastly the smallest branc
the interventricular foram en of h. the lacrim al nerve.
the lateral ventricle with the third Monro comm unicates Stimulation of the ophthalmic
ventricle. Behind the level of this division of the trigem inal nerve
foram en lies the body may lead to the oculocardiac in ophthalmic surgery
of the lateral ventricle. Its floor reflex and an afferent vagal outpu
is the thalamus and body of the t resulting in severe
is the corpus callosum. The poste caudate nucleuS. Its roof bradycardia or even asystole.
Sensory innervation to the skin
rior horn lies above the collateral the trigem inal nerve. A useful of the face is carried by
wall is made up above by the fibres sulcus. Its medial mnem onic is LaSS IE III A Big
of forceps major (splenium of corpu Mongrel:
below by the calcar avis (form s callosum) and 1 The ophthalmic division: Lacri
ed by the calcarine sulcus). mal nerve. ~praorbital nerve
The optic radlations lie . ~upratrochlear nerve.
against the lateral wall of the !nfratrochlear nerve and !Xtem
posterior horn of the lateral ventr al nasal nerve.
icle. 2 The maxillary division: The
!nfraorbital nerve. the ~gom atico
facial nerve. ~gom atl-
cotem poral nerve.
48 A = False B '" False C = False =
3 The mandibular division: ~ricu
\Otem poral nerve. Quccal nerve
D False E = True and mental nerve.
The auriculotemporal nerve arise
The oculomotor nerve emerges s from the posterior division.
from the mid-brain medial to the middle meningeal artery and splits biiefly to enclose
Each oculomotor complex inner the cerebral peduncles. then passes back to the neck
vates the ipsilateral medial rectu auricular part of the auriculotempor of the mandible. The
inferior oblique as well as the s, Inferior rectus and al nerve innervates the skin of
contralateral superior rectus and Part of the pinna. the external the tragus. the upper
levators on both sides. ear canal and the outer surface
The ciliary ganglion is a perip of the tympanic mem -
heral ganglion lying betw een brane. The temporal part of the
lateral rectus. It is usually found the optic nerve and the auriculotemporal nerve supplies
lateral to the ophthalmic artery. the skin of the temple.
It receives preganglio-
 Anatomy Answers 33
Anatomy Answers
32 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
nlc parasyrnpathetic fibres from the nerve to the inferior oblique (a branch of the
46 A '" True B '" False C = False D '" True E '" True oculomotor nerve).
The oculomotor nerve does not supply the lacrimal gland and therefore section does
Fibres of the ipsilateral temporal retina synapse in layers 2. 3 and 5 of the lateral not result in increased lacrimation.
geniculate nucleus and fibres of the contralateral nasal retina synapse in \ayers 1. 4
and 6. Superior retinal fibres correspond to the ventromedial portion of the lateral
geniculate nucleus and inferior retinal fibres correspond to the dorsolateral portion. 49 A = True B = True C = False D = True E = True F = False
Macular fibres correspond to a wedge-like area in the most dorsal portion of the lateral
The trochlear nerve is the thinnest cranial nerve. It enters the orbital cavity through the
geniculate nucleus.
The loop of Meyer refers to the fibres of the optic radiation (corresponding to the superior orbital fissure outside the common tendinous ring medial to the frontal nerve.
inferior retinal quadrants) that swing out furthest before tuming medially to reach the In the orbital cavity the trochlea nerve passes medially above levator to pierce the
lower lip of the calcarine sulcus. As these fibres bend out. they are relatad inferolaterally superior oblique. It is the only cranial nerve to emerge from the brainstem from its
to the anterior tip of the temporal hom of the lateral ventricle. It explains the superior dorsal aspect.
The IV nucleus lies in the floor of the aqueduct (of Sylvius) in the mid-brain and also
quadrantanopia defect seen in temporal lobe lesions.
medial to the medial longitudinal fasciculus. Connections include the rostral interstitial
nucleus of the medial longitudinal fasciculus and the medial longitudinal fasciculus
itself. connecting it to the Ill. VI and VIII nuclei. Fibres from the IV nucleus decussate as
47 A = True B = False C = True D '" True E = False F = True
they pass posterioriy before emerging from the dorsal aspect of the mid-brain. The IV

The third ventricle is a slit-like cavity whose lateral walls are formed by the thalamus. It nucleus innervates the contralateral superior oblique.
receives a communication from the two lateral ventricles via the interventricular for-
amina (of Monro) and continues caudally through the mid-brain as the narrow aqueduct
of Sylvius. eventually arriving at the fourth ventricle.
50 A = True B = True C = True D = True E = False F = False
The fourth ventricle lies in the pons and upper medulla. It has a mid-line slit-like
aperture (the foramen of Magendie) and two lateral apertures that open anterioriy Sensory fibres of the trigeminal nerve carrying pain and temperature sensation are
(foramina of Luschka). These form the only ports of exit of cerebrosPinal fluid from somatotopically organized in the spinal tract. Fibres from the ophthalmic division lie
ventrolaterally. followed by those of the maxillary division and finally the fibres from the
the ventricles. mandibular division lie dorsomedially. General visceral afferents from the glossophar-
The lateral ventricle is described as a C-shaped cavity lying in the cerebral hemi-
yngeal. vagus and facial nerves form a column adjacent and dorsal to the spinal tract.
sphere. It is lined by ependymal cells and is made up of an anterior. posterior and
The frontal nerve is the largest branch of the ophthalmic division followed by the
inferior horn as well as a body. The anterior hom is enclosed by its roof. the fibres of the
intermediate sized nasociliary nerve and lastly the smallest branch. the lacrimal nerve.
corpus callosum. Stimulation of the ophthalmic division of the trigeminal nerve in ophthalmic surgery
Inferomedially. a small aperture. the interventricular foramen of Monro communicates
may lead to the oculocardiac reflex and an afferent vagal output resulting in severe
the lateral ventricle with the third ventricle. Behind the level of this foramen lies the body
bradycardia or even asystole. Sensory innervation to the skin of the face is carried by
of the lateral ventricle. Its floor is the thalamus and body of the caudate nucleuS. Its roof
the trigeminal nerve. A useful mnemonic is LaSSIE III A Big Mongrel:
is the corpus callosum. The posterior horn lies above the collateral sulcus. Its medial
wall is made up above by the fibres of forceps major (splenium of corpus callosum) and 1 The ophthalmic division: Lacrimal nerve. ~praorbital nerve. ~upratrochlear nerve.
below by the calcar avis (formed by the calcarine sulcus). The optic radlations lie !nfratrochlear nerve and !Xtemal nasal nerve.
against the lateral wall of the posterior horn of the lateral ventricle. 2 The maxillary division: The !nfraorbital nerve. the ~gomaticofacial nerve. ~gomatl-
cotemporal nerve.
3 The mandibular division: ~ricu\Otemporal nerve. Quccal nerve and mental nerve.
48 A = False B '" False C = False D = False E = True The auriculotemporal nerve arises from the posterior division. splits biiefly to enclose
the middle meningeal artery and then passes back to the neck of the mandible. The
The oculomotor nerve emerges from the mid-brain medial to the cerebral peduncles.
auricular part of the auriculotemporal nerve innervates the skin of the tragus. the upper
Each oculomotor complex innervates the ipsilateral medial rectus, Inferior rectus and
Part of the pinna. the external ear canal and the outer surface of the tympanic mem-
inferior oblique as well as the contralateral superior rectus and levators on both sides.
brane. The temporal part of the auriculotemporal nerve supplies the skin of the temple.
The ciliary ganglion is a peripheral ganglion lying between the optic nerve and the
lateral rectus. It is usually found lateral to the ophthalmic artery. It receives preganglio-
34gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers 35

Although the auriculotemporal nerve carries hitch-hiking postganglionic secretomotor 53 A = False B = False C = True 0 = False E = False F = False
fibres from the otic ganglion to the parotid gland, it does not Innervate the parotid fascia
enclosing the gland. This is innervated by the great auricular nerve (C2). The pterygomandibular raphe consists of interdigitating fibres of buccinator and super-
ior constrictor. It attaches from the pterygoid hamulus down to the mandible just above
and behind the posterior end of the mylohyoid line.
51 A = False B = True C = True 0 = True E = False Buccinator (the trumpeter's muscle) helps in retuming food from the cheek to
between the teeth. It is accessory to the muscles of mastication and is innervated by
The sixth nucleus innervates the ipsilateral lateral rectus. The abducent nerve emerges the facial nerve.
from the brainstem at the lower border of the pons. After arching over the ridge of the The arterial supply to the scalp is by the extemal carotid artery (occipital, posterior
petrous temporal bone and passing through Dorello's canal it passes through the auricular and superficial temporal arteries) and the intemal carotid artery (supraorbital
cavemous sinus lying lateral to and running parallel with the internal carotid artery. and supratrochlear). They anastomose most at the junction between the forehead and
Here it briefly receives sympathetic fibres from the intemal carotid sympathetic plexus the temple. The superficial temporal artery is a terminal branch of the extemal carotid
which then leave to join the ophthalmic division of the trigeminal nerve. This would artery. It passes up behind the temporomandibular joint, passing in front of the tragus
explain how the long ciliary nerves of the nasociliary nerve (Va) supply sympathetic and finally branches out supplying skin over the temporalis fascia A deep branch. the
innervation to the eye. middle temporal artery runs alongside t~e squamous part of the temporal bone deep to
the temporalis muscle.
The scalp is made up of five layers (SCALP): !!kin, £onnective tissue, !poneurosis,
52 A = False B = True C = True 0 = True E = True F = True !oose areolar tissue and the Q8ricranium. The anastomosing arteries lie in the connec-
tive tissue and are seen to bleed heavily in scalp lacerations due to the fact that whilst
The facial nerve is made up of a motor component and a sensory component, the embedded in dense connective tissue they are held open.
nervus intermedius (which also carries preganglionic parasympathetic efferent fibres). Ternporalis inserts into the mandible from the mandibular notch to the coronary
The greater petrosal nerve, which essentially is a branch of the nervus intermedius process. Its Jpper fibres elevate the jaw and its posterior fibres retract the jaw. Medial
portion, leaves the main facial nerve at the geniculate ganglion. It passes through the pterygoid has a deep head arising from the medial side of the lateral pterygoid plate
petrous temporal bone, beneath the temporal lobe and the underlying dura of the and fossa, and a superficial head arising from the tuberosity of the maxilla and pyr-
middle cranial fossa under the trigeminal ganglion until it is joined by the deep petrosal amidal process of the palatine bone. It inserts into the medial aspect of the angle of the
nerve (sympathetic fibres from the internal carotid plexus), now called the nerve of the mandible and acts to elevate, protract and laterally displace the mandible to the
pterygoid canal. opposite side (for chewing). Temporalis is the only muscle to retract the mandible.
Passing through the pterygoid canal it reaches the pterygopalatine fossa where the
preganglionic parasympathetic fibres synapse at the pterygopalatine ganglion. The
postganglionic parasympathetic fibres are thought to either hitch-hike along the max-
54 A = False B = True C = True 0 = True E = False
illary and the zygomatic nerve to reach the lacrimal nerve or enter via the inferior orbital
fissure in what is known as the retro-orbital plexus to supply secretomotor innervation The thyroid gland ('shield-like1 is made up of two lobes and an isthmus lying in front of
to the lacrimal gland. The special sensory taste fibres of the greater petrosal nerve as the second third and fourth tracheal rings. The gland is completely enclosed in pre-
well as some sympathetic fibres pass straight through the pterygopalatine ganglion and tracheal fascia, thus accounting for the gland moving up and down with the larynx
are distributed amongst the sensory nerves of the maxillary dlvison of the trigeminal
during swallowing.
nerve. It is by these that taste fibres are carried from the hard and soft palate. The arterial supply to the thyroid gland is by the superior and inferior thyroid arteries.
The chorda tympani is a branch of the facial nerve, once again, essentially part of the The superior thyroid artery is the first branch of the anterior aspect of the external
nervus intermedius. It receives taste innervation (not somatic sensation) from the carotid artery and descends in front of the external laryngeal nerve after giving off its
anterior two-thirds of the tongue and supplies preganglionic parasympathetic secreto-
superior laryngeal branch towards the apex of each lobe.
motor fibres to the the submandibular ganglion. Motor branches of thE! facial nerve The inferior thyroid artery is a branch of the thyrocervical trunk (a branch of the first
include On order ): nerve to stapedius, the posterior auricular nerve (to the occipital belly part of the subclavian artery) and the left rises in front of the left recurrent laryngeal
of occipitofrontalis) given off along with the muscular nerve to the posterior belly of nerve (occasionally the right runs behind the right recurrent laryngeal nerve) towards
digastric soon after emerging from the stylomastoid foramen, and finally, the temporal,
the lower pole of each gland. The interior thyroid artery is the sole arterial blood supply
zygomatlc, buccal, mandibular and cervical divisions arising beyond the pes anserinus
to the upper and lower parathyroid glands.
in the parotid gland.
The venous drainage of the thyroid gland is by the superior, middle and interior
34gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers 35

Although the auriculotemporal nerve carries hitch-hiking postganglionic secretomotor 53 A = False B = False C = True 0 = False E = False F = False
fibres from the otic ganglion to the parotid gland, it does not Innervate the parotid fascia
enclosing the gland. This is innervated by the great auricular nerve (C2). The pterygomandibular raphe consists of interdigitating fibres of buccinator and super-
ior constrictor. It attaches from the pterygoid hamulus down to the mandible just above
and behind the posterior end of the mylohyoid line.
51 A = False B = True C = True 0 = True E = False Buccinator (the trumpeter's muscle) helps in retuming food from the cheek to
between the teeth. It is accessory to the muscles of mastication and is innervated by
The sixth nucleus innervates the ipsilateral lateral rectus. The abducent nerve emerges the facial nerve.
from the brainstem at the lower border of the pons. After arching over the ridge of the The arterial supply to the scalp is by the extemal carotid artery (occipital, posterior
petrous temporal bone and passing through Dorello's canal it passes through the auricular and superficial temporal arteries) and the intemal carotid artery (supraorbital
cavemous sinus lying lateral to and running parallel with the internal carotid artery. and supratrochlear). They anastomose most at the junction between the forehead and
Here it briefly receives sympathetic fibres from the intemal carotid sympathetic plexus the temple. The superficial temporal artery is a terminal branch of the extemal carotid
which then leave to join the ophthalmic division of the trigeminal nerve. This would artery. It passes up behind the temporomandibular joint, passing in front of the tragus
explain how the long ciliary nerves of the nasociliary nerve (Va) supply sympathetic and finally branches out supplying skin over the temporalis fascia A deep branch. the
innervation to the eye. middle temporal artery runs alongside t~e squamous part of the temporal bone deep to
the temporalis muscle.
The scalp is made up of five layers (SCALP): !!kin, £onnective tissue, !poneurosis,
52 A = False B = True C = True 0 = True E = True F = True !oose areolar tissue and the Q8ricranium. The anastomosing arteries lie in the connec-
tive tissue and are seen to bleed heavily in scalp lacerations due to the fact that whilst
The facial nerve is made up of a motor component and a sensory component, the embedded in dense connective tissue they are held open.
nervus intermedius (which also carries preganglionic parasympathetic efferent fibres). Ternporalis inserts into the mandible from the mandibular notch to the coronary
The greater petrosal nerve, which essentially is a branch of the nervus intermedius process. Its Jpper fibres elevate the jaw and its posterior fibres retract the jaw. Medial
portion, leaves the main facial nerve at the geniculate ganglion. It passes through the pterygoid has a deep head arising from the medial side of the lateral pterygoid plate
petrous temporal bone, beneath the temporal lobe and the underlying dura of the and fossa, and a superficial head arising from the tuberosity of the maxilla and pyr-
middle cranial fossa under the trigeminal ganglion until it is joined by the deep petrosal amidal process of the palatine bone. It inserts into the medial aspect of the angle of the
nerve (sympathetic fibres from the internal carotid plexus), now called the nerve of the mandible and acts to elevate, protract and laterally displace the mandible to the
pterygoid canal. opposite side (for chewing). Temporalis is the only muscle to retract the mandible.
Passing through the pterygoid canal it reaches the pterygopalatine fossa where the
preganglionic parasympathetic fibres synapse at the pterygopalatine ganglion. The
postganglionic parasympathetic fibres are thought to either hitch-hike along the max-
54 A = False B = True C = True 0 = True E = False
illary and the zygomatic nerve to reach the lacrimal nerve or enter via the inferior orbital
fissure in what is known as the retro-orbital plexus to supply secretomotor innervation The thyroid gland ('shield-like1 is made up of two lobes and an isthmus lying in front of
to the lacrimal gland. The special sensory taste fibres of the greater petrosal nerve as the second third and fourth tracheal rings. The gland is completely enclosed in pre-
well as some sympathetic fibres pass straight through the pterygopalatine ganglion and tracheal fascia, thus accounting for the gland moving up and down with the larynx
are distributed amongst the sensory nerves of the maxillary dlvison of the trigeminal
during swallowing.
nerve. It is by these that taste fibres are carried from the hard and soft palate. The arterial supply to the thyroid gland is by the superior and inferior thyroid arteries.
The chorda tympani is a branch of the facial nerve, once again, essentially part of the The superior thyroid artery is the first branch of the anterior aspect of the external
nervus intermedius. It receives taste innervation (not somatic sensation) from the carotid artery and descends in front of the external laryngeal nerve after giving off its
anterior two-thirds of the tongue and supplies preganglionic parasympathetic secreto-
superior laryngeal branch towards the apex of each lobe.
motor fibres to the the submandibular ganglion. Motor branches of thE! facial nerve The inferior thyroid artery is a branch of the thyrocervical trunk (a branch of the first
include On order ): nerve to stapedius, the posterior auricular nerve (to the occipital belly part of the subclavian artery) and the left rises in front of the left recurrent laryngeal
of occipitofrontalis) given off along with the muscular nerve to the posterior belly of nerve (occasionally the right runs behind the right recurrent laryngeal nerve) towards
digastric soon after emerging from the stylomastoid foramen, and finally, the temporal,
the lower pole of each gland. The interior thyroid artery is the sole arterial blood supply
zygomatlc, buccal, mandibular and cervical divisions arising beyond the pes anserinus
to the upper and lower parathyroid glands.
in the parotid gland.
The venous drainage of the thyroid gland is by the superior, middle and interior
36 Anatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers 37

thyroid veins. The superior thyroid vein usually drains directly into the internal jugular In 'cervical sympathectomy' for excessive sweating of the hands, the second and
vein, however occasionally via the facial vein. The middle thyroid vein drains directly third thoracic ganglia are removed, thus interrupting the fibres of T2-6 reaching the
into the intemal jugular vein. The inferior thyroidEDCBA
v e in drains Into the brachiocephalic middle and inferior cervical ganglia. Fibres of T1 are able to pass via the first thoracic
vein (usually the left). ganglion (or more often the stellate ganglion) to reach the superior cervical ganglion
uninterrupted, thereby avoiding a Homer's syndrome.

55 A = True B = True C = False 0 = False E = False F = False G = True

H = True 57 A = False B = False C = True 0 = True E = True F = False G = False

The cervical sympathetic trunk carries preganglionic sympathetic fibres to synapse at The parotid gland and masseter lie In the parotid region. The facial artery (a branch of
the superior middle and inferior cervical ganglia. It continues up from the thorax and the anteromedial surface of the external carotid artery) emerges at the lower border of
passes anterior to the neck of the first rib. At this point it lies medial to the supreme the mandible, crossing the bone anterior to masseter where it is palpable. The parotid
intercostal vein (which lies medial to the superior intercostal artery followed by the first gland is mainly a serous gland surrounded by a tough fibrous capsule derived from the
thoracic nerve) ('SVAT'). The inferior cervical ganglion lies here anterior to the neck of investing layer of deep cervical fascia.
the first rib behind the start of the vertebral artery. From the anteromedial surface of th~ parotid gland emerge the five branches of the
Continuing up, the cervical sympathetic trunk runs medial to the vertebral artery in facial nerve. Deep to this emerges the parotid duct and deep to this lies the retro-
the root of the neck and lies in front of the prevertebral fascia. The middle cervical mandibular vein and the terminal branches of the extemal carotid artery (the maxillary
ganglion arises at the level of C6 vertebra medial to the carotid tubercle (of Chas- artery and the superficial temporal artery). The preauricular lymph nodes lie deep as
saignac) and anterior to the vertebral artery. well as superficial to the parotid capsule and also exist within the parotid gland itself.
Note that the vertebral artery enters the transverse foramen at the level of C6 The parotid duct is S cm long and runs forward over the surface of masseter, tuming
vertebra. In its course it lies in front of the inferior cervical ganglion and behind the inwards at its anterior border to pierce buccinator. It runs a very short course forward
middle cervical ganglion. The cervical trunk runs up behind the carotid sheath and again, deep to the mucous membrane of the cheek (creating a non-retum valve flap)
medial to the vagus nerve. It terminates at the superior cervical ganglion anterior to the before piercing the mucous membrane opposite the sacond upper molar tooth.
lateral mass of the atlas and axis. Section of the cervical sympathetic trunk results in a The parotid gland receives parasympathetic secretomotor fibres from the IX (glosso-
preganglionic Homer's syndrome with ipsilateral miosis, ptosis, anhydrosis of the face pharyngeal) nerve by way of the lesser petrosal nerve. The preganglionic fibres synapse
and enophthalmos. at the otic ganglion. Postganglionic fibres hitch-hike along the auriculotemporal nerve
to reach the parotid gland.

56 A = True B = True C = False 0 = True E = True

56 A = False B = True C = Fal3e 0 = True E = True
The superior cervical ganglion supplies postganglionic fibres to the internal and exter-
nal carotid arteries, their branches the pterygopalatine ganglion, the eye Ontemal See notes to Anatomy Question 60.
carotid plexus), the pharyngeal plexus and the submandibular and otic ganglia (external
carotid plexus). It also distributes fibres to C1-4 of the cervical plexus as well as fibres
to the cardiac plexus. 59 A = True B = False C = False 0 = False E = True
The middle cervical ganglion supplies fibres to the subclavian artery and its
branches, the inferior thyroid artery and thus to the trachea, lower larynx and upper See notes to Anatomy Question 60.
oesophagus. It also distributes fibras to CS and 6 of the cervical plexus (brachial
plexus) and the cardiac plexus.
The inferior cervical ganglion supplies fibres to the vertebral artery and its branches 60 A = True B = True C = True 0 = True E = True
(not the organs it supplies), C7 and 8 of the cervical plexus (brachial pleXus) and to the
cardiac plexus. All three cervical ganglia supply fibres to the cardiac plexus. The circle of Willis is formed by the intemal carotid and basilar arteries only. The
It is seen that the middle and inferior cervical ganglia supply sympathetic fibres to the anterior cerebral artery arises from the intemal carotid artery at the perforated sub-
upper limb (and therefore the hand). They receive preganglionic fibres from T1-6, stance and passes forward above the optic nerve. It communicates with the opposite
however the majority of fibres from T1 go to the superior cervical ganglion. side by the anterior communicating artery and from then on runs around the corpus
36 Anatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers 37

thyroid veins. The superior thyroid vein usually drains directly into the internal jugular In 'cervical sympathectomy' for excessive sweating of the hands, the second and
vein, however occasionally via the facial vein. The middle thyroid vein drains directly third thoracic ganglia are removed, thus interrupting the fibres of T2-6 reaching the
into the intemal jugular vein. The inferior thyroidEDCBA
v e in drains Into the brachiocephalic middle and inferior cervical ganglia. Fibres of T1 are able to pass via the first thoracic
vein (usually the left). ganglion (or more often the stellate ganglion) to reach the superior cervical ganglion
uninterrupted, thereby avoiding a Homer's syndrome.

55 A = True B = True C = False 0 = False E = False F = False G = True

H = True 57 A = False B = False C = True 0 = True E = True F = False G = False

The cervical sympathetic trunk carries preganglionic sympathetic fibres to synapse at The parotid gland and masseter lie In the parotid region. The facial artery (a branch of
the superior middle and inferior cervical ganglia. It continues up from the thorax and the anteromedial surface of the external carotid artery) emerges at the lower border of
passes anterior to the neck of the first rib. At this point it lies medial to the supreme the mandible, crossing the bone anterior to masseter where it is palpable. The parotid
intercostal vein (which lies medial to the superior intercostal artery followed by the first gland is mainly a serous gland surrounded by a tough fibrous capsule derived from the
thoracic nerve) ('SVAT'). The inferior cervical ganglion lies here anterior to the neck of investing layer of deep cervical fascia.
the first rib behind the start of the vertebral artery. From the anteromedial surface of th~ parotid gland emerge the five branches of the
Continuing up, the cervical sympathetic trunk runs medial to the vertebral artery in facial nerve. Deep to this emerges the parotid duct and deep to this lies the retro-
the root of the neck and lies in front of the prevertebral fascia. The middle cervical mandibular vein and the terminal branches of the extemal carotid artery (the maxillary
ganglion arises at the level of C6 vertebra medial to the carotid tubercle (of Chas- artery and the superficial temporal artery). The preauricular lymph nodes lie deep as
saignac) and anterior to the vertebral artery. well as superficial to the parotid capsule and also exist within the parotid gland itself.
Note that the vertebral artery enters the transverse foramen at the level of C6 The parotid duct is S cm long and runs forward over the surface of masseter, tuming
vertebra. In its course it lies in front of the inferior cervical ganglion and behind the inwards at its anterior border to pierce buccinator. It runs a very short course forward
middle cervical ganglion. The cervical trunk runs up behind the carotid sheath and again, deep to the mucous membrane of the cheek (creating a non-retum valve flap)
medial to the vagus nerve. It terminates at the superior cervical ganglion anterior to the before piercing the mucous membrane opposite the sacond upper molar tooth.
lateral mass of the atlas and axis. Section of the cervical sympathetic trunk results in a The parotid gland receives parasympathetic secretomotor fibres from the IX (glosso-
preganglionic Homer's syndrome with ipsilateral miosis, ptosis, anhydrosis of the face pharyngeal) nerve by way of the lesser petrosal nerve. The preganglionic fibres synapse
and enophthalmos. at the otic ganglion. Postganglionic fibres hitch-hike along the auriculotemporal nerve
to reach the parotid gland.

56 A = True B = True C = False 0 = True E = True

56 A = False B = True C = Fal3e 0 = True E = True
The superior cervical ganglion supplies postganglionic fibres to the internal and exter-
nal carotid arteries, their branches the pterygopalatine ganglion, the eye Ontemal See notes to Anatomy Question 60.
carotid plexus), the pharyngeal plexus and the submandibular and otic ganglia (external
carotid plexus). It also distributes fibres to C1-4 of the cervical plexus as well as fibres
to the cardiac plexus. 59 A = True B = False C = False 0 = False E = True
The middle cervical ganglion supplies fibres to the subclavian artery and its
branches, the inferior thyroid artery and thus to the trachea, lower larynx and upper See notes to Anatomy Question 60.
oesophagus. It also distributes fibras to CS and 6 of the cervical plexus (brachial
plexus) and the cardiac plexus.
The inferior cervical ganglion supplies fibres to the vertebral artery and its branches 60 A = True B = True C = True 0 = True E = True
(not the organs it supplies), C7 and 8 of the cervical plexus (brachial pleXus) and to the
cardiac plexus. All three cervical ganglia supply fibres to the cardiac plexus. The circle of Willis is formed by the intemal carotid and basilar arteries only. The
It is seen that the middle and inferior cervical ganglia supply sympathetic fibres to the anterior cerebral artery arises from the intemal carotid artery at the perforated sub-
upper limb (and therefore the hand). They receive preganglionic fibres from T1-6, stance and passes forward above the optic nerve. It communicates with the opposite
however the majority of fibres from T1 go to the superior cervical ganglion. side by the anterior communicating artery and from then on runs around the corpus
38gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers
39
callosum in the longitudinal fissure. The anterior cerebral artery supplies the corpus
and left posterior cerebral arteries. It gives off pontine arteries to the pons, a labyr-
callosum, the medial surface of hemisphere as far back as the parieto-occipital sulcus,
septum pellucidum, the anterior part of the putamen, the head of the caudate nucleus, inthine artery to the internal ear, the anterior inferior cerebellar artery supplying the
the orbital surface of the frontal lobe Oncluding the olfactory lobe) part of the chiasma anterolateral area of the inferior surface of the cerebellum and Infamlateral portion of
and the intracranial portion of the optic nerve. the pons, the superior cerebellar arteries supplying the superior cerebellar surface and
The anterior communicating artery is approximately 4 mm in length and lies ante- the pons, and finally the posterior cerebral arteries.
rosuperior to the optic chiasma. It connects the two anterior cerebral arteries in the The pons is mainly SUpplied by the pontine branches of the basilar artery and
longitudinal fissure. Its branches supply the optic chiasma, lamina terminalis and the occlusion of the basilar artery may affect bilateral motor pathways causing bilateral
hypothalamus. The optic chiasma receives biood from a pial plexus whose main supr Iy
paralysis as well as other more common bulbar signs. The arterial supply to the optic
are the superior hypophyseal branches of the internal carotid artery, the internal carotid
tract is by branches from the anterior choroidal and POsterior communicating arteries.
artery itself, the anterior cerebral artery, the anterior communicating artery and the
middle cerebral and posterior communicating arteries ('providing a few twigs1 to its
The optic radiation is supplied by the anterior choroidal arteryEDCBA
(a n te rio rly ) and posterior

inferior surface. cerebral artery (posteriorly) as well as deep branches from the middle cerebral artery.
The middle cerebral artery is the largest branch of the internal carotid artery. It runs
laterally into the lateral sulcus before qividing into branches on the insula. The middle
cerebral artery supplies the lateral aspect of the hemisphere except for a strip at the
upper border supplied by the anterior cerebral artery and a strip at the lower border
supplied by the posterior cerebral artery. It gives off striate arteries that pass at the base
of the external capsule and supply the caudate and lentifonn nuclei. It also supplies a
few small branches to the optic chiasma. anterior optic tract and optic radiations. It
contributes to the supply of the macula portion of the visual cortex by anastomosing
with calcarine branches of the posterior cerebral artery. This gives rise to the phenom-
enon of 'macula sparing' with occlusion of the posterior cerebral artery causing a
contralateral hemianopia and intact macula. Occlusion of the middle cerebral artery
results in complete contralateral hemiplegia Oncluding an upper motor neurone facial
weakness affecting the contralateral lower face only), hemianaesthesia and aphasia (rf
the lesion affects the dominant hemisphere).
The posterior cerebral artery is a branch of the basilar artery and is fonned by its
bifurcation at the upper border of the pons. It passes around the inferior border of the
cerebral peduncle and runs below the optic tract and above and parallel to the superior
cerebellar artery. It passes above the tentorium cerebelli to supply the inferior surfaces
of the temporal and occipital lobes. It supplies the posteromedial aspect of the lateral
geniculate nucleus, the posterior two-thirds of the optic radiation and almost all of the

-
visual cortex except for an anastomosis with the middle cerebral artery over the
macular area at the occipital pole. Occlusion of the posterior cerebral artery produces
a contralateral homonymous hemianopia, possibly with macula sparing and hemia-
naesthesia (posterior limb of internal capsule).
The posterior communicating artery arises from the internal carotid artery and runs
back parallel with and above the oculomotor nerve to anastomose with the posterior
cerebral artery. Its branches pierce the posterior perforated substance to supply the
thalamus and the posterior limb of the internal capsule. It also supplies the anterior third
of the optic tract (with the anterior choroidal artery supplying the posterior two-thirds)
and gives a few smali branches to the optic chiasma.
The basilar artery is formed at the lower border of the pons by the junction of the right
and left vertebral arteries and bifurcates at the upper border of the pons into the right
38gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAAnatom y AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Anatom y Answers
39
callosum in the longitudinal fissure. The anterior cerebral artery supplies the corpus
and left posterior cerebral arteries. It gives off pontine arteries to the pons, a labyr-
callosum, the medial surface of hemisphere as far back as the parieto-occipital sulcus,
septum pellucidum, the anterior part of the putamen, the head of the caudate nucleus, inthine artery to the internal ear, the anterior inferior cerebellar artery supplying the
the orbital surface of the frontal lobe Oncluding the olfactory lobe) part of the chiasma anterolateral area of the inferior surface of the cerebellum and Infamlateral portion of
and the intracranial portion of the optic nerve. the pons, the superior cerebellar arteries supplying the superior cerebellar surface and
The anterior communicating artery is approximately 4 mm in length and lies ante- the pons, and finally the posterior cerebral arteries.
rosuperior to the optic chiasma. It connects the two anterior cerebral arteries in the The pons is mainly SUpplied by the pontine branches of the basilar artery and
longitudinal fissure. Its branches supply the optic chiasma, lamina terminalis and the occlusion of the basilar artery may affect bilateral motor pathways causing bilateral
hypothalamus. The optic chiasma receives biood from a pial plexus whose main supr Iy
paralysis as well as other more common bulbar signs. The arterial supply to the optic
are the superior hypophyseal branches of the internal carotid artery, the internal carotid
tract is by branches from the anterior choroidal and POsterior communicating arteries.
artery itself, the anterior cerebral artery, the anterior communicating artery and the
middle cerebral and posterior communicating arteries ('providing a few twigs1 to its
The optic radiation is supplied by the anterior choroidal arteryEDCBA
(a n te rio rly ) and posterior

inferior surface. cerebral artery (posteriorly) as well as deep branches from the middle cerebral artery.
The middle cerebral artery is the largest branch of the internal carotid artery. It runs
laterally into the lateral sulcus before qividing into branches on the insula. The middle
cerebral artery supplies the lateral aspect of the hemisphere except for a strip at the
upper border supplied by the anterior cerebral artery and a strip at the lower border
supplied by the posterior cerebral artery. It gives off striate arteries that pass at the base
of the external capsule and supply the caudate and lentifonn nuclei. It also supplies a
few small branches to the optic chiasma. anterior optic tract and optic radiations. It
contributes to the supply of the macula portion of the visual cortex by anastomosing
with calcarine branches of the posterior cerebral artery. This gives rise to the phenom-
enon of 'macula sparing' with occlusion of the posterior cerebral artery causing a
contralateral hemianopia and intact macula. Occlusion of the middle cerebral artery
results in complete contralateral hemiplegia Oncluding an upper motor neurone facial
weakness affecting the contralateral lower face only), hemianaesthesia and aphasia (rf
the lesion affects the dominant hemisphere).
The posterior cerebral artery is a branch of the basilar artery and is fonned by its
bifurcation at the upper border of the pons. It passes around the inferior border of the
cerebral peduncle and runs below the optic tract and above and parallel to the superior
cerebellar artery. It passes above the tentorium cerebelli to supply the inferior surfaces
of the temporal and occipital lobes. It supplies the posteromedial aspect of the lateral
geniculate nucleus, the posterior two-thirds of the optic radiation and almost all of the

-
visual cortex except for an anastomosis with the middle cerebral artery over the
macular area at the occipital pole. Occlusion of the posterior cerebral artery produces
a contralateral homonymous hemianopia, possibly with macula sparing and hemia-
naesthesia (posterior limb of internal capsule).
The posterior communicating artery arises from the internal carotid artery and runs
back parallel with and above the oculomotor nerve to anastomose with the posterior
cerebral artery. Its branches pierce the posterior perforated substance to supply the
thalamus and the posterior limb of the internal capsule. It also supplies the anterior third
of the optic tract (with the anterior choroidal artery supplying the posterior two-thirds)
and gives a few smali branches to the optic chiasma.
The basilar artery is formed at the lower border of the pons by the junction of the right
and left vertebral arteries and bifurcates at the upper border of the pons into the right
 Physiology Questions 41
PHYSIOLOGY
4 aaroreceptors
QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
A are all in the arterial circulation
B stimulate vasoconstrictor activity through increased baroreceptor output
C reduce blood pressure by venodilation
General PhysiologyEDCBA D are found in cerebral arteries
E are found in retinal arteries
C a r d io v a s c u la r

1 With regard to blood flow and blood vessels, 5 Which of the following statements concerning neural and hormonal control of blood
flow are true?
A cardiac output can be determined using Fick's principle
B velocity of blood flow through a vessel is proportional to the cross-sectional area A Vasodilation in genital organs is due ~-adrenergic stimulation.
C all capillaries are open under normal conditions at rest B Adrenaline is a vasoconstrictor in both low and high concentrations.
D haemaglobln concentration is not required in order to calculate cardiac output C Antidiuretic hormone (AOH) causes significant vasoconstriction in v iv o .
E the velocity of blood flow through capillaries is approximately 0.3 mmls D Pain results in a rise in blood pressure.
F blood flow is more likely to be turbulent in anaemia than when haemaglobin levels E Inspiration causes a rise in blood pressure.

are normal
G coronary blood flow is 10% of cardiac output 6 Regarding blood pressure.

A mean pulmonary artery pressure is 10 mmHg

2 Which of the following statements about autoregulation are true? B pulse pressure is proportional to total peripheral resistance
C pulmonary hypertension occurs when living at high altitude
A Coronary blood flow is directly related to systolic blood pressure. D the use of an inflatable cuff is a direct method of measuring blood pressure
B Skeletal muscle blood flow in exercise is increased mainly by sympathetic E mean arterial blood pressure in a young adult Is 120 mmHg
vasodilation.
C Renal blood flow is directly related to mean blood pressure.
D Pulmonary vasculature undergoes vasoconstriction in response to a rise In blood 7 In the cardiac cycle.

pressure. A end-diastolic ventricular volume is 70 ml

E Hypoxia causes vasoconstriction in pulmonary blood vessels. B ventricular filling at rest is mainly due to atrial contraction
F A rise in local temperature causes vasodilation. C systole begins when the aortic valve opens
D coronary blood flow to the right ventricle takes place only in diastole
E the v-wave of the jugular venous pulse is due to the closure of the tricuspid valve
3 Regarding capillary exchange,

A 5% of plasma flow is filtered by capillaries into the interstitial space 8 Ventricularend-diastolic volume is increased by
B 30% of ultrafiltrate re-enters blood via lymph
A lying supine
C capillary permeability to proteins is greatest in the liver
B increased total blood volume
D red blood cells increase in size as they pass through capillaries
C venous contraction
E haematocrit of blood decreases as it passes through capillaries o cardiac tamponade
F the haemoglobin dissociation curve shifts to the right as blood passes through a E tachycardia
capillary
 Physiology Questions 41
PHYSIOLOGY
4 aaroreceptors
QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
A are all in the arterial circulation
B stimulate vasoconstrictor activity through increased baroreceptor output
C reduce blood pressure by venodilation
General PhysiologyEDCBA D are found in cerebral arteries
E are found in retinal arteries
C a r d io v a s c u la r

1 With regard to blood flow and blood vessels, 5 Which of the following statements concerning neural and hormonal control of blood
flow are true?
A cardiac output can be determined using Fick's principle
B velocity of blood flow through a vessel is proportional to the cross-sectional area A Vasodilation in genital organs is due ~-adrenergic stimulation.
C all capillaries are open under normal conditions at rest B Adrenaline is a vasoconstrictor in both low and high concentrations.
D haemaglobln concentration is not required in order to calculate cardiac output C Antidiuretic hormone (AOH) causes significant vasoconstriction in v iv o .
E the velocity of blood flow through capillaries is approximately 0.3 mmls D Pain results in a rise in blood pressure.
F blood flow is more likely to be turbulent in anaemia than when haemaglobin levels E Inspiration causes a rise in blood pressure.

are normal
G coronary blood flow is 10% of cardiac output 6 Regarding blood pressure.

A mean pulmonary artery pressure is 10 mmHg

2 Which of the following statements about autoregulation are true? B pulse pressure is proportional to total peripheral resistance
C pulmonary hypertension occurs when living at high altitude
A Coronary blood flow is directly related to systolic blood pressure. D the use of an inflatable cuff is a direct method of measuring blood pressure
B Skeletal muscle blood flow in exercise is increased mainly by sympathetic E mean arterial blood pressure in a young adult Is 120 mmHg
vasodilation.
C Renal blood flow is directly related to mean blood pressure.
D Pulmonary vasculature undergoes vasoconstriction in response to a rise In blood 7 In the cardiac cycle.

pressure. A end-diastolic ventricular volume is 70 ml

E Hypoxia causes vasoconstriction in pulmonary blood vessels. B ventricular filling at rest is mainly due to atrial contraction
F A rise in local temperature causes vasodilation. C systole begins when the aortic valve opens
D coronary blood flow to the right ventricle takes place only in diastole
E the v-wave of the jugular venous pulse is due to the closure of the tricuspid valve
3 Regarding capillary exchange,

A 5% of plasma flow is filtered by capillaries into the interstitial space 8 Ventricularend-diastolic volume is increased by
B 30% of ultrafiltrate re-enters blood via lymph
A lying supine
C capillary permeability to proteins is greatest in the liver
B increased total blood volume
D red blood cells increase in size as they pass through capillaries
C venous contraction
E haematocrit of blood decreases as it passes through capillaries o cardiac tamponade
F the haemoglobin dissociation curve shifts to the right as blood passes through a E tachycardia
capillary
 Physiology Questions 43
42 Physiology Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
13 When calculating respiratory volumes, the following are used
9 In foetal circulation
A Residual volume is measured using a spirometer.
B Vital capacity is the tidal volume plus the Inspiratory reserve volume.
A oxygenated foetal placental blood has an oxygen saturation of 65%
C Residual volume is greater or equal to functional residual capacity.
•
B oxygenated blood flows from the umbilical artery to the ductus venosus
C the ductus arteriosus closes within 12 hours of birth o Inspiratory reserve volume is approximately 3 L in an adult.
E Functional residual capacity is approximately 3 L in an adult.
o oxygen saturation of blood in the umbilical artery is approximately 65%
E at birth ventilation is stimulated by a rise in ~
F the haemoglobin-dissociation curve is shifted to the left
14 With regard to alveolar surface tension,

A lung surfactant allows collapse of alveoli

Resplratoty B alveolar surface tension has its largest effect on increasing pulmonary static
compliance
10 Which of the following statements regarding gas exchange are correct?
C the LaPlace relationship relates surface tension in a sphere as a product of
pressure and radius
A ~ in dry air at sea level is 21 kPa.
o lung surfactant is reduced in heavy smoking
B ~ in expired air is 6 kPa. ' E lung surfactant predominantly contains lecithinase
C The percentage of CO:l in expired air is 15%.
o Alveolar ~ is identical to mixed venous ~.
E Alveolar ~ and ~ are reduced at high altitudes. 15 Which of the following statements about ventilation and perfusion are true?
F Alveolar PH~ is 47 mmHg.
A Alveolar ventilation is greater in the apex than in the base of the lung when
upright.
11 In gas exchange, B When supine, the pulmonary blood flow (per unit volume) increases from apex to
base.
A lung surfactant increases alveolar surface tension C The ventilation:perfusion ratio decreases from apex to base when erect.
B dead space equals tidal volume plus alveolar volume o Transection of the spinal cord above the level of C3 is fatal.
C physiological dead space is usually less than actual anatomical dead space E Physiological dead space causes a low ventilation:perfusion ratio.
o at rest alveolar volume is 70% of tidal volume
E alveolar ventilation is increased by rapid shallow breathing
F physiological dead space is increased by pulmonary embolus 16 Regarding CO 2 binding transport and distribution,
G anatomical dead space is approximately 300 ml
H dead space is calculated using the Bohr equation A CO:zis more soluble than O:zin blood.
B oxyhaemoglobin binds CO 2 more readily than does deoxyhaemoglobin
C W diffuses easily across the bIood-brain barrier
12 With regard to the mechanics of respiration,
o carotid body chemoreceptors respond primarily to changes in Pco.
E 20% of CO 2 in blood is bound to haemoglobin

A intrapleural pressure is positive in forced expiration

B pulmonary compliance is the ratio of change in intrapulmonary pressure per unit
17 In oxygen transport, binding and distribution,
of change in volume
C pulmonary compliance is the reciprocal of elastance
A mixed venous blood is 50% saturated with oxygen
o pulmonary compliance is reduced in emphysema
B cyanosis cannot occur without tissue hypoxia
E surfactant is produced by type I alveolar epithelial cells
C central chemoreceptors are stimulated mainly by hypoxia
F intrapleural pressure is recorded using an intraoesophageal balloon
 Physiology Questions 43
42 Physiology Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
13 When calculating respiratory volumes, the following are used
9 In foetal circulation
A Residual volume is measured using a spirometer.
B Vital capacity is the tidal volume plus the Inspiratory reserve volume.
A oxygenated foetal placental blood has an oxygen saturation of 65%
C Residual volume is greater or equal to functional residual capacity.
•
B oxygenated blood flows from the umbilical artery to the ductus venosus
C the ductus arteriosus closes within 12 hours of birth o Inspiratory reserve volume is approximately 3 L in an adult.
E Functional residual capacity is approximately 3 L in an adult.
o oxygen saturation of blood in the umbilical artery is approximately 65%
E at birth ventilation is stimulated by a rise in ~
F the haemoglobin-dissociation curve is shifted to the left
14 With regard to alveolar surface tension,

A lung surfactant allows collapse of alveoli

Resplratoty B alveolar surface tension has its largest effect on increasing pulmonary static
compliance
10 Which of the following statements regarding gas exchange are correct?
C the LaPlace relationship relates surface tension in a sphere as a product of
pressure and radius
A ~ in dry air at sea level is 21 kPa.
o lung surfactant is reduced in heavy smoking
B ~ in expired air is 6 kPa. ' E lung surfactant predominantly contains lecithinase
C The percentage of CO:l in expired air is 15%.
o Alveolar ~ is identical to mixed venous ~.
E Alveolar ~ and ~ are reduced at high altitudes. 15 Which of the following statements about ventilation and perfusion are true?
F Alveolar PH~ is 47 mmHg.
A Alveolar ventilation is greater in the apex than in the base of the lung when
upright.
11 In gas exchange, B When supine, the pulmonary blood flow (per unit volume) increases from apex to
base.
A lung surfactant increases alveolar surface tension C The ventilation:perfusion ratio decreases from apex to base when erect.
B dead space equals tidal volume plus alveolar volume o Transection of the spinal cord above the level of C3 is fatal.
C physiological dead space is usually less than actual anatomical dead space E Physiological dead space causes a low ventilation:perfusion ratio.
o at rest alveolar volume is 70% of tidal volume
E alveolar ventilation is increased by rapid shallow breathing
F physiological dead space is increased by pulmonary embolus 16 Regarding CO 2 binding transport and distribution,
G anatomical dead space is approximately 300 ml
H dead space is calculated using the Bohr equation A CO:zis more soluble than O:zin blood.
B oxyhaemoglobin binds CO 2 more readily than does deoxyhaemoglobin
C W diffuses easily across the bIood-brain barrier
12 With regard to the mechanics of respiration,
o carotid body chemoreceptors respond primarily to changes in Pco.
E 20% of CO 2 in blood is bound to haemoglobin

A intrapleural pressure is positive in forced expiration

B pulmonary compliance is the ratio of change in intrapulmonary pressure per unit
17 In oxygen transport, binding and distribution,
of change in volume
C pulmonary compliance is the reciprocal of elastance
A mixed venous blood is 50% saturated with oxygen
o pulmonary compliance is reduced in emphysema
B cyanosis cannot occur without tissue hypoxia
E surfactant is produced by type I alveolar epithelial cells
C central chemoreceptors are stimulated mainly by hypoxia
F intrapleural pressure is recorded using an intraoesophageal balloon
 Phys iolog y Questions
44gfedcbaZYXWVUTSRQP Phys iolog y Questions
ONMLKJIHGFEDCBA 45
C only the proximal convolute
o the oxygen dissociation curve
is shifted to the left in stored
d tubule and the collecting ducts
are perm eable to
blood urea
E the oxygen dissociation curve
is shifted to the right by a fall
in pH o Na+K+ ATPase pump is found on the apica
l mem brane of the tubular cells
E penicillin is mainly excreted
by filtration at the glom erulus

Renal
22 Which of the follow ing state
ments about sodium balance
18 In the kidneys, are true?
A Sodium reabsorption in the
kidneys occurs from the proxi
A production of 1a-hydroxylase to the collecting ducts inclusive. mal convoluted tubule
occurs
B the proximal convoluted tubul B Seventy per cent of sodium
e cells do not possess a brush border is filtered in the proximal conv
C the distal convoluted tubule C Sodiu m reabsorptio n is oluted tubule.
cells have a rich bNSh border reduced by carbonic anhydrase
o the macula densa exists at the dista
l convoluted tubule o Loop diuretics inhibit the Na+K+ ATPa inhibitors.
se pump at the thick ascending
E the distal convoluted tubule Henle. loop of
is rich in mitochondria
E Aldosterone increases sodiu
m reabsorption at the collecting
ducts.
19 Which of the follow ing state
ments about renal circulation
are true? 23 With regard to water balan
ce, which of the follow ing are
true?
A Renal blood now is 25% of
cardiac output.
S Autoregulation of renal blood A A 70 kg man is made up of
flow occurs mainly at the level approXimately 42 L of water.
C Autoregulation of renal blood of the renal artery. B One-third of body water conte
flow remains constant with mean nt is extracellular.
arterial blood C Plasm a volum e is 5% of
pressure betw een 40 and 200 total body water.
mmH g. •
o Renal blood flow may be calcu lated using the Fick's principle.
o A 3% minim um increase in serum osmo
lality is required to increase the
E Para-aminohippuric acid (PAH antidiuretic horm one (AOH J. release of
) is filtered by the glom eNIU S
and reabsorbed by E Alcohol inhibits ADH release.
the proximal convoluted tubul
e cells.
F 50% of PAH is filtered throu
gh the kidney in each Circulation
.
24 In the renin-angiotensin system,
20 Which of the follow ing are
correct? A renin is produced and slore
d as pro-renin in the juxtaglom
B angiotensin " acts directly erular cells
A The GFR (glom erular filtrat o n the kidne y 10 reduc e
ion rate) in a norm al adult is salt and water excretion
proportional to body C renin converts angio tensi
n I to angiotensin "
surface area. o aldosterone is produced at the zona
S The GFR in each kidney is glom erulosa
125 mVm in. E primary hyperaldosteronism
C The GFR is increased in diabe results in hypernatraemia
tes
o Blood urea concentration is a test insip idus.
of glom erular function.
e GFR is 20% of renal plasm a flow. Endocrlnology
F Urine volum e varies from 1%
to 20% of glom erular filtrate in
a day.
G The GFR rate is measured 25 With regard to the thyroid
by inulin clearance. gland,

A thyroid-stimulating horm one

(fSH) secretion is increased in
21 With regard to tubular trans B thyroxine increases oxygen iodine deficiency
port, uptake by cells
C hype rcholesterolaem ia is
seen in hypothyro
A glucose is reabsorbed by
secondary transportEDC
o n ly BA
in the proximal convoluted
o iodide uptake is seen in the ciliary body idism
of the eye
tubule E the half-life of thyroxine is
6 days
B creatinine, uric acid, potas
sium and W ions are actively
secreted into renal
tubules
 Physiology Questions 45
Physiology Questions
44gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA C only the proximal convoluted tubule and the collecting ducts are permeable to
urea
o the oxygen dissociation curve is shifted to the left in stored blood o Na+K+ ATPase pump is found on the apical membrane of the tubular cells
E the oxygen dissociation curve is shifted to the right by a fall in pH E penicillin is mainly excreted by filtration at the glomerulus

22 Which of the following statements about sodium balance are true?

Renal

18 In the kidneys, A Sodium reabsorption in the kidneys occurs from the proximal convoluted tubule
to the collecting ducts inclusive.
A production of 1a-hydroxylase occurs B Seventy per cent of sodium is filtered in the proximal convoluted tubule.
B the proximal convoluted tubule cells do not possess a brush border C Sodium reabsorption is reduced by carbonic anhydrase inhibitors.
C the distal convoluted tubule cells have a rich bNSh border o Loop diuretics inhibit the Na+K+ ATPase pump at the thick ascending loop of
o the macula densa exists at the distal convoluted tubule Henle.
E the distal convoluted tubule is rich in mitochondria E Aldosterone increases sodium reabsorption at the collecting ducts.

19 Which of the following statements about renal circulation are true? 23 With regard to water balance, which of the following are true?

A A 70 kg man is made up of approXimately 42 L of water.

A Renal blood now is 25% of cardiac output.
S Autoregulation of renal blood flow occurs mainly at the level of the renal artery. B One-third of body water content is extracellular.
C Autoregulation of renal blood flow remains constant with mean arterial blood C Plasma volume is 5% of total body water. •
o A 3% minimum increase in serum osmolality is required to increase the release of
pressure between 40 and 200 mmHg.
antidiuretic hormone (AOHJ.
o Renal blood flow may be calculated using the Fick's principle.
E Alcohol inhibits ADH release.
E Para-aminohippuric acid (PAH) is filtered by the glomeNIUS and reabsorbed by
the proximal convoluted tubule cells.
F 50% of PAH is filtered through the kidney in each Circulation.
24 In the renin-angiotensin system,

A renin is produced and slored as pro-renin in the juxtaglomerular cells

20 Which of the following are correct? B angiotensin " acts directly o n the kidney 10 reduce salt and water excretion
C renin converts angiotensin I to angiotensin "
A The GFR (glomerular filtration rate) in a normal adult is proportional to body
o aldosterone is produced at the zona glomerulosa
surface area. E primary hyperaldosteronism results in hypernatraemia
S The GFR in each kidney is 125 mVmin.
C The GFR is increased in diabetes insipidus.
o Blood urea concentration is a test of glomerular function. Endocrlnology
e GFR is 20% of renal plasma flow.
F Urine volume varies from 1% to 20% of glomerular filtrate in a day. 25 With regard to the thyroid gland,
G The GFR rate is measured by inulin clearance.
A thyroid-stimulating hormone (fSH) secretion is increased in iodine deficiency
B thyroxine increases oxygen uptake by cells
21 With regard to tubular transport, C hypercholesterolaemia is seen in hypothyroidism
o iodide uptake is seen in the ciliary body of the eye
A glucose is reabsorbed by secondary transportEDCBA
o n ly in the proximal convoluted E the half-life of thyroxine is 6 days

tubule
B creatinine, uric acid, potassium and W ions are actively secreted into renal

tubules
 Physiology Questions
Physiology QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 47
46gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
31 In calcium metabolism,
26 Which of the following statements about the thyroid are true?

A Ninety-nine per cent of circulating T4 is bound to protein. A hypercalcaemia is caused due to hyperthyroidism
B Thyroid hormones alter cell function by cell membrane receptor signalling. B hypercalcaemia is caused due to thiazide diuretic therapy
e Cerebrospinal fluid protein levels are raised in hypothyroidism. e hypocalcaemia is caused due to chronic renal failure
D hypercalcaemia is caused due to acute pancreatitis
D TSH secretion peaks at midnight.
E Thyroid hormones directly inhibit both TSH release at the anterior pituitary and E hypercalcaemia causes secondary hyperparathyroidism
thyrotrophin-releasing hormone (fRH) release from the hypothalamus.
F T4 is more active than T3.
32 Which of the following statements about calcium are true?

27 Glucagon A A 70 kg man contains over 1 kg of calcium.

B Parathyroid hormone is produced by the chief cells of the parathyroid gland.
A has a half-life of 5-10 min e Calcitonin is produced by the parafollicular C cells of the parathyroid gland.
B is destroyed in the liver D Parathyroid hormone stimulates increased vitamin D production.
C is produced in the A cells of the islets of Langerhans E Oestrogen receptors in bone inhibit bone osteoclast activity.
D has the same structure in all mammals
E secretion is inhibited by high levels of insulin
33 With regards to glucocorticoids,

28 Insulin A glucocorticoids cause an increase in the glomerular filtration rate

B aldosterone secretion is increased in phaeochromocytoma
A increases potassium release from cells C increased levels of glucocorticoids are associated with eosinophilia
B has a half-life of 10-30 min D aldosterone receptors are intracellular
C increases glucose uptake in the brain E glucocorticoids in the circulation are mostly bound to transcortin
D is a steroid F aldosterone in the circulation exists largely unbound to protein
E increases gluconeogenesis in the liver G aldosterone is a 21 carbon 18-hydroxycorticosteroid

29 Vasopressin or ADH
34 Which of the following statements about catecholomines are true?

A secretion is reduced by pain

A Dopamine, tyrosine and phenylalanine are precursors of adrenaline.
B is produced by the posterior pituitary
BThe half-life of adrenaline is approximately 2 min.
e increases water permeability at the loop of Henle
D release increases with a fall in plasma osmolality of over 3 mOsrnlkg ~O
e Adrenaline in the circulation causes an increase in both systolic and diastolic
arterial blood pressure.
E causes glycogenolysis in the liver
D Metabolites of adrenaline and noradrenaline in urine include VMA and 5-HIAA.
E Adrenalectomy results in reduced plasma levels of noradrenaline and adrenaline.
30 With regard to the pituitary,

A the anterior pituitary directly regulates output of the adrenal medulla eNS
B hypophysectomy reduces aldosterone release
e ACTH is not a steroid hormone 35 Cerebrospinal fluid
D hypertension as a result of excess growth hormone is due to increased heart size
resulting in increased cardiac output A absorption is due to sodium transport
E prolactin is made up of an a andEDCBA
f3 subunit B protein content is approximately 20-40 mg/l
 Physiology Questions
Physiology QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 47
46gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
31 In calcium metabolism,
26 Which of the following statements about the thyroid are true?

A Ninety-nine per cent of circulating T4 is bound to protein. A hypercalcaemia is caused due to hyperthyroidism
B Thyroid hormones alter cell function by cell membrane receptor signalling. B hypercalcaemia is caused due to thiazide diuretic therapy
e Cerebrospinal fluid protein levels are raised in hypothyroidism. e hypocalcaemia is caused due to chronic renal failure
D hypercalcaemia is caused due to acute pancreatitis
D TSH secretion peaks at midnight.
E Thyroid hormones directly inhibit both TSH release at the anterior pituitary and E hypercalcaemia causes secondary hyperparathyroidism
thyrotrophin-releasing hormone (fRH) release from the hypothalamus.
F T4 is more active than T3.
32 Which of the following statements about calcium are true?

27 Glucagon A A 70 kg man contains over 1 kg of calcium.

B Parathyroid hormone is produced by the chief cells of the parathyroid gland.
A has a half-life of 5-10 min e Calcitonin is produced by the parafollicular C cells of the parathyroid gland.
B is destroyed in the liver D Parathyroid hormone stimulates increased vitamin D production.
C is produced in the A cells of the islets of Langerhans E Oestrogen receptors in bone inhibit bone osteoclast activity.
D has the same structure in all mammals
E secretion is inhibited by high levels of insulin
33 With regards to glucocorticoids,

28 Insulin A glucocorticoids cause an increase in the glomerular filtration rate

B aldosterone secretion is increased in phaeochromocytoma
A increases potassium release from cells C increased levels of glucocorticoids are associated with eosinophilia
B has a half-life of 10-30 min D aldosterone receptors are intracellular
C increases glucose uptake in the brain E glucocorticoids in the circulation are mostly bound to transcortin
D is a steroid F aldosterone in the circulation exists largely unbound to protein
E increases gluconeogenesis in the liver G aldosterone is a 21 carbon 18-hydroxycorticosteroid

29 Vasopressin or ADH
34 Which of the following statements about catecholomines are true?

A secretion is reduced by pain

A Dopamine, tyrosine and phenylalanine are precursors of adrenaline.
B is produced by the posterior pituitary
BThe half-life of adrenaline is approximately 2 min.
e increases water permeability at the loop of Henle
D release increases with a fall in plasma osmolality of over 3 mOsrnlkg ~O
e Adrenaline in the circulation causes an increase in both systolic and diastolic
arterial blood pressure.
E causes glycogenolysis in the liver
D Metabolites of adrenaline and noradrenaline in urine include VMA and 5-HIAA.
E Adrenalectomy results in reduced plasma levels of noradrenaline and adrenaline.
30 With regard to the pituitary,

A the anterior pituitary directly regulates output of the adrenal medulla eNS
B hypophysectomy reduces aldosterone release
e ACTH is not a steroid hormone 35 Cerebrospinal fluid
D hypertension as a result of excess growth hormone is due to increased heart size
resulting in increased cardiac output A absorption is due to sodium transport
E prolactin is made up of an a andEDCBA
f3 subunit B protein content is approximately 20-40 mg/l
 Physiology Questions
48 Physiology Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 49
Ocular physiology
C rate of production is approximately 20 mllh
o volume Is 150 ml The tesrs
E is not produced in the aqueduct of Monro
F has a lower pH than plasma 39 Which of the following statements about tears are correct?
G normal lumbar pressure is 20-25 cmCSF
A Tear fluid contains lactoferrin.
B Aqueous tear production remains relatively constant with age.
36 Which of the following statements about the CNS are true? C Basal tear production is 1.2 mllh.
o The mucin layer is made up of an inner tight glycocalyx produced by the comeal
A The anterior spinothalamic tract conveys (mainly) signals of touch. epithelial cells.
B Dorsal columns carry signals of proprioception. E Comeal goblet cells contribute to the mucin layer.
C In the dorsal column, sacral and lumbar fibres are medial to thoracic and cervical
fibres.
o In the spinothalamic tract, sacral and lumbar fibres are more medial than thoracic
40 With regard to structures associated with tears.
and cervical fibres.
E The anterior corticospinal tract contains the majority of corticospinal fibres.
A the precorneal tear film has a thickness of 10 urn
F Babinski's sign results from damage to the lateral corticospinal tract.
B the outer hydrophobic lipid layer is produced by the glands of Zeiss, glands of
Moll and meibomian glands
C the aqueous layer is usually slightly hypertonic
37 With regard to the tendon reflexes, o general anaesthesia reduces tear production
E the lacrimal gland is a tubuloacinar gland, comprising of mainly tubular cells
A the knee jerk is a monosynaptic reflex elicited by stimulation of quadriceps
tendon organs
B the ankle jerk is a monosynaptic stretch reflex
41 Regarding tears,
C Golgi tendon organs are stimulated by passive stretch as well as active muscle
contraction
A lipid meibom has a higher melting temperature than skin sebaceous secretions
o muscle spindle afferents synapse directly on to ipSilateral homonymous a-motor
B contact lens wearing causes an abnormal tear film with faster and greater
neurones evaporation
E muscles spindles are stimulated by contraction of extrafusal fibres
C 85% of tears are drained by the lower canaliculus
o partial pressure of oxygen in tears with eyelids open is approximately 155 mmHg
E partial pressure of oxygen in tears with eyelids closed is approximately 55 mmHg
38 In the cerebellum,

A the flocculonodular lobe receives proprioceptive information from the body

The eyelids
B resting tremor is a feature in cerebellar lesions
C PUrkinje cells are inhibitory
42 Which of the following statements about the eyelids are true?
o cerebellar hemispheric lesions affect the contralateral side of the body
E spastic knee jerks are seen in cerebellar disease
A Cilia are replaced every two months.
F lesions of the lateral cerebellar hemisphere produces truncal ataxia
B Orbicularis oculi is an example of a yoke muscle.
C Bell's phenomenon occurs during reflex blink closure of the eyelids.
D The chronaxie of the palpebral portion of orbicularis oculi is half that of the orbital
portion.
E Spontaneous blinking may change in response to changes in visual acuity.
 Physiology Questions
48 Physiology Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 49
Ocular physiology
C rate of production is approximately 20 mllh
o volume Is 150 ml The tesrs
E is not produced in the aqueduct of Monro
F has a lower pH than plasma 39 Which of the following statements about tears are correct?
G normal lumbar pressure is 20-25 cmCSF
A Tear fluid contains lactoferrin.
B Aqueous tear production remains relatively constant with age.
36 Which of the following statements about the CNS are true? C Basal tear production is 1.2 mllh.
o The mucin layer is made up of an inner tight glycocalyx produced by the comeal
A The anterior spinothalamic tract conveys (mainly) signals of touch. epithelial cells.
B Dorsal columns carry signals of proprioception. E Comeal goblet cells contribute to the mucin layer.
C In the dorsal column, sacral and lumbar fibres are medial to thoracic and cervical
fibres.
o In the spinothalamic tract, sacral and lumbar fibres are more medial than thoracic
40 With regard to structures associated with tears.
and cervical fibres.
E The anterior corticospinal tract contains the majority of corticospinal fibres.
A the precorneal tear film has a thickness of 10 urn
F Babinski's sign results from damage to the lateral corticospinal tract.
B the outer hydrophobic lipid layer is produced by the glands of Zeiss, glands of
Moll and meibomian glands
C the aqueous layer is usually slightly hypertonic
37 With regard to the tendon reflexes, o general anaesthesia reduces tear production
E the lacrimal gland is a tubuloacinar gland, comprising of mainly tubular cells
A the knee jerk is a monosynaptic reflex elicited by stimulation of quadriceps
tendon organs
B the ankle jerk is a monosynaptic stretch reflex
41 Regarding tears,
C Golgi tendon organs are stimulated by passive stretch as well as active muscle
contraction
A lipid meibom has a higher melting temperature than skin sebaceous secretions
o muscle spindle afferents synapse directly on to ipSilateral homonymous a-motor
B contact lens wearing causes an abnormal tear film with faster and greater
neurones evaporation
E muscles spindles are stimulated by contraction of extrafusal fibres
C 85% of tears are drained by the lower canaliculus
o partial pressure of oxygen in tears with eyelids open is approximately 155 mmHg
E partial pressure of oxygen in tears with eyelids closed is approximately 55 mmHg
38 In the cerebellum,

A the flocculonodular lobe receives proprioceptive information from the body

The eyelids
B resting tremor is a feature in cerebellar lesions
C PUrkinje cells are inhibitory
42 Which of the following statements about the eyelids are true?
o cerebellar hemispheric lesions affect the contralateral side of the body
E spastic knee jerks are seen in cerebellar disease
A Cilia are replaced every two months.
F lesions of the lateral cerebellar hemisphere produces truncal ataxia
B Orbicularis oculi is an example of a yoke muscle.
C Bell's phenomenon occurs during reflex blink closure of the eyelids.
D The chronaxie of the palpebral portion of orbicularis oculi is half that of the orbital
portion.
E Spontaneous blinking may change in response to changes in visual acuity.
 Physiology QuestionsbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions 51
50
D in vivo u s e o f c a rb o n ic a n h y d ra s e in h ib ito rs Is a s s o c ia te d w ith im p a ire d
4 3 W ith re g a rd s to th e e y e lid s ,
'e n d o th e lia l p u m p ' fu n c tio n a n d s o m e c o m e a l s w e llin g

A th e fa s t c o m p o n e n t o f th e c o rn e a l b lin k re fle x is ip s ila te ra l a n d d is y n a p tic w ith a E s tro m a l a c tiv e s o d iu m c o n c e n tra tio n is 1 3 4 m E q II

la te n c y o f 1 0 -1 5 m s
B o e d e m a o r h a e m a to m a c o m m o n ly c o lle c ts w ith in a n d d is te n d s th e p re ta rs a l
4 7 In th e c o rn e a ,
space
C th e g la n d s o f Z e is s a re le s s n u m e ro u s th a n th e g la n d s o f M o ll
D th e c o n ju n c tiv a l e p ith e liu m la rg e ly c o n s is ts o f n o n -k e ra tin iz e d s tra tifie d c o lu m n a r A n o rm a l c o rn e a l s w e llin g p re s s u re is 3 5 m m H g
B s w e llin g p re s s u re is in flu e n c e d b y p o s itiv e ly c h a rg e d g ly c o s a rn in o g ly c a n s in th e
e p ith e liu m s tro m a
E M u lle r's m u s c le is a s m o o th m u s c le In n e rv a te d b y s y m p a th e tic n e rv e s in b o th
C e v a p o ra tio n o n c e th e e y e s a re o p e n a c c o u n ts fo r 5 % o f c o rn e a l th in n in g d u rin g
u p p e r a n d lo w e r e y e lid s
th e d a y
D in re s p o n s e to s tro m a l w o u n d in g , s tro m a l k e ra to c y te s a re s e e n to h y p e rtro p h y
a n d p ro life ra te
4 4 R e g a rd in g th e e y e lid s , w h ic h o f th e fo llo w in g a re tru e ? E in re s p o n s e to p e n e tra tin g s tro m a l w o u n d s , te n s ile s tre n g th re a c h e s n o rm a l
le v e ls b y s ix m o n th s .
A M y o k y m ia o r fib rilla ry tw itc h in g o f th e e y e lid s is a s s o c ia te d w ith fa tig u e .
F th e c o rn e a l s tro m a c o n s is ts o f 7 8 % w a te r
B T h e s k in la y e r o f th e e y e lid is g la b ro u s (h a irle s s ).
C C ilia h a v e a v e ry h ig h th re s h o ld fo r ta c tile s e n s a tio n .
D A t p h o to p ic le v e ls , b lin k in g w ith a d u ra tio n o f u p to 1 0 m s s h o w s n o d is c O n tin u ity
4 8 W h ic h o f th e fo llo w in g s ta te m e n t a b o u t th e c o rn e a a re c o rre c t?
o f v is u a l p e rc e p tio n .
E T h e lo n g , th in d u c ts o f th e s e b e c e o u s g la n d s o f Z e is s e m p ty d ire c tly in to c ilia ry
A Im m e d ia te e v e n ts a fte r c o rn e a l a b ra s io n in c lu d e a n in c re a s e in th e h e m id e s m o -
fo llic le s . s o m a l a tta c h m e n t o f c e lls a t th e w o u n d e d g e to th e b a s e m e n t m e m b ra n e .
B Im m e d ia te e v e n ts a fte r c o rn e a l a b ra s io n in c lu d e a n in c re a s e in m ito s is .
C E p ith e lia l c e ll m ig ra tio n c a n b e in c re a s e d in th e p re s e n c e o f c h o le ra to x in .

C0nHI8
o T h e tra n s e p ith e lia l p o te n tia l o f th e c o rn e a l e p ith e liu m is a p p ro x im a te ly - 70 m V.
E C h o rid e io n s e n te r th e c o rn e a l e p ith e lia l v ia th e 'C I- c u rre n t' o f s e c o n d a ry a c tiv e
4 5 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e c o rn e a a re tru e ? c o -tra n s p o rt a n d d iffu s e p a s s iv e lY o u t o f te a rs .
F In s ta lla tio n o f flu o re s c e in d y e is a re lia b le c lin ic a l te s t o f w h e th e r th e ju n c tio n a l
A D u rin g s le e p , o x y g e n d e liv e ry to th e c o rn e a is v ia th e b u lb a r c o n ju n c tiv a c o m p le x e s a lo n g th e la te ra l w a lls o f th e s u p e rfic ia l c e lls a re in ta c t.
B E p ith e lia l o e d e m a re d u c e s c o n tra s t s e n s itiv ity .
C T h e p e rip h e ry o f th e c o rn e a is th e m o s t s e n s itiv e a re a o f th e e y e .
D B a s a l c e lls o f th e e p ith e liu m a re la te ra lly in te rd ig ita te d to o n e a n o th e r b y z o n u la e 4 9 W ith re g a rd to th e c o rn e a ,
a d h e re n s a n d g a p ju n c tio n s , a n d in fe rio rly a tta c h e d to th e b a s a l la m in a b y

h e m id e s m o s o m e s . A th e c o rn e a tra n s m its ra d ia tio n fro m 3 1 0 n m to a m a x im u m o f 9 0 0 n m

E T h ic k e n in g s o f D e s c e m e t's m e m b ra n e (H a s s a ll-H e n le 'w a rts ') a re c o m m o n in th e B c o rn e a l e p ith e liu m c o n ta in s k e ra tin

c o m e a l p e rip h e ry . C tu rn o v e r o f th e e n tire e p ith e liu m is w ith in 7 d a y s

o b a s a l c e lls o f th e c o rn e a l e p ith e liu m fo rm a s in g le la y e r o f c o lu m n a r e p ith e liu m
E th e c o lla g e n o f th e c o rn e a l s tro m a is m a in ly ty p e I v a rie ty

4 6 W ith re g a rd to th e c o rn e a ,

A u p to 8 0 % o f n o rm a l c o rn e a l e n d o th e lia l c e lls a re h e x a g o n a l in s h a p e 5 0 R e g a rd in g th e c o rn e a , w h ic h o f th e fo llo w in g s ta te m e n ts a re tru e ?

B th e c o rn e a d is p la y s 'te m p e ra tu re re v e rs a l' in th a t its th ic k n e s s is re d u c e d w ith

re d u c e d s u rro u n d in g te m p e ra tu re a n d re tu m s to n o rm a l in n o rm a l te m p e ra tu re A T h e c o rn e a p o s s e s s e s a v a s c u la r e n d o th e liu m w ith a h ig h m e ta b o lic a c tiv ity .
B T h e c o rn e a d e riv e s its e n e rg y la rg e ly fro m a n a e ro b ic m e ta b o lis m .
C tra n s e n d o th e lia l p o te n tia l is 5 m V
 Physiology QuestionsbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions 51
50
D in vivo u s e o f c a rb o n ic a n h y d ra s e in h ib ito rs Is a s s o c ia te d w ith im p a ire d
4 3 W ith re g a rd s to th e e y e lid s ,
'e n d o th e lia l p u m p ' fu n c tio n a n d s o m e c o m e a l s w e llin g

A th e fa s t c o m p o n e n t o f th e c o rn e a l b lin k re fle x is ip s ila te ra l a n d d is y n a p tic w ith a E s tro m a l a c tiv e s o d iu m c o n c e n tra tio n is 1 3 4 m E q II

la te n c y o f 1 0 -1 5 m s
B o e d e m a o r h a e m a to m a c o m m o n ly c o lle c ts w ith in a n d d is te n d s th e p re ta rs a l
4 7 In th e c o rn e a ,
space
C th e g la n d s o f Z e is s a re le s s n u m e ro u s th a n th e g la n d s o f M o ll
D th e c o n ju n c tiv a l e p ith e liu m la rg e ly c o n s is ts o f n o n -k e ra tin iz e d s tra tifie d c o lu m n a r A n o rm a l c o rn e a l s w e llin g p re s s u re is 3 5 m m H g
B s w e llin g p re s s u re is in flu e n c e d b y p o s itiv e ly c h a rg e d g ly c o s a rn in o g ly c a n s in th e
e p ith e liu m s tro m a
E M u lle r's m u s c le is a s m o o th m u s c le In n e rv a te d b y s y m p a th e tic n e rv e s in b o th
C e v a p o ra tio n o n c e th e e y e s a re o p e n a c c o u n ts fo r 5 % o f c o rn e a l th in n in g d u rin g
u p p e r a n d lo w e r e y e lid s
th e d a y
D in re s p o n s e to s tro m a l w o u n d in g , s tro m a l k e ra to c y te s a re s e e n to h y p e rtro p h y
a n d p ro life ra te
4 4 R e g a rd in g th e e y e lid s , w h ic h o f th e fo llo w in g a re tru e ? E in re s p o n s e to p e n e tra tin g s tro m a l w o u n d s , te n s ile s tre n g th re a c h e s n o rm a l
le v e ls b y s ix m o n th s .
A M y o k y m ia o r fib rilla ry tw itc h in g o f th e e y e lid s is a s s o c ia te d w ith fa tig u e .
F th e c o rn e a l s tro m a c o n s is ts o f 7 8 % w a te r
B T h e s k in la y e r o f th e e y e lid is g la b ro u s (h a irle s s ).
C C ilia h a v e a v e ry h ig h th re s h o ld fo r ta c tile s e n s a tio n .
D A t p h o to p ic le v e ls , b lin k in g w ith a d u ra tio n o f u p to 1 0 m s s h o w s n o d is c O n tin u ity
4 8 W h ic h o f th e fo llo w in g s ta te m e n t a b o u t th e c o rn e a a re c o rre c t?
o f v is u a l p e rc e p tio n .
E T h e lo n g , th in d u c ts o f th e s e b e c e o u s g la n d s o f Z e is s e m p ty d ire c tly in to c ilia ry
A Im m e d ia te e v e n ts a fte r c o rn e a l a b ra s io n in c lu d e a n in c re a s e in th e h e m id e s m o -
fo llic le s . s o m a l a tta c h m e n t o f c e lls a t th e w o u n d e d g e to th e b a s e m e n t m e m b ra n e .
B Im m e d ia te e v e n ts a fte r c o rn e a l a b ra s io n in c lu d e a n in c re a s e in m ito s is .
C E p ith e lia l c e ll m ig ra tio n c a n b e in c re a s e d in th e p re s e n c e o f c h o le ra to x in .

C0nHI8
o T h e tra n s e p ith e lia l p o te n tia l o f th e c o rn e a l e p ith e liu m is a p p ro x im a te ly - 70 m V.
E C h o rid e io n s e n te r th e c o rn e a l e p ith e lia l v ia th e 'C I- c u rre n t' o f s e c o n d a ry a c tiv e
4 5 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e c o rn e a a re tru e ? c o -tra n s p o rt a n d d iffu s e p a s s iv e lY o u t o f te a rs .
F In s ta lla tio n o f flu o re s c e in d y e is a re lia b le c lin ic a l te s t o f w h e th e r th e ju n c tio n a l
A D u rin g s le e p , o x y g e n d e liv e ry to th e c o rn e a is v ia th e b u lb a r c o n ju n c tiv a c o m p le x e s a lo n g th e la te ra l w a lls o f th e s u p e rfic ia l c e lls a re in ta c t.
B E p ith e lia l o e d e m a re d u c e s c o n tra s t s e n s itiv ity .
C T h e p e rip h e ry o f th e c o rn e a is th e m o s t s e n s itiv e a re a o f th e e y e .
D B a s a l c e lls o f th e e p ith e liu m a re la te ra lly in te rd ig ita te d to o n e a n o th e r b y z o n u la e 4 9 W ith re g a rd to th e c o rn e a ,
a d h e re n s a n d g a p ju n c tio n s , a n d in fe rio rly a tta c h e d to th e b a s a l la m in a b y

h e m id e s m o s o m e s . A th e c o rn e a tra n s m its ra d ia tio n fro m 3 1 0 n m to a m a x im u m o f 9 0 0 n m

E T h ic k e n in g s o f D e s c e m e t's m e m b ra n e (H a s s a ll-H e n le 'w a rts ') a re c o m m o n in th e B c o rn e a l e p ith e liu m c o n ta in s k e ra tin

c o m e a l p e rip h e ry . C tu rn o v e r o f th e e n tire e p ith e liu m is w ith in 7 d a y s

o b a s a l c e lls o f th e c o rn e a l e p ith e liu m fo rm a s in g le la y e r o f c o lu m n a r e p ith e liu m
E th e c o lla g e n o f th e c o rn e a l s tro m a is m a in ly ty p e I v a rie ty

4 6 W ith re g a rd to th e c o rn e a ,

A u p to 8 0 % o f n o rm a l c o rn e a l e n d o th e lia l c e lls a re h e x a g o n a l in s h a p e 5 0 R e g a rd in g th e c o rn e a , w h ic h o f th e fo llo w in g s ta te m e n ts a re tru e ?

B th e c o rn e a d is p la y s 'te m p e ra tu re re v e rs a l' in th a t its th ic k n e s s is re d u c e d w ith

re d u c e d s u rro u n d in g te m p e ra tu re a n d re tu m s to n o rm a l in n o rm a l te m p e ra tu re A T h e c o rn e a p o s s e s s e s a v a s c u la r e n d o th e liu m w ith a h ig h m e ta b o lic a c tiv ity .
B T h e c o rn e a d e riv e s its e n e rg y la rg e ly fro m a n a e ro b ic m e ta b o lis m .
C tra n s e n d o th e lia l p o te n tia l is 5 m V
 Physiology QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
52gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Physiology Questions 53

C The posterior surface of the cornea provides the major retractive component of Aqueous and c ilia r y epithelium

the eye.
54 Which of the following statements are correct?
D The superficial cell layer of the epithelium is covered with a thick layer of microvilli.
E The single layer of the comeal endothelial cells have a cell density of approxI-
A Aqueous production is 2.5 J lV s .
mately 3500 cells per mm 2 at birth.
B Pigmented ciliary epithelium is responsible for aqueous formation.
C Ultrafiltration is responsible for up to 15% of aqueous formation.
o Aqueous flow increases during sleep.
51 In the cornea, E The comeal endothelium 'fluid pump' accounts for 15% of aqueous fluid
production.
A the cellular Bowman's layer consists of randomly arranged collagen fibrils
B Bowman's layer is one-fifth of the thickness of the comeal epithelium
C the basement membrane of the comeal epithelium consists mainly of type rv 55 With regards to the aqueous,
collagen in the centre
D the stroma forms 98% of the corneal thickness A the main pathway for aqueous outflow is via the tralbecular meshwork and
E Descemet's membrane is 1(}-5 EDCBA
J lm thick decreases with the Valsalva manoeuvre
B uveoscleral outflow of aqueous Is an energy-dependent active process
C intraocular pressure in the general population has a normal Gaussian distribution
52 Regarding the comea, with a mean of 16 mmHg
o regular exercises are associated with long-term reduction in intraocular pressure
A long-term contact lens use (greater than 6 years) is associated with endothelial E intraocular pressure increases with inspiration and decreases with expiration

cell loss
B the posterior layer of Descemet's membrane increases in thickness throughout
56 Regarding the aqueous,
life
C Descemet's membrane is extremely resistent to proteolytic enzymes
A small quantities of complement are found in primary aqueous
D the endothelium acts as a tight barrier between aqueous humour and stroma
B the uveal layer of the trabecular meshwork poses greatest resistance to aqueous
E corneal innervation, with the presence of the neuropeptides substance P and
outflow
calcitonin gene-related peptide (CGRp), exerts a trophic (nutritional) effect on
C aqueous passing through the trabecular meshwork enters Schlemm's canal by
corneal wound healing
bulk flow.
o uveoscleral drainage of aqueous passes through the anterior chamber angle to
reach the suprachoroidal space .
53 Which of the following are true? E pulsatile intraocular pressure is due to arterial blood flow into the central retinal
artery
A Nerve axons that pass through the anterior stroma are usually unmyelinated with
a covering layer of Schwann cells.
B Corneal stroma has a lamellar arrangement of collagen fibrils with a diameter of 57 In the aqueous,
between 24 and 30 nm.
e Corneal sensitivity is influenced by pigmentation of the iris. A IgA is the only detectable immunoglobulin
D The comeal epithelium has chemical receptors for high pH and hypertonic B protein concentration is less than 20 mg/100 ml
solutions. C fibrinogen is present in significant amounts
E The cell size of normal comeal endothelial cells has a coefficient of variation D insulin is present
(standard deviation of mean cell area/mean cell area) of 0.25. E active secretion by the ciliary epithelium Is at a constant rate regardless of
F Endothelial cell density is the most useful indicator of normal endothelial stalbility. intraocular pressure
 Physiology QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
52gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Physiology Questions 53

C The posterior surface of the cornea provides the major retractive component of Aqueous and c ilia r y epithelium

the eye.
54 Which of the following statements are correct?
D The superficial cell layer of the epithelium is covered with a thick layer of microvilli.
E The single layer of the comeal endothelial cells have a cell density of approxI-
A Aqueous production is 2.5 J lV s .
mately 3500 cells per mm 2 at birth.
B Pigmented ciliary epithelium is responsible for aqueous formation.
C Ultrafiltration is responsible for up to 15% of aqueous formation.
o Aqueous flow increases during sleep.
51 In the cornea, E The comeal endothelium 'fluid pump' accounts for 15% of aqueous fluid
production.
A the cellular Bowman's layer consists of randomly arranged collagen fibrils
B Bowman's layer is one-fifth of the thickness of the comeal epithelium
C the basement membrane of the comeal epithelium consists mainly of type rv 55 With regards to the aqueous,
collagen in the centre
D the stroma forms 98% of the corneal thickness A the main pathway for aqueous outflow is via the tralbecular meshwork and
E Descemet's membrane is 1(}-5 EDCBA
J lm thick decreases with the Valsalva manoeuvre
B uveoscleral outflow of aqueous Is an energy-dependent active process
C intraocular pressure in the general population has a normal Gaussian distribution
52 Regarding the comea, with a mean of 16 mmHg
o regular exercises are associated with long-term reduction in intraocular pressure
A long-term contact lens use (greater than 6 years) is associated with endothelial E intraocular pressure increases with inspiration and decreases with expiration

cell loss
B the posterior layer of Descemet's membrane increases in thickness throughout
56 Regarding the aqueous,
life
C Descemet's membrane is extremely resistent to proteolytic enzymes
A small quantities of complement are found in primary aqueous
D the endothelium acts as a tight barrier between aqueous humour and stroma
B the uveal layer of the trabecular meshwork poses greatest resistance to aqueous
E corneal innervation, with the presence of the neuropeptides substance P and
outflow
calcitonin gene-related peptide (CGRp), exerts a trophic (nutritional) effect on
C aqueous passing through the trabecular meshwork enters Schlemm's canal by
corneal wound healing
bulk flow.
o uveoscleral drainage of aqueous passes through the anterior chamber angle to
reach the suprachoroidal space .
53 Which of the following are true? E pulsatile intraocular pressure is due to arterial blood flow into the central retinal
artery
A Nerve axons that pass through the anterior stroma are usually unmyelinated with
a covering layer of Schwann cells.
B Corneal stroma has a lamellar arrangement of collagen fibrils with a diameter of 57 In the aqueous,
between 24 and 30 nm.
e Corneal sensitivity is influenced by pigmentation of the iris. A IgA is the only detectable immunoglobulin
D The comeal epithelium has chemical receptors for high pH and hypertonic B protein concentration is less than 20 mg/100 ml
solutions. C fibrinogen is present in significant amounts
E The cell size of normal comeal endothelial cells has a coefficient of variation D insulin is present
(standard deviation of mean cell area/mean cell area) of 0.25. E active secretion by the ciliary epithelium Is at a constant rate regardless of
F Endothelial cell density is the most useful indicator of normal endothelial stalbility. intraocular pressure
54 Physiology QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions 55

58 How many of the following statements about the aqueous are correct? Pupil

A Glucose is transported by carrier mediator transport across the blood-aqueous 62 Which of the following statements about the pupils are true?
barrier.
S Intraocular pressure shows a diumal variation with a peak occurring between 7 A Pupil diameter range from 2 mm to a maximum of 6 mm.
and 9 am. B Pupil size is largest during adolescence.
e Aqueous production increases with age. C Simply physiological anisocoria Is present in 10% of the population.
D Glucose concentration in aqueous is two-thirds that of plasma D In reaction to light, the latent period of the light reflex in bright light is 0.2 s.
E Partial pressure of oxygen in aqueous humour Is between 30 and 40 mmHg. E A supratentorial space-occupying lesion damaging the third nerve causes a tonic
pupil.

59 With regard to the aqueous,

63 Complications of puplllary dilation include
A the blood-aqueous barrier is formed partly by the impermeable fenestrated iris
vessels A blurred vision
B the ciliary body plays a role in the secretion of hyaluronic acid into the vitreous B light sensitivity
e small lipid-soluble molecules are able to penetrate the bIood-aqueous barrier C acute closed-anole glaucoma
D the anterior and posterior chamber are iso-osmolar with plasma o uveitis
E urea induces a greater fall in intraocular pressure than mannitol E raised intraocular pressure

64 Pupil size is affected by

60 Which of the following are correct?

A iris pigment
A The ciliary body is divided into a smooth pars plana anteriorly and a pars plicata
B myopia (myopes have larger pupils than hypermetropes)
posteriorly.
C distance of object of fixation
S The basal aspect of the pigmented ciliary epithelium faces the ciliary stroma.
o sleep
e Gap junctions exist between pigmented and non-pigmented ciliary epithelial
E severe depression
cells.
o Tight junctions exist between the apices of the pigmented ciliary epithelial cells.
E Capillaries of the ciliary body are similar to those in the liver sinusoids. 65 Which of the following statements about pupillary defects are true?

A Dense lens opacities cause an afferent pupillary defect.

61 With regard to the ciliary epithelium and the aqueous, B Consensual light reflex is equally as strong as direct light reflex in the normal subject.
C An efferent pupillary defect describes a fixed dilated pupil.
A non-pigmented ciliary epithelial cells are cuboidal o Adie's tonic pupils constrict less than the normal pupil to 0.1 % pilocarpine.
B acetazolamide lowers the rate of the production of aqueous humour by up to E Argyll Robertson pupils are dilated, react well to accommodation, but react
50% poorly to light.
e ciliary channels exist between pigmented and non-pigmented ciliary epithelial
cells
D secondary aqueous is the result of primary aqueous reaching the anterior 66 MydriasiS
chamber
E release of prostaglandins E and F in response to chemical or mechanical insult A can be induced by botulinum toxin
disrupts the blood-aqueous barrier B is induced by atropine because it is a competitive antinicotinic antagonist of
acetylcholine
54 Physiology QuestionsyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions 55

58 How many of the following statements about the aqueous are correct? Pupil

A Glucose is transported by carrier mediator transport across the blood-aqueous 62 Which of the following statements about the pupils are true?
barrier.
S Intraocular pressure shows a diumal variation with a peak occurring between 7 A Pupil diameter range from 2 mm to a maximum of 6 mm.
and 9 am. B Pupil size is largest during adolescence.
e Aqueous production increases with age. C Simply physiological anisocoria Is present in 10% of the population.
D Glucose concentration in aqueous is two-thirds that of plasma D In reaction to light, the latent period of the light reflex in bright light is 0.2 s.
E Partial pressure of oxygen in aqueous humour Is between 30 and 40 mmHg. E A supratentorial space-occupying lesion damaging the third nerve causes a tonic
pupil.

59 With regard to the aqueous,

63 Complications of puplllary dilation include
A the blood-aqueous barrier is formed partly by the impermeable fenestrated iris
vessels A blurred vision
B the ciliary body plays a role in the secretion of hyaluronic acid into the vitreous B light sensitivity
e small lipid-soluble molecules are able to penetrate the bIood-aqueous barrier C acute closed-anole glaucoma
D the anterior and posterior chamber are iso-osmolar with plasma o uveitis
E urea induces a greater fall in intraocular pressure than mannitol E raised intraocular pressure

64 Pupil size is affected by

60 Which of the following are correct?

A iris pigment
A The ciliary body is divided into a smooth pars plana anteriorly and a pars plicata
B myopia (myopes have larger pupils than hypermetropes)
posteriorly.
C distance of object of fixation
S The basal aspect of the pigmented ciliary epithelium faces the ciliary stroma.
o sleep
e Gap junctions exist between pigmented and non-pigmented ciliary epithelial
E severe depression
cells.
o Tight junctions exist between the apices of the pigmented ciliary epithelial cells.
E Capillaries of the ciliary body are similar to those in the liver sinusoids. 65 Which of the following statements about pupillary defects are true?

A Dense lens opacities cause an afferent pupillary defect.

61 With regard to the ciliary epithelium and the aqueous, B Consensual light reflex is equally as strong as direct light reflex in the normal subject.
C An efferent pupillary defect describes a fixed dilated pupil.
A non-pigmented ciliary epithelial cells are cuboidal o Adie's tonic pupils constrict less than the normal pupil to 0.1 % pilocarpine.
B acetazolamide lowers the rate of the production of aqueous humour by up to E Argyll Robertson pupils are dilated, react well to accommodation, but react
50% poorly to light.
e ciliary channels exist between pigmented and non-pigmented ciliary epithelial
cells
D secondary aqueous is the result of primary aqueous reaching the anterior 66 MydriasiS
chamber
E release of prostaglandins E and F in response to chemical or mechanical insult A can be induced by botulinum toxin
disrupts the blood-aqueous barrier B is induced by atropine because it is a competitive antinicotinic antagonist of
acetylcholine
 P h y s io lo g y Questions Physiology Questions 57
56baZYXWVUTSRQPONMLKJIHGFEDCBA
7 0 In th e le n s ,
C is in d u c e d b y e d ro p h o n iu m
o and c y c lo p le g ia can be caused b y p h e n y le p h rin e A th e re s tin g v o lta g e is - 7 0 m V
E c a n b e c a u s e d b y p h e n o b a rb ito n e B th e p o ta s s iu m c o n c e n tra tio n is 125 m m o lll
C 33% o f th e p ro te in c o n te n t is m a d e u p o f w a te r-s o lu b le p ro te in s
o c o n c e n tra tio n o f g lu ta th io n e is 1 0 0 0 tim e s g re a te r th a n th a t o f th e a q u e o u s h u m o u r

6 7 W h ic h o f th e fo llo w in g s ta te m e n ts about m io s is a re tru e ? E g lu ta th io n e c o n c e n tra tio n s a re fo u n d to b e ra is e d in th e p re s e n c e o f c a ta ra c ts

A H is ta m in e c a u s e s m io s is .
71 W ith re g a rd to th e le n s ,
B M o rp h in e c a n c a u s e m io s is , b o th b y its d ire c t a c tio n o n s m o o th m u s c le a n d v ia

th e c e n tra l n e rv o u s s y s te m . A c e n tra l le n s e p ith e lia l c e lls a re c o lu m n a r

C p ilo c a rp in e c a n a b o lis h th e p u p illa ry lig h t re fle x fo r m a n y h o u rs a fte r its m io tic
B c ry s ta llin s a re s y n th e s iz e d b y th e le n s e p ith e lia l c e lls
a ffe c t d is a p p e a rs . C o n ly s u p e rfic ia l c o rtic a l le n s fib re s possess n u c le i
o R e b o u n d m io s is is s e e n o n c e th e m y d ria tic a ffe c t o f c o c a in e d is a p p e a rs . o th e b a s a l le n s e p ith e lia l m e m b ra n e is ric h in N a + 1 ('" A T P a s e p u m p s
E T h y m o x a m in e c a u s e s m io s is w ith n o e ffe c t o n th e c ilia ry b o d y . E th e le n s in te rio r h a s a n o s m o la lity ' of 300 m O sm

7 2 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e le n s a re tru e ?
6 8 W ith re g a rd to H o rn e r's a n d P a n c o a s t's s y n d ro m e s , w h ic h o f th e fo llo w in g a re tru e ?

A G lu c o s e e n te rs th e le n s b y in s u lin -in d e p e n d e n t fa c ilita te d d iffu s io n .

A C o n g e n ita l H o m e r's s y d ro m e causes h e te ro c h ro m ia iris .
B A e ro b ic g ly c o ly s is is re s p o n s ib le fo r u p to 4 0 % o f le n s e n E l(9 y p ro d u c tio n .
B In u n ila te ra l H o m e r's , d ila tio n la g a n d a n is o c o ria a re c le a rly p re s e n t a fte r 5 s C A m in o a c id s a re tra n s p o rte d in to th e le n s fro m th e a q u e o u s b y s e c o n d a ry a c tiv e
d u rin g a sudden change fro m b rig h t lig h t to d a rk . c o -tra n s p o rt.
C C o c a in e d ila tio n is re d u c e d in p o s t-g a n g lio n ic H o m e r's p u p ils o n ly . o S o rb ito l is p ro d u c e d in th e le n s d u rin g h y p E l(9 ly c a e m ia .
o B ased o n th e p rin c ip le o f d e n e rv a tio n h y p e rs e n s itiv ity , th e a d re n a lin e te s t is a E C a lc iu m le v e ls in th e le n s a re 5 0 tim e s lo w e r th a n in th e a q u e o u s .

re lia b le te s t in d is tin g u iS h in g p re - a n d p o s t-g a n g lio n ic H o rn e r's s y n d ro m e .

E P a n c o a s t's s y n d ro m e is a s s o c ia te d w ith fa ilu re o f h y d ro x y a m p h e ta m in e to d ila te
7 3 R e g a rd in g c ry s ta llin s ,
th e a ffe c te d p u p il.

A g a m m a c ry s ta llin s a re fo u n d m a in ly in th e fe ta l n u c le u s
B a lp h a c ry s ta llln s a re th e o n ly c ry s ta llin s fo u n d in th e le n s e p ith e liu m
The lens C a lp h a c ry s ta llin is fo u n d p re d o m in a n tly in th e n u c le u s
o b e ta c ry s ta llin is th e m o s t a b u n d a n t c ry s ta llin
6 9 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e le n s a re tru e ? E gam m a c ry s ta llin h a s th e h ig h e s t m o le c u la r m ass

A T h e le n s p la y s a ro le in filte rin g in fra re d lig h t.

7 4 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e c a u s e o f a n d a s s o c ia tio n s w ith c a ta r-
B T h e c a p s u le is m a in ly m a d e u p o f ty p e W c o lla g e n .
C The c a p s u le is s y n th e s iz e d b y th e le n s e p ith e liu m and s u p e rfic ia l le n s fib re s a c t fo rm a tio n a re tru e ?

p o s te rio r1 y . A H y p o c a lc a e m ia c a u s e s c o rtic a l c a ta ra c ts .
o The le n s is u n iq u e in its tw o -th ird s p ro te in c o n te n t n e c e s s a ry fo r a h ig h re fra c tiv e
B R e d u c tio n s o f m e th io n in e a n d c y s te in e le v e ls a re fo u n d in c a ta ra c ts .
in d e x . C P U V A th e ra p y c a u s e s c a ta ra c t fo rm a tio n .
E T h e re g u la r h e lic a l a rra n g e m e n t o f le n s p ro te in s w ith s m a ll d iffe re n c e s in re fra c - o S y s te m ic c o rtic o s te ro id causes p o s te rio r s u b c a p s u la r c a ta ra c t.
tiv e in d e x p la y s a ro le in tra n s p a re n c y . E C h lo rp ro m a z in e c a u s e s c a ta ra c t.
 P h y s io lo g y Questions Physiology Questions 57
56baZYXWVUTSRQPONMLKJIHGFEDCBA
7 0 In th e le n s ,
C is in d u c e d b y e d ro p h o n iu m
o and c y c lo p le g ia can be caused b y p h e n y le p h rin e A th e re s tin g v o lta g e is - 7 0 m V
E c a n b e c a u s e d b y p h e n o b a rb ito n e B th e p o ta s s iu m c o n c e n tra tio n is 125 m m o lll
C 33% o f th e p ro te in c o n te n t is m a d e u p o f w a te r-s o lu b le p ro te in s
o c o n c e n tra tio n o f g lu ta th io n e is 1 0 0 0 tim e s g re a te r th a n th a t o f th e a q u e o u s h u m o u r

6 7 W h ic h o f th e fo llo w in g s ta te m e n ts about m io s is a re tru e ? E g lu ta th io n e c o n c e n tra tio n s a re fo u n d to b e ra is e d in th e p re s e n c e o f c a ta ra c ts

A H is ta m in e c a u s e s m io s is .
71 W ith re g a rd to th e le n s ,
B M o rp h in e c a n c a u s e m io s is , b o th b y its d ire c t a c tio n o n s m o o th m u s c le a n d v ia

th e c e n tra l n e rv o u s s y s te m . A c e n tra l le n s e p ith e lia l c e lls a re c o lu m n a r

C p ilo c a rp in e c a n a b o lis h th e p u p illa ry lig h t re fle x fo r m a n y h o u rs a fte r its m io tic
B c ry s ta llin s a re s y n th e s iz e d b y th e le n s e p ith e lia l c e lls
a ffe c t d is a p p e a rs . C o n ly s u p e rfic ia l c o rtic a l le n s fib re s possess n u c le i
o R e b o u n d m io s is is s e e n o n c e th e m y d ria tic a ffe c t o f c o c a in e d is a p p e a rs . o th e b a s a l le n s e p ith e lia l m e m b ra n e is ric h in N a + 1 ('" A T P a s e p u m p s
E T h y m o x a m in e c a u s e s m io s is w ith n o e ffe c t o n th e c ilia ry b o d y . E th e le n s in te rio r h a s a n o s m o la lity ' of 300 m O sm

7 2 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e le n s a re tru e ?
6 8 W ith re g a rd to H o rn e r's a n d P a n c o a s t's s y n d ro m e s , w h ic h o f th e fo llo w in g a re tru e ?

A G lu c o s e e n te rs th e le n s b y in s u lin -in d e p e n d e n t fa c ilita te d d iffu s io n .

A C o n g e n ita l H o m e r's s y d ro m e causes h e te ro c h ro m ia iris .
B A e ro b ic g ly c o ly s is is re s p o n s ib le fo r u p to 4 0 % o f le n s e n E l(9 y p ro d u c tio n .
B In u n ila te ra l H o m e r's , d ila tio n la g a n d a n is o c o ria a re c le a rly p re s e n t a fte r 5 s C A m in o a c id s a re tra n s p o rte d in to th e le n s fro m th e a q u e o u s b y s e c o n d a ry a c tiv e
d u rin g a sudden change fro m b rig h t lig h t to d a rk . c o -tra n s p o rt.
C C o c a in e d ila tio n is re d u c e d in p o s t-g a n g lio n ic H o m e r's p u p ils o n ly . o S o rb ito l is p ro d u c e d in th e le n s d u rin g h y p E l(9 ly c a e m ia .
o B ased o n th e p rin c ip le o f d e n e rv a tio n h y p e rs e n s itiv ity , th e a d re n a lin e te s t is a E C a lc iu m le v e ls in th e le n s a re 5 0 tim e s lo w e r th a n in th e a q u e o u s .

re lia b le te s t in d is tin g u iS h in g p re - a n d p o s t-g a n g lio n ic H o rn e r's s y n d ro m e .

E P a n c o a s t's s y n d ro m e is a s s o c ia te d w ith fa ilu re o f h y d ro x y a m p h e ta m in e to d ila te
7 3 R e g a rd in g c ry s ta llin s ,
th e a ffe c te d p u p il.

A g a m m a c ry s ta llin s a re fo u n d m a in ly in th e fe ta l n u c le u s
B a lp h a c ry s ta llln s a re th e o n ly c ry s ta llin s fo u n d in th e le n s e p ith e liu m
The lens C a lp h a c ry s ta llin is fo u n d p re d o m in a n tly in th e n u c le u s
o b e ta c ry s ta llin is th e m o s t a b u n d a n t c ry s ta llin
6 9 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e le n s a re tru e ? E gam m a c ry s ta llin h a s th e h ig h e s t m o le c u la r m ass

A T h e le n s p la y s a ro le in filte rin g in fra re d lig h t.

7 4 W h ic h o f th e fo llo w in g s ta te m e n ts a b o u t th e c a u s e o f a n d a s s o c ia tio n s w ith c a ta r-
B T h e c a p s u le is m a in ly m a d e u p o f ty p e W c o lla g e n .
C The c a p s u le is s y n th e s iz e d b y th e le n s e p ith e liu m and s u p e rfic ia l le n s fib re s a c t fo rm a tio n a re tru e ?

p o s te rio r1 y . A H y p o c a lc a e m ia c a u s e s c o rtic a l c a ta ra c ts .
o The le n s is u n iq u e in its tw o -th ird s p ro te in c o n te n t n e c e s s a ry fo r a h ig h re fra c tiv e
B R e d u c tio n s o f m e th io n in e a n d c y s te in e le v e ls a re fo u n d in c a ta ra c ts .
in d e x . C P U V A th e ra p y c a u s e s c a ta ra c t fo rm a tio n .
E T h e re g u la r h e lic a l a rra n g e m e n t o f le n s p ro te in s w ith s m a ll d iffe re n c e s in re fra c - o S y s te m ic c o rtic o s te ro id causes p o s te rio r s u b c a p s u la r c a ta ra c t.
tiv e in d e x p la y s a ro le in tra n s p a re n c y . E C h lo rp ro m a z in e c a u s e s c a ta ra c t.
58gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions 59

75 How many of the following statements about the lens are correct? C has osmolality usually less than that of serum
o potassium levels can be used In forensic medicine in determining the time
A The lens has no sensory innervation. elapsed since death
B The human lens increases in thickness at a rate of about 0.02 mm perEDCBA
y e a r.
E to plasma ratio of ascorbic acid is 2:1
C The anterior radius of curvature is 10 mm.
o During accommodation, the posterior surface of the lens remains still and the
anterior surface of the lens moves forwards toward the cornea.
80 The vitreous
E The anterior lens capsule is three times thicker than the posterior capsule.

A occupies up to 60% of the globe

B has a refractive index similar to that of the aqueous
V 'r tr e o u s
C is composed mainly of type I collagen
o in the human has no hyaluronic acid before birth
76 Which of the following statements about the vitreous are true? E contains hyaluronic acid concentrated mainly in the cortex

A The vitreous transports low molecular weight substances by diffusion and high
molecular weight substances' by bulk flow.
The retina
B Collagen provides the major resistance to flow of water In the vitreous.
C Hyaluronic acid possesses a cationic charge.
81 Which of the following statements about the retina are true?
D Zonule fibres like the vitreous collagen fibrils resist collagenase.
E Age-related liquefaction of the vitreous begins in the central vitreous. A The central retinal artery only receives sympathetic innervation beyond the
lamina cribrosa.
B The central retinal artery beyond the lamina cribrosa displays a-adrenergic
77 The vitreous
receptors.
C Sympathetic innervation increases ocular blood flow.
A contains hyaluronic acid produced by hyalocytes
D The choroidal vessels receive parasympathetic innervation.
B is absent of fibroblasts, except in response to trauma
E Both retinal and choroidal vessels vasodilate during hypoxia or hypercapnia.
C shortens the partial thromboplastin time and aggregates platelets
D provides nutrients for the retina
E actively replaces 50% of water every 10-15 min
82 In the retina,

A Muller cells are a form of oligodendrocyte

78 How many of the following are true?
B shedding of rod discs occurs predominantly in the morning
C the foveola is deficient in blue cones
A In the vitreous, collagen density is greatest in the posterior cortex.
o the external limiting membrane is formed by the zonula occludens of the retinal
B Cloquet's canal is devoid of ccllagen fibrils.
pigment epithelium
C The vitreous is susceptible to osmotic dehydration through mannitol therapy.
E the inner segment of the photoreceptors receive their blood supply from the
D The vitreous cortex is thin over the optic disc and absent over the macula.
central retinal artery
E Hyalocytes are found in a single layer anterior to the inner limiting membrane of
the retina.

83 With regard to the retina,

79 The vitreous
A Muller cells are confined by the internal and external limiting membranes
B the inner and outer segments of a photoreceptor are connected by a ciliary stalk
A does not transmit UV light below 400 nm
consisting of ten pairs of microtubules
B plays a role in the blood-ocular barrier
C visual pigments are insoluble membrane proteins found on photoreceptor discs
58gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions 59

75 How many of the following statements about the lens are correct? C has osmolality usually less than that of serum
o potassium levels can be used In forensic medicine in determining the time
A The lens has no sensory innervation. elapsed since death
B The human lens increases in thickness at a rate of about 0.02 mm perEDCBA
y e a r.
E to plasma ratio of ascorbic acid is 2:1
C The anterior radius of curvature is 10 mm.
o During accommodation, the posterior surface of the lens remains still and the
anterior surface of the lens moves forwards toward the cornea.
80 The vitreous
E The anterior lens capsule is three times thicker than the posterior capsule.

A occupies up to 60% of the globe

B has a refractive index similar to that of the aqueous
V 'r tr e o u s
C is composed mainly of type I collagen
o in the human has no hyaluronic acid before birth
76 Which of the following statements about the vitreous are true? E contains hyaluronic acid concentrated mainly in the cortex

A The vitreous transports low molecular weight substances by diffusion and high
molecular weight substances' by bulk flow.
The retina
B Collagen provides the major resistance to flow of water In the vitreous.
C Hyaluronic acid possesses a cationic charge.
81 Which of the following statements about the retina are true?
D Zonule fibres like the vitreous collagen fibrils resist collagenase.
E Age-related liquefaction of the vitreous begins in the central vitreous. A The central retinal artery only receives sympathetic innervation beyond the
lamina cribrosa.
B The central retinal artery beyond the lamina cribrosa displays a-adrenergic
77 The vitreous
receptors.
C Sympathetic innervation increases ocular blood flow.
A contains hyaluronic acid produced by hyalocytes
D The choroidal vessels receive parasympathetic innervation.
B is absent of fibroblasts, except in response to trauma
E Both retinal and choroidal vessels vasodilate during hypoxia or hypercapnia.
C shortens the partial thromboplastin time and aggregates platelets
D provides nutrients for the retina
E actively replaces 50% of water every 10-15 min
82 In the retina,

A Muller cells are a form of oligodendrocyte

78 How many of the following are true?
B shedding of rod discs occurs predominantly in the morning
C the foveola is deficient in blue cones
A In the vitreous, collagen density is greatest in the posterior cortex.
o the external limiting membrane is formed by the zonula occludens of the retinal
B Cloquet's canal is devoid of ccllagen fibrils.
pigment epithelium
C The vitreous is susceptible to osmotic dehydration through mannitol therapy.
E the inner segment of the photoreceptors receive their blood supply from the
D The vitreous cortex is thin over the optic disc and absent over the macula.
central retinal artery
E Hyalocytes are found in a single layer anterior to the inner limiting membrane of
the retina.

83 With regard to the retina,

79 The vitreous
A Muller cells are confined by the internal and external limiting membranes
B the inner and outer segments of a photoreceptor are connected by a ciliary stalk
A does not transmit UV light below 400 nm
consisting of ten pairs of microtubules
B plays a role in the blood-ocular barrier
C visual pigments are insoluble membrane proteins found on photoreceptor discs
60gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions Physiology Questions 61

o yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
the 11-eis-retinaldehyde in rhodopsln lies parallel to the disc membrane
C The outer segment of the retina is vulnerable to hypoxia In the dark.
E the Muller cell is responsible for the b-wave in the electroretinogram
D ATP synthesis is found on the inner membrane on the mitochondria.
E Sixty per cent of glucose metabolism in the retina is by anaerobic glycolysis.

84 How many of the following statements about the retina are correct?

88 Regarding the retina, which of the following are correct?

A The Gs protein 'transducin' in the photoreceptors remains inactive due to the
presence of the a subunit.
B The retinal pigment epithelium stores photopigment. A Photoreceptors store glycogen.
C The apicolateral surfaces of the retinal pigment epithelium contains zonula adhe- B Glucose uptake in the retina is Insulin independent.
rens and zonula occludens. C ON bipolar and OFF bipolar cells both release glutamate and directly excite
o 11-cis-Retinol is oxidized to 1t-cis-retinaldehyde by tt-eis-retinol dehydrogen- ganglion cells.
ase in the retinal pigment epithelium. o Pyruvate production in the retina is always greater than pyruvate metabolism.
E AII-trans-retinaldehyde combines with the apoprotein opsin to form rhodopsin. E Light adaptation is delayed at high altitude.EDCBA

85 With regard to the retina, a .c tr o p h y s io lo g ic a l investigations

A cGMP levels in the photoreceptors are low in the dark and rise in response to light 89 Which of the following statements about electroretinography are true?
B light exposure results in inhibition of phosphodiesterase
C a 'triad' refers to a penetration of two central dendrites from a bipolar cell anli a A The electroretinogram (ERG) Is normal if disease is confined to the macula.
process from a horizontal cell into a cone pedicle B The electro-oculogram (EOG) is abnormal In retinitis pigmentosa.
o the retinal pigment epithelium is a bilayer of cells arranged in a mainly hexagonal C The pattern ERG P50 wave is abnormal in disease confined to the macula.
array o Visual evoked potential (VEP) may be used to predict location of compressive
E photoreceptor tips are attached to retinal pigment epithelium processes by
lesions of the optic nerve.
junctional complexes
E The early recaptor potential of the ERG only occurs in dim light.

86 In the retina,
90 With regard to electroretinography and electro-oculography,

A rhodopsin has a half-life of to days

B the 'dark current' refers to the inflow of sodium ions from the extracellular space A the a-wave of the ERG is absenVabnormal in glaucoma
entering the inner segment of the photoreceptor B 30 Hz flicker ERG produces a pure cone response
C photoreceptors are ON cells C a normal Arden index is less than 180%
o less than one-fifth of glucose oxidation is via the hexose monophosphate shunt o the Arden index refers to the ratio of the light peak and the dark peak of the EOG
pathway E the c-wave of the ERG is produced by the retinal pigment epithelium
E the blood flow per unit mass to the retina is three times higher than to the kidney

91 How many of the following are true?

87 Which of the following are true?
A ERG is performed using electrodes placed over the visual cortex.
A j}-Carotene and retinyl esters are converted to retinol or vitamin A alcohol by the B The pattern ERG is commonly used to confirm central retinal artery occlusion.
retinal pigment epithelium. C The flash VEP is unaffected by refractive errors.
B The only visual pigment reaction requiring light is the conversion of rhodopsin to o The b-wave of the ERG increases in amplitude in dark adaptation.
bathorhodopsin. E Barbiturates reduce the amplitude of the ERG response.
60gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Questions Physiology Questions 61

o yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
the 11-eis-retinaldehyde in rhodopsln lies parallel to the disc membrane
C The outer segment of the retina is vulnerable to hypoxia In the dark.
E the Muller cell is responsible for the b-wave in the electroretinogram
D ATP synthesis is found on the inner membrane on the mitochondria.
E Sixty per cent of glucose metabolism in the retina is by anaerobic glycolysis.

84 How many of the following statements about the retina are correct?

88 Regarding the retina, which of the following are correct?

A The Gs protein 'transducin' in the photoreceptors remains inactive due to the
presence of the a subunit.
B The retinal pigment epithelium stores photopigment. A Photoreceptors store glycogen.
C The apicolateral surfaces of the retinal pigment epithelium contains zonula adhe- B Glucose uptake in the retina is Insulin independent.
rens and zonula occludens. C ON bipolar and OFF bipolar cells both release glutamate and directly excite
o 11-cis-Retinol is oxidized to 1t-cis-retinaldehyde by tt-eis-retinol dehydrogen- ganglion cells.
ase in the retinal pigment epithelium. o Pyruvate production in the retina is always greater than pyruvate metabolism.
E AII-trans-retinaldehyde combines with the apoprotein opsin to form rhodopsin. E Light adaptation is delayed at high altitude.EDCBA

85 With regard to the retina, a .c tr o p h y s io lo g ic a l investigations

A cGMP levels in the photoreceptors are low in the dark and rise in response to light 89 Which of the following statements about electroretinography are true?
B light exposure results in inhibition of phosphodiesterase
C a 'triad' refers to a penetration of two central dendrites from a bipolar cell anli a A The electroretinogram (ERG) Is normal if disease is confined to the macula.
process from a horizontal cell into a cone pedicle B The electro-oculogram (EOG) is abnormal In retinitis pigmentosa.
o the retinal pigment epithelium is a bilayer of cells arranged in a mainly hexagonal C The pattern ERG P50 wave is abnormal in disease confined to the macula.
array o Visual evoked potential (VEP) may be used to predict location of compressive
E photoreceptor tips are attached to retinal pigment epithelium processes by
lesions of the optic nerve.
junctional complexes
E The early recaptor potential of the ERG only occurs in dim light.

86 In the retina,
90 With regard to electroretinography and electro-oculography,

A rhodopsin has a half-life of to days

B the 'dark current' refers to the inflow of sodium ions from the extracellular space A the a-wave of the ERG is absenVabnormal in glaucoma
entering the inner segment of the photoreceptor B 30 Hz flicker ERG produces a pure cone response
C photoreceptors are ON cells C a normal Arden index is less than 180%
o less than one-fifth of glucose oxidation is via the hexose monophosphate shunt o the Arden index refers to the ratio of the light peak and the dark peak of the EOG
pathway E the c-wave of the ERG is produced by the retinal pigment epithelium
E the blood flow per unit mass to the retina is three times higher than to the kidney

91 How many of the following are true?

87 Which of the following are true?
A ERG is performed using electrodes placed over the visual cortex.
A j}-Carotene and retinyl esters are converted to retinol or vitamin A alcohol by the B The pattern ERG is commonly used to confirm central retinal artery occlusion.
retinal pigment epithelium. C The flash VEP is unaffected by refractive errors.
B The only visual pigment reaction requiring light is the conversion of rhodopsin to o The b-wave of the ERG increases in amplitude in dark adaptation.
bathorhodopsin. E Barbiturates reduce the amplitude of the ERG response.
 Physiology Questions
62 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
PHYSIOLOGY
The extraocular muscles
Answers
92 Which of the following statements about the extraocular muscles are true?

A The outer orbital layer of muscle fibres consist mainly of motor end-plates General physiology
scattered along the whole length of the muscle.
Cardiovascular
B Calcium influx for excitation contraction coupling of the global fibres is from the
surface membrane and not the sarcoplasmic reticulum. 1 A = True B = False C = False D = True E = True F:o True G = False
CY'Theextraocular muscles display a depolarizing block on exposure to succinyl-
choline (suxamethonium) that is enhanced by further exposure to a cholinester- cardiac output is the volume expelled by the left ventricle per unit time. It is heart rate x
ase. stroke volume and can be determined using Fick's principle:
o Sherrington's law describes the movement of yoke muscles.
Cardiac output = oxygen consumption (~ divided by
E Concentration of mitochondria is greater in the orbital layer than the global layer
arteriovenous ~ concentration difference (av~)
of the rectus muscle.
Cardiac output is usually calculated by thermodilution. Haemoglobin concentration is
not required in order to calculate cardiac output.
93 With regard to the extraocular muscles, As a unit volume of blood passes successively through the aorta. large arteries. major
branches.arterioles and capillaries. velocity decreases progressively as the total cross-
A they contain a high number of muscle spindles sectional area increases. The velocity of flow is inversely proportionally to the total
cross-sectional area of the vessels. The flow is usually laminar (streamline) in large
B tertiary positions of gaze involve rotation about the Y-axis
vessels.with greatest velocity being in the centre of the flow. At a critical velocity flow
C torsion by obliques involves rotation about the Y-axis
changes from the silent streamline to the noisy turbulent flow (I.e. bruits, Korotkoff
o in the isolated agonist model, the primary action of superior oblique Is of depres-
sounds).
sion and abduction
In anaemia. turbulence is seen due to reduced viscosity (haematocrit) and so
E inferior oblique causes intorsion
increased velocity of flow. The Hagen-Poiseuille Law explains that resistance to flow
is proportional to the length of a tube (Q and the viscosity of the fluidEDCBA
( n ) . and inversely

proportional to the fourth power of the radius.

Blood flow in systole may be as high as 0.7 mJs in the aorta but compliance of the
aortic vessel wall causes stretch followed by rebound. Blood flows in diastole with a
smooth type of flow and an overall mean velocity of 0.2 mJs.
Coronary blood flow at rest is 250 mVmin (5% of cardiac output) and during exercise
can rise up to 750 mVmin. remaining approximately 5% of cardiac output. Increased
coronary oxygen consumption is further facilitated by a greater av~.

2 A = False B = False C:o False D = False E = True F = True

Blood flow depends on vessel diameter which is influenced and regulated by local,
neural and hormonal control.
M y o g e n ic a u to r e g u la tio n describes vasoconstriction secondary to a rise in blood
pressure causing vessels to stretch. Renal and cerebral blood flow are controlled by
 Physiology Questions
62 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
PHYSIOLOGY
The extraocular muscles
Answers
92 Which of the following statements about the extraocular muscles are true?

A The outer orbital layer of muscle fibres consist mainly of motor end-plates General physiology
scattered along the whole length of the muscle.
Cardiovascular
B Calcium influx for excitation contraction coupling of the global fibres is from the
surface membrane and not the sarcoplasmic reticulum. 1 A = True B = False C = False D = True E = True F:o True G = False
CY'Theextraocular muscles display a depolarizing block on exposure to succinyl-
choline (suxamethonium) that is enhanced by further exposure to a cholinester- cardiac output is the volume expelled by the left ventricle per unit time. It is heart rate x
ase. stroke volume and can be determined using Fick's principle:
o Sherrington's law describes the movement of yoke muscles.
Cardiac output = oxygen consumption (~ divided by
E Concentration of mitochondria is greater in the orbital layer than the global layer
arteriovenous ~ concentration difference (av~)
of the rectus muscle.
Cardiac output is usually calculated by thermodilution. Haemoglobin concentration is
not required in order to calculate cardiac output.
93 With regard to the extraocular muscles, As a unit volume of blood passes successively through the aorta. large arteries. major
branches.arterioles and capillaries. velocity decreases progressively as the total cross-
A they contain a high number of muscle spindles sectional area increases. The velocity of flow is inversely proportionally to the total
cross-sectional area of the vessels. The flow is usually laminar (streamline) in large
B tertiary positions of gaze involve rotation about the Y-axis
vessels.with greatest velocity being in the centre of the flow. At a critical velocity flow
C torsion by obliques involves rotation about the Y-axis
changes from the silent streamline to the noisy turbulent flow (I.e. bruits, Korotkoff
o in the isolated agonist model, the primary action of superior oblique Is of depres-
sounds).
sion and abduction
In anaemia. turbulence is seen due to reduced viscosity (haematocrit) and so
E inferior oblique causes intorsion
increased velocity of flow. The Hagen-Poiseuille Law explains that resistance to flow
is proportional to the length of a tube (Q and the viscosity of the fluidEDCBA
( n ) . and inversely

proportional to the fourth power of the radius.

Blood flow in systole may be as high as 0.7 mJs in the aorta but compliance of the
aortic vessel wall causes stretch followed by rebound. Blood flows in diastole with a
smooth type of flow and an overall mean velocity of 0.2 mJs.
Coronary blood flow at rest is 250 mVmin (5% of cardiac output) and during exercise
can rise up to 750 mVmin. remaining approximately 5% of cardiac output. Increased
coronary oxygen consumption is further facilitated by a greater av~.

2 A = False B = False C:o False D = False E = True F = True

Blood flow depends on vessel diameter which is influenced and regulated by local,
neural and hormonal control.
M y o g e n ic a u to r e g u la tio n describes vasoconstriction secondary to a rise in blood
pressure causing vessels to stretch. Renal and cerebral blood flow are controlled by
64gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers Answers 65

autoregulation and are influenced by this myogenic effect. Skin and pulmonary vessels
are not regulated by myogenic autoregulation.EDCBA
-
Physiology

4 It. '" False B = False C = False 0 = False E = False

H y p o x ic a u to r e g u la tio n describes vasodilation in response to low levels of oxygen, earoreceptors are stretch receptors. They are found in blood vessel walls over the
thereby allowing Increased blood flow and oxygen supply. Most vessels vasodilate in aortic arch and carotid sinus. They are also found in the walls of left ventricle, left and
the presence of hypoxia, however pulmonary vessels undergo h y p o x ic v a s o c o n s tr ic - right atria, the superior vena cava and the inferior vena cava as well as the pulmonary
which facilitates blood to lung areas of greater ventilation in oxygenation. Note that
tio n veins. They discharge with stretch and inhibit sympathetic vasoconstrictor activity and
vasoconstriction of greater than 50% of pulmonary vasculature results in pulmonary stimulate vagal cardiac activity. Blood pressure decreases by vasodilation, bradycardia
hypertension. and a fall in cardiac output. Venodilation also occurs.
Increased local levels of metabolites such as CO 2 (especially skin and brain) and W
(decreased pH), ADP, AMp, adenosine (cardiac muscle not skeleta~ and t<+ (especially
skeletal) cause vasodilation (reactive h y p e r a e m ia ) to facilitate faster removal. A rise In
5 A = False B = False C = False 0 = True E = False
local temperature also causes a vasodilation as does the release of EDRF (endothe-
lium-derived relaxing factor) which is now known to be nitric oxide.
Vasodilation during erection in genital organs is due to parasympathetic stimulation by
There is n e u r a l c o n tr o l of both vasoconstriction and vasodilation. The arterioles in the
postganglionic cholinergiC fibres. Adrenaline vasodilates in low concentrations by its
skeletal muscles circulation are mainly under control of p:!-adrenergic receptors; how-
effect on p:! receptors in skeletal muscle and the liver. In high concentrations it is a
ever, the increased blood flow observed in exercise is mainly due to vasodilation
vasoconstrictor by acting on a receptors.
secondary to the accumulation of tissue metabolites.
ADH (vasopressin) is a potent vasoconstrictor in v itr o .
Pain via afferent impulses to the reticular formation ects on the vasomotor centre
causing raised blood pressure.
Inspiration causes increased venous retum to the right side of the heart and
3 A = False B = False C = True 0 = True E = False F = True
reduced venous return to the left side of the heart. This in turn briefly reduces left
ventricular output. Also, via vagal afferent signals there is a brief Inhibition of the
Between 0.3 and 0.5% of plasma flow is filtered by capillaries into the interstitial space.
vasomotor centre causing vasodilation and a transient fall in blood pressure. This fall
This is calculated by cardiac output being 5 Umin, therefore 7200 L a day. Haematocrit
in blood pressure is detected by baroreceptors that trigger activation of the vaso-
is 0.45, therefore plasma flow is 3960 L a day. It is known that approximately 2~24 L of
motor centre and reduce activation of the vagal cardioinhlbitory centre in compensa-
fluid each day enters the interstitial space through capillaries outside the kidneys, thus
tion. The process of inspiration and expiration thus causes a physiOlogical sinus
a calculation of 0.3-<l.5% can be made. Ninety per cent of this ultrafiltrate is resorbed
arrythmia.
through the capillaries back into the circulation. Ten per cent returns via lymph.
At heart level, precapillary hydrostatic pressure Is 30 mmHg, failing to 14 mmHg at
the venous end. The oncotic pressure difference is about 20 mmHg. This decreases
with increasing capillary permeability. Starling's hypothesis explains that this difference 6 A = False B = False C = True 0 = False E = False
along with available area of exchange detennines the extent of trenscapillary filtration
and resorptlon. In most organs the capillary wall is almost completely impermeable to Pulse pressure is the difference in systolic and diastolic pressure. It Is a function of
protein. Permeability is greater, however, in the liver and also the intestines. arterial compliance and stroke volume. It rises with increased vessel rigidity (decreased
As blood passes through capillaries, fluid filters out into the interstitia~ space. Hae- compliance) and increased stroke volume. Mean pressure is proportional to total
matocrit therefore increases as blood undergoes haemoconcentration. CO 2 fonned by peripheral resistance. It is the geometric mean of systolic and diastolic pressure, or
metabolism dissolves readily in the interstitial space and diffuses into the red blood roughly equates to the diastolic plus one-third of the difference between systolic and
cells. It is converted to HCOa- and W quickly by carbonic anhydrase. W is buffered in diastolic pressure.
the cell and HCOa- diffuses passively into the plasma in exchange for CI- diffusing into Pulmonary artery pressure is approximately 25 mmHg (13.3 kPa) systolic and
the red cells. The greater concentration of CI- in venous red cells than in arterial red 10 mmHg (1.3 kPa) diastolic. Mean pressure Is therefore approximately 15 mmHg.
cells results In a fluid shift into the red cell, thereby increasing mean cell volume. COnditions causing chronic hypoxia such as living at high altitudes and chronic
The Bohr effect describes how a fall in pH reduces the affinity of haemoglobin for obstructive airways disease, cause pulmonary hypoxic vasoconstriction in order to
oxygen. For a given ~, a reduction in percentage saturation of haemoglobin and COmpensate for a ventilation: perfusion mismatch. Vasoconstriction of greater than
oxygen-carrying capacity of blood is seen. The oxygen-/laemoglobin dissociation 50% of the pulmonary vasculature raises resistance enough to cause pulmonary
curve shifts to the right. hypertension.
64gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers Answers 65

autoregulation and are influenced by this myogenic effect. Skin and pulmonary vessels
are not regulated by myogenic autoregulation.EDCBA
-
Physiology

4 It. '" False B = False C = False 0 = False E = False

H y p o x ic a u to r e g u la tio n describes vasodilation in response to low levels of oxygen, earoreceptors are stretch receptors. They are found in blood vessel walls over the
thereby allowing Increased blood flow and oxygen supply. Most vessels vasodilate in aortic arch and carotid sinus. They are also found in the walls of left ventricle, left and
the presence of hypoxia, however pulmonary vessels undergo h y p o x ic v a s o c o n s tr ic - right atria, the superior vena cava and the inferior vena cava as well as the pulmonary
which facilitates blood to lung areas of greater ventilation in oxygenation. Note that
tio n veins. They discharge with stretch and inhibit sympathetic vasoconstrictor activity and
vasoconstriction of greater than 50% of pulmonary vasculature results in pulmonary stimulate vagal cardiac activity. Blood pressure decreases by vasodilation, bradycardia
hypertension. and a fall in cardiac output. Venodilation also occurs.
Increased local levels of metabolites such as CO 2 (especially skin and brain) and W
(decreased pH), ADP, AMp, adenosine (cardiac muscle not skeleta~ and t<+ (especially
skeletal) cause vasodilation (reactive h y p e r a e m ia ) to facilitate faster removal. A rise In
5 A = False B = False C = False 0 = True E = False
local temperature also causes a vasodilation as does the release of EDRF (endothe-
lium-derived relaxing factor) which is now known to be nitric oxide.
Vasodilation during erection in genital organs is due to parasympathetic stimulation by
There is n e u r a l c o n tr o l of both vasoconstriction and vasodilation. The arterioles in the
postganglionic cholinergiC fibres. Adrenaline vasodilates in low concentrations by its
skeletal muscles circulation are mainly under control of p:!-adrenergic receptors; how-
effect on p:! receptors in skeletal muscle and the liver. In high concentrations it is a
ever, the increased blood flow observed in exercise is mainly due to vasodilation
vasoconstrictor by acting on a receptors.
secondary to the accumulation of tissue metabolites.
ADH (vasopressin) is a potent vasoconstrictor in v itr o .
Pain via afferent impulses to the reticular formation ects on the vasomotor centre
causing raised blood pressure.
Inspiration causes increased venous retum to the right side of the heart and
3 A = False B = False C = True 0 = True E = False F = True
reduced venous return to the left side of the heart. This in turn briefly reduces left
ventricular output. Also, via vagal afferent signals there is a brief Inhibition of the
Between 0.3 and 0.5% of plasma flow is filtered by capillaries into the interstitial space.
vasomotor centre causing vasodilation and a transient fall in blood pressure. This fall
This is calculated by cardiac output being 5 Umin, therefore 7200 L a day. Haematocrit
in blood pressure is detected by baroreceptors that trigger activation of the vaso-
is 0.45, therefore plasma flow is 3960 L a day. It is known that approximately 2~24 L of
motor centre and reduce activation of the vagal cardioinhlbitory centre in compensa-
fluid each day enters the interstitial space through capillaries outside the kidneys, thus
tion. The process of inspiration and expiration thus causes a physiOlogical sinus
a calculation of 0.3-<l.5% can be made. Ninety per cent of this ultrafiltrate is resorbed
arrythmia.
through the capillaries back into the circulation. Ten per cent returns via lymph.
At heart level, precapillary hydrostatic pressure Is 30 mmHg, failing to 14 mmHg at
the venous end. The oncotic pressure difference is about 20 mmHg. This decreases
with increasing capillary permeability. Starling's hypothesis explains that this difference 6 A = False B = False C = True 0 = False E = False
along with available area of exchange detennines the extent of trenscapillary filtration
and resorptlon. In most organs the capillary wall is almost completely impermeable to Pulse pressure is the difference in systolic and diastolic pressure. It Is a function of
protein. Permeability is greater, however, in the liver and also the intestines. arterial compliance and stroke volume. It rises with increased vessel rigidity (decreased
As blood passes through capillaries, fluid filters out into the interstitia~ space. Hae- compliance) and increased stroke volume. Mean pressure is proportional to total
matocrit therefore increases as blood undergoes haemoconcentration. CO 2 fonned by peripheral resistance. It is the geometric mean of systolic and diastolic pressure, or
metabolism dissolves readily in the interstitial space and diffuses into the red blood roughly equates to the diastolic plus one-third of the difference between systolic and
cells. It is converted to HCOa- and W quickly by carbonic anhydrase. W is buffered in diastolic pressure.
the cell and HCOa- diffuses passively into the plasma in exchange for CI- diffusing into Pulmonary artery pressure is approximately 25 mmHg (13.3 kPa) systolic and
the red cells. The greater concentration of CI- in venous red cells than in arterial red 10 mmHg (1.3 kPa) diastolic. Mean pressure Is therefore approximately 15 mmHg.
cells results In a fluid shift into the red cell, thereby increasing mean cell volume. COnditions causing chronic hypoxia such as living at high altitudes and chronic
The Bohr effect describes how a fall in pH reduces the affinity of haemoglobin for obstructive airways disease, cause pulmonary hypoxic vasoconstriction in order to
oxygen. For a given ~, a reduction in percentage saturation of haemoglobin and COmpensate for a ventilation: perfusion mismatch. Vasoconstriction of greater than
oxygen-carrying capacity of blood is seen. The oxygen-/laemoglobin dissociation 50% of the pulmonary vasculature raises resistance enough to cause pulmonary
curve shifts to the right. hypertension.
 Physiology AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
66gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Physiology Answers 67

Blood pressure may be measured directly by placing sensory devices directly into the entering the right ventricle and pulmonary artery through to the aorta At birth the
arterial blood stream, and indirectly by using an inflatable cuff. direction of flow reverses. It closes a few days after birth.
The umbilical artery carries deoxygenated blood from the foetus to the placenta.
At birth, sudden loss of the placenta results in an increased CO 2 and other waste
7 A = False B = False C = False D = False E = False prodUCts. The rise in ~ stimulates ventilation via chernoreceptors.

The phases of the cardiac cycle are: (1) systolic contraction phase; (2) systolic ejection
phase; (3) relaxation phase of diastole; (4) diastolic filling phase. Respiratory
End-diastolic ventricular volume is approximately 125 ml, which can double in exer-
cise. The ventricular filling at rest is mainly passive. Atrial contraction contributes to the 10 A = True B = False C = False D = False E = True F = True
final 20% , but at higher heart rates, because diastole is shorter, it contributes more.
Systole begins with a contraction phase, initially with isovolumetrlc contraction: Dry air at sea level has an atmospheric pressure of 760 mmHg (101.3 kPa), ~ =
ventricular pressure rises with fixed volume. Once ventricular pressure is greater than 601 mmHg (80.1 kPa), ~ = 159 mmHg (21.2 kPa) and ~
'" 0.23 mmHg (0.03 kPa).
aortic pressure, the next phase of ejection proceeds by opening of the semilunar Before reaching the alveoli, expired area is humidified by the trachea and Pti:tJ is at
valves. the constant value of 47 mmHg (6.37 kPa). This results in alveolar PN2 = 574 mmHg
Coronary blood flow to the left ventricle occurs only in diastole because the left (76.5 kPa), P o .z = 100 mmHg (13.3 kPa), ~ = 39 mmHg (5.2 kPa) and Pti:tJ =
ventricular walls squeeze the vessels during contraction. Pressure in the right ventricleEDCBA 47 mmHg (6.27 kPa).
reaches up to 25 mmHg. For this reason, coronary blood flow to the right ventricle
o n ly PhYSiological arteriovenous shunting due to ventilation: perfusion mismatching and
mainly occurs in diastole but also occurs at a reduced rate in systole. *. bronchial veins carrying deoxygenated blood into the oxygenated pulmonary vein
The jugular venous pulse is made of five main waves: a, c, x, v, y. The positive a-wave causes arterial blood gases different to those of alveoli.
represents atrial contraction. This is followed by a second positive c-wave, represent- In the aorta ~ = 95 mmHg (12.66 kPa) and ~ '" 41 mmHg (5.47 kPa).
ing closure of the tricuspid valve. The negative x-wave represents a fall in venous Mixed venous blood ~ '" 40 mmHg (5.33 kPa), P c o , = 45 mmHg (6.0 kPa).
pressure as contraction in the ventricle pulls the valves and results in depression of Expired air ~ = 115 mmHg (15.33 kPa), ~ = 33 mmHg (4.4 kPa), Pti:tJ =
their level. This creates a 'suction effect' in the great veins. Next is the positive v-wave 47 mmHg (6.27 kPa), PN2 = 565 mmHg (76.5 kPa). Note that the fractional concentra-
representing the opening of the tricuspid valve forced by a rise in the atrial pressure tions of expired air are O 2 = 0.14-0.15% , CO 2 = 0.45% , H2 0 = 0.06% and N2 =
(filling). The final negative y-wave represents passive filling of blood from the atrium to 0.75% .
the ventricle.

11 A = False B = False C = False 0 = True E = False F = True G = False

8 A = True B = True C = True D = False E = False H = True

The.Frank-8tarling Law describes how the 'energy of muscle contraction is related to lung surfactant decreases alveolar surface tension.
the initial length of the cardiac muscle fibre'. The initial length is proportional to end- Dead space refers to the total volume of air channels transmitting inspired air to the
dlastolic volume and if plotted against stroke volume gives the Frank-8tarling curve. alveoli and not taking part in gas exchange Q.e. mouth, nose, pharynx, trachea and
lying supine rather than standing increases venous return to the heart as does venous bronchQ. Physiological dead space refers to anatomical dead space plus any areas of
c o n tr a c tio n . Ventricular filling occurs in diastole and is reduced in tachycardia. Cardiac reduced gas exchange either by reducing perfuslon to alveoli or by impairing diffusion
tamponade causes reduced ventricular volume. across alveolar membranes, thereby creating further dead space. Physiological dead
space is at least equal to anatomical dead space, but may well be greater. Pulmonary
embolus impairs lung perfusion, creating a ventilation: perfusion mismatch and
9 A = False B = False C = False 0 = True E = True F = True increases physiological dead space.
Tidal volume (VT) equals volume reaching alveoli (V,..) plus air shifted in dead space
Foetal placental blood has an oxygen saturation of 80% . Oxygenated blood is carried (Vo). Dead space is approximately 150 ml, It may be calculated using the Bohr
from the placenta in the umbilical vein through the ductus venosus, bypassing the liver, equation.
to the inferior vena cava and the heart. Tidal volume equals 500 ml, therefore the volume reaching alveoli is approximately
The ductus arteriosus carries venous blood largely from the superior vena cava 350 rnl.
 Physiology AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
66gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Physiology Answers 67

Blood pressure may be measured directly by placing sensory devices directly into the entering the right ventricle and pulmonary artery through to the aorta At birth the
arterial blood stream, and indirectly by using an inflatable cuff. direction of flow reverses. It closes a few days after birth.
The umbilical artery carries deoxygenated blood from the foetus to the placenta.
At birth, sudden loss of the placenta results in an increased CO 2 and other waste
7 A = False B = False C = False D = False E = False prodUCts. The rise in ~ stimulates ventilation via chernoreceptors.

The phases of the cardiac cycle are: (1) systolic contraction phase; (2) systolic ejection
phase; (3) relaxation phase of diastole; (4) diastolic filling phase. Respiratory
End-diastolic ventricular volume is approximately 125 ml, which can double in exer-
cise. The ventricular filling at rest is mainly passive. Atrial contraction contributes to the 10 A = True B = False C = False D = False E = True F = True
final 20% , but at higher heart rates, because diastole is shorter, it contributes more.
Systole begins with a contraction phase, initially with isovolumetrlc contraction: Dry air at sea level has an atmospheric pressure of 760 mmHg (101.3 kPa), ~ =
ventricular pressure rises with fixed volume. Once ventricular pressure is greater than 601 mmHg (80.1 kPa), ~ = 159 mmHg (21.2 kPa) and ~
'" 0.23 mmHg (0.03 kPa).
aortic pressure, the next phase of ejection proceeds by opening of the semilunar Before reaching the alveoli, expired area is humidified by the trachea and Pti:tJ is at
valves. the constant value of 47 mmHg (6.37 kPa). This results in alveolar PN2 = 574 mmHg
Coronary blood flow to the left ventricle occurs only in diastole because the left (76.5 kPa), P o .z = 100 mmHg (13.3 kPa), ~ = 39 mmHg (5.2 kPa) and Pti:tJ =
ventricular walls squeeze the vessels during contraction. Pressure in the right ventricleEDCBA 47 mmHg (6.27 kPa).
reaches up to 25 mmHg. For this reason, coronary blood flow to the right ventricle
o n ly PhYSiological arteriovenous shunting due to ventilation: perfusion mismatching and
mainly occurs in diastole but also occurs at a reduced rate in systole. *. bronchial veins carrying deoxygenated blood into the oxygenated pulmonary vein
The jugular venous pulse is made of five main waves: a, c, x, v, y. The positive a-wave causes arterial blood gases different to those of alveoli.
represents atrial contraction. This is followed by a second positive c-wave, represent- In the aorta ~ = 95 mmHg (12.66 kPa) and ~ '" 41 mmHg (5.47 kPa).
ing closure of the tricuspid valve. The negative x-wave represents a fall in venous Mixed venous blood ~ '" 40 mmHg (5.33 kPa), P c o , = 45 mmHg (6.0 kPa).
pressure as contraction in the ventricle pulls the valves and results in depression of Expired air ~ = 115 mmHg (15.33 kPa), ~ = 33 mmHg (4.4 kPa), Pti:tJ =
their level. This creates a 'suction effect' in the great veins. Next is the positive v-wave 47 mmHg (6.27 kPa), PN2 = 565 mmHg (76.5 kPa). Note that the fractional concentra-
representing the opening of the tricuspid valve forced by a rise in the atrial pressure tions of expired air are O 2 = 0.14-0.15% , CO 2 = 0.45% , H2 0 = 0.06% and N2 =
(filling). The final negative y-wave represents passive filling of blood from the atrium to 0.75% .
the ventricle.

11 A = False B = False C = False 0 = True E = False F = True G = False

8 A = True B = True C = True D = False E = False H = True

The.Frank-8tarling Law describes how the 'energy of muscle contraction is related to lung surfactant decreases alveolar surface tension.
the initial length of the cardiac muscle fibre'. The initial length is proportional to end- Dead space refers to the total volume of air channels transmitting inspired air to the
dlastolic volume and if plotted against stroke volume gives the Frank-8tarling curve. alveoli and not taking part in gas exchange Q.e. mouth, nose, pharynx, trachea and
lying supine rather than standing increases venous return to the heart as does venous bronchQ. Physiological dead space refers to anatomical dead space plus any areas of
c o n tr a c tio n . Ventricular filling occurs in diastole and is reduced in tachycardia. Cardiac reduced gas exchange either by reducing perfuslon to alveoli or by impairing diffusion
tamponade causes reduced ventricular volume. across alveolar membranes, thereby creating further dead space. Physiological dead
space is at least equal to anatomical dead space, but may well be greater. Pulmonary
embolus impairs lung perfusion, creating a ventilation: perfusion mismatch and
9 A = False B = False C = False 0 = True E = True F = True increases physiological dead space.
Tidal volume (VT) equals volume reaching alveoli (V,..) plus air shifted in dead space
Foetal placental blood has an oxygen saturation of 80% . Oxygenated blood is carried (Vo). Dead space is approximately 150 ml, It may be calculated using the Bohr
from the placenta in the umbilical vein through the ductus venosus, bypassing the liver, equation.
to the inferior vena cava and the heart. Tidal volume equals 500 ml, therefore the volume reaching alveoli is approximately
The ductus arteriosus carries venous blood largely from the superior vena cava 350 rnl.
 Physiology Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers 69
68
3 --
If f is the frequency of breathing, then:
VT.f= VA.f+ VoJ TOTAL LUNG
CAPACITY
I VITAL
CAPACITY
IHSPIAATORY
RESERve
VOlUMe
In rapid shallow breathing V T is reduced as frequency increases. Minute ventilation
(VT.f) increases slightly; however, as dead space (VD)remains constant the result is that
dead space ventilation (Vo.f) is increased markedly and alveolar ventilation (VAf) and
gas exchange are reduced.
c

~
5
0 +-+ ">---V \,./ \ volUMEi k t \ /
+
\ /
12 A = True B = False C = True D = False E = False F = True >

The lungs have a tendency to contract, causing intrapleural pressure to be negative. -,

Intrapleural pressure beComes positive mainly in forced expiration.
Pulmonary compliance is changed in volume per unit of change in transpu!monary -2

pressure.
Compliance is the reciprocal of elastance. It is increased in emphysema because of
loss of elasticity and an enlargement of respiratory bronchioles and alveoli, and break- ~r/6/////A///////////V///'
TIME (s)
down of alveolar walls.
Alveoli are lined with two types of epithelial cells: type I cells are the primary lining of
figure 1 Parameters used to calculate respiratory volumes
the alveoli and are flat with lots of cytoplasm; type 11 cells (or granular pneumocytes) are
thicker, contain inclusion bodies, and produce surfactant. 14 A = False B = True C = True D = True E = False

Lung surfactant is made up of dipalmitoylphosphatidylcholine, other phospholipids.

13 A = False B = False C = False D = True E = True lipids and proteins. It lowers surface tension in the walls of alveoli, increasing com-
pliance and preventing collapse. It is reduced In hyaline membrane disease and heavy
Vital capacity (Vel is the volume expired from maximum inspiration to maximum smoking.
expiration. Vc = 4.5 L. however varies from 2.5 to 7 L according to height. age, sex The Laplace relationship defines surface tension in the wall of a sphere as being
proportional to transmural pressure times radius. For a given fluid lining the sphere the
and physical training.
surface tension is constant and so pressure across the wall reduces as radius
TIdal volume (Yr) is the volume inspired during quiet respiration. V T = 0.5 L.
increases.
Inspiratory reserve volume (IRV)is the volume of gas inspired by expiration at rest to
full inspiration. IRV = 3 L.
Expiratory reserve volume (ERV)is the volume expired from expiration at rest to full
expiration. ERV = 1.5 L. 15 A = False B = False C = True D = True E = False
Residual volume (RV)is the volume of gas remaining in the lungs after full expiration.
Alveolar ventilation is greater in the base of the lung compared to the apex when
RV = 1.5 L.
Functional residual capacity (FRC) is the volume of gas remaining in lungs after upright. This is because the apex is already expanded due to stretch as a result of
the weight of the lung before inspiration begins. The base of the lung has a greater
expiration at rest. FRC = 3 L.
Total lung capacity (TlC) is the vital capacity plus residual volume. Vc + RV = TLC = volume of expansion during inspiration. When erect. the pulmonary blood flow (per unit
volume) increases from apex to base. When supine, this difference disappears.
6 L. This varies with age. sex, size and physical training.
Due to ventilation increasing less steeply than pulmonary blood flow from apex to
Vc. Yr. IRV and ERV may be measured using spirometry. RV and FRC must be
base. the ventilation: perfusion ratio is greater in the apex (3.3) than the base (0.63) of
measured indirectly using helium or nitrogen dilution. or whole-body plethysmography
the lung when erect.
(to also include encapsulated air spaces such as cysts etc.). See Figure 1.
 Physiology Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers 69
68
3 --
If f is the frequency of breathing, then:
VT.f= VA.f+ VoJ TOTAL LUNG
CAPACITY
I VITAL
CAPACITY
IHSPIAATORY
RESERve
VOlUMe
In rapid shallow breathing V T is reduced as frequency increases. Minute ventilation
(VT.f) increases slightly; however, as dead space (VD)remains constant the result is that
dead space ventilation (Vo.f) is increased markedly and alveolar ventilation (VAf) and
gas exchange are reduced.
c

~
5
0 +-+ ">---V \,./ \ volUMEi k t \ /
+
\ /
12 A = True B = False C = True D = False E = False F = True >

The lungs have a tendency to contract, causing intrapleural pressure to be negative. -,

Intrapleural pressure beComes positive mainly in forced expiration.
Pulmonary compliance is changed in volume per unit of change in transpu!monary -2

pressure.
Compliance is the reciprocal of elastance. It is increased in emphysema because of
loss of elasticity and an enlargement of respiratory bronchioles and alveoli, and break- ~r/6/////A///////////V///'
TIME (s)
down of alveolar walls.
Alveoli are lined with two types of epithelial cells: type I cells are the primary lining of
figure 1 Parameters used to calculate respiratory volumes
the alveoli and are flat with lots of cytoplasm; type 11 cells (or granular pneumocytes) are
thicker, contain inclusion bodies, and produce surfactant. 14 A = False B = True C = True D = True E = False

Lung surfactant is made up of dipalmitoylphosphatidylcholine, other phospholipids.

13 A = False B = False C = False D = True E = True lipids and proteins. It lowers surface tension in the walls of alveoli, increasing com-
pliance and preventing collapse. It is reduced In hyaline membrane disease and heavy
Vital capacity (Vel is the volume expired from maximum inspiration to maximum smoking.
expiration. Vc = 4.5 L. however varies from 2.5 to 7 L according to height. age, sex The Laplace relationship defines surface tension in the wall of a sphere as being
proportional to transmural pressure times radius. For a given fluid lining the sphere the
and physical training.
surface tension is constant and so pressure across the wall reduces as radius
TIdal volume (Yr) is the volume inspired during quiet respiration. V T = 0.5 L.
increases.
Inspiratory reserve volume (IRV)is the volume of gas inspired by expiration at rest to
full inspiration. IRV = 3 L.
Expiratory reserve volume (ERV)is the volume expired from expiration at rest to full
expiration. ERV = 1.5 L. 15 A = False B = False C = True D = True E = False
Residual volume (RV)is the volume of gas remaining in the lungs after full expiration.
Alveolar ventilation is greater in the base of the lung compared to the apex when
RV = 1.5 L.
Functional residual capacity (FRC) is the volume of gas remaining in lungs after upright. This is because the apex is already expanded due to stretch as a result of
the weight of the lung before inspiration begins. The base of the lung has a greater
expiration at rest. FRC = 3 L.
Total lung capacity (TlC) is the vital capacity plus residual volume. Vc + RV = TLC = volume of expansion during inspiration. When erect. the pulmonary blood flow (per unit
volume) increases from apex to base. When supine, this difference disappears.
6 L. This varies with age. sex, size and physical training.
Due to ventilation increasing less steeply than pulmonary blood flow from apex to
Vc. Yr. IRV and ERV may be measured using spirometry. RV and FRC must be
base. the ventilation: perfusion ratio is greater in the apex (3.3) than the base (0.63) of
measured indirectly using helium or nitrogen dilution. or whole-body plethysmography
the lung when erect.
(to also include encapsulated air spaces such as cysts etc.). See Figure 1.
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 71
70
is anionic and binds avidly to deoxyhaemoglobin. Increased levels are seen during
Transection of the spinal cord above the level of C3 is fatal as both phrenic nerves are
exercise, altitude and anaemia that may cause hypoxia.
lost as well as the innervation to the intercostal muscles. A rise in 2,3-DPG is seen to facilitate oxygen release from haemoglobin to the
Physiological dead space causes a high ventilation:perfusion ratio.
tissues. Storing blood results in reduced glycolysis and reduced 2,3-OPG production.
This results in a shift to the left of the oxygen dissociation curve and reduced oxygen
release from haemoglobin.
16 A = True B = False C '" False 0 = False E = False

CO is approximately 20 times more soluble than ~ in blood. Deoxygenated haemo-

2
globin binds C~ more readily than does oxyhaemoglobin. This allows C02 to be
Renal
carried away from tissue in venous blood and results in release of C~ in the pulmonary
capillaries where haemoglobin is then oxygenated. 18 A = True B = False C = False 0 = True E = False
CO2 diffuses easily across the blood-brain barrier. W and HC03 ". however, do not
diffuse easily across the blood-brain barrier. The kidneys have three main roles: (1) an excretory role, (2) a homeostatic role, and (3)
Carotid body chemoreceptors respond primarily to changes In ~. an endocrine role, whereby they produce hormones including renin, erythropoietin and
The majority of CO2 in blood is distributed as HC03 - • C 02 diffusing into a red blood 1 a-hydroxylase. .
cell is converted quickly into HC03 - by the enzyme carbonic anhydrase. $e'l9l1ty per
1a-Hydroxylase is a crucial enzyme in the final step in production of 1,25-di/1ydrox-
cent of this HC03 - leaves the red blood cell in exchange for CI- entering. In arterial
ycholecalciferol (calcitriol) from 25-hydroxycholecalclferol. Calcitriol plays an important
blood, 3% of CO is dissolved in plasma and 2% is dissolved in the red blood cell; role in calcium and skeletal mineralization.
2
0.5% is bound to plasma proteins and 5% is bound to haemoglobin in the red blood
The cells of the proximal convoluted tubule possess a rich brush border and numer-
cell; 60% is distributed as HC03 - dissolved in plasma and 30% as HC~ - in the red ous mitochondria beside the basolateral membrane. The distal convoluted tubules are
blood cell. poor in mitochondria and do not possess a brush border. The macula densa exists early
In venous blood the distribution remains relatively similar with C~ boUnd to hae- on at the distal convoluted tubule.
3
moglobin increasing to up to 6%. The rise in the C~ level is reflected in the HC0 -

concentration in venous blood being higher.

19 A = True B = False C = False 0 = True E = False F = False

17 A = False B = False C = False 0 = True E = True
Renal blood flow at rest is 25% of cardiac output (1.2 Umin). The renal artery divides
Mixed venous blood is 75% saturated with O 2 , into interlobar arteries, then into arcuate arteries, then into interlobular arteries in the
Cyanosis is due to the dark colour of deoxygenated haemoglobin which gives skin a
cortex of the kidney. finally dividing into afferent arterioles. AutoregUlation of renal
bluish-grey discoloration. It occurs when the concentration of deoxygenated haemo- blood flow occurs mainly at the level of the afferent arteriole. The interlobular arteries
globin in blood is greater than 5 gl100 ml and is due to the abSOlute concentration. It
play a role in controlling renal blood flow and are highly sensitive to local catechola-
occurs in polycythaemia in the absence of tissue hypoxia. mines. The efferent arterioles are constricted by angiotensin 11 and improve perfusion
Hypoxia stimulates peripheral (carotid) chemoreceptors. A rise in ~ stimulates when pressure is low.
central chemoreceptors and also sensitizes the peripheral chernoreceptors to changes
Autoregulation maintains constant renal blood flow with mean arterial blood pressure
in~. between 80 and 200 mmHg. Mean arterial blood pressure may be roughly calculated as
The oxygen dissociation curve is a sigmoid curve with the x-axis being ~ and the y- diastolic plus one-third of the difference between systolic and diastolic.
axis being either O saturation or concentration of oxygenated haemoglobin. It may be The kidneys filter plasma rather than blood. Plasma volume = blood volume x (1-
2
displaced to the left or right as well as 'stretched' vertically when cl&scribing oxyhae-
haematocrit). Renal plasma flow can be measured using Fick's principle by measuring
moglobin concentration (02 capacity) with haemoglobin fully saturated. the amount of a given substance removed per unit time divided by the arteriovenous
The curve is shifted to the left Oncreased O 2 affinity) by a rise in pH (decreased [H+}- difference in concentration.
the Bohr effect), a fall in temperature and a fall in the levels of 2,3-diphosphoglycerate Para-aminohippuric acid is useful in calculating renal blood flow as it is filtered by the
(2,3-DPG) in the red blood cells. The curve is shifted to the right with the opposite
glomerulus and further secreted into the proximal convoluted tubule. " is also reliable
conditions. because at low-dose infusions 90% is cleared in each single renal circulation.
2,3-DPG is the product of anaerobic glycolysis and is found in the red blood cells. It
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 71
70
is anionic and binds avidly to deoxyhaemoglobin. Increased levels are seen during
Transection of the spinal cord above the level of C3 is fatal as both phrenic nerves are
exercise, altitude and anaemia that may cause hypoxia.
lost as well as the innervation to the intercostal muscles. A rise in 2,3-DPG is seen to facilitate oxygen release from haemoglobin to the
Physiological dead space causes a high ventilation:perfusion ratio.
tissues. Storing blood results in reduced glycolysis and reduced 2,3-OPG production.
This results in a shift to the left of the oxygen dissociation curve and reduced oxygen
release from haemoglobin.
16 A = True B = False C '" False 0 = False E = False

CO is approximately 20 times more soluble than ~ in blood. Deoxygenated haemo-

2
globin binds C~ more readily than does oxyhaemoglobin. This allows C02 to be
Renal
carried away from tissue in venous blood and results in release of C~ in the pulmonary
capillaries where haemoglobin is then oxygenated. 18 A = True B = False C = False 0 = True E = False
CO2 diffuses easily across the blood-brain barrier. W and HC03 ". however, do not
diffuse easily across the blood-brain barrier. The kidneys have three main roles: (1) an excretory role, (2) a homeostatic role, and (3)
Carotid body chemoreceptors respond primarily to changes In ~. an endocrine role, whereby they produce hormones including renin, erythropoietin and
The majority of CO2 in blood is distributed as HC03 - • C 02 diffusing into a red blood 1 a-hydroxylase. .
cell is converted quickly into HC03 - by the enzyme carbonic anhydrase. $e'l9l1ty per
1a-Hydroxylase is a crucial enzyme in the final step in production of 1,25-di/1ydrox-
cent of this HC03 - leaves the red blood cell in exchange for CI- entering. In arterial
ycholecalciferol (calcitriol) from 25-hydroxycholecalclferol. Calcitriol plays an important
blood, 3% of CO is dissolved in plasma and 2% is dissolved in the red blood cell; role in calcium and skeletal mineralization.
2
0.5% is bound to plasma proteins and 5% is bound to haemoglobin in the red blood
The cells of the proximal convoluted tubule possess a rich brush border and numer-
cell; 60% is distributed as HC03 - dissolved in plasma and 30% as HC~ - in the red ous mitochondria beside the basolateral membrane. The distal convoluted tubules are
blood cell. poor in mitochondria and do not possess a brush border. The macula densa exists early
In venous blood the distribution remains relatively similar with C~ boUnd to hae- on at the distal convoluted tubule.
3
moglobin increasing to up to 6%. The rise in the C~ level is reflected in the HC0 -

concentration in venous blood being higher.

19 A = True B = False C = False 0 = True E = False F = False

17 A = False B = False C = False 0 = True E = True
Renal blood flow at rest is 25% of cardiac output (1.2 Umin). The renal artery divides
Mixed venous blood is 75% saturated with O 2 , into interlobar arteries, then into arcuate arteries, then into interlobular arteries in the
Cyanosis is due to the dark colour of deoxygenated haemoglobin which gives skin a
cortex of the kidney. finally dividing into afferent arterioles. AutoregUlation of renal
bluish-grey discoloration. It occurs when the concentration of deoxygenated haemo- blood flow occurs mainly at the level of the afferent arteriole. The interlobular arteries
globin in blood is greater than 5 gl100 ml and is due to the abSOlute concentration. It
play a role in controlling renal blood flow and are highly sensitive to local catechola-
occurs in polycythaemia in the absence of tissue hypoxia. mines. The efferent arterioles are constricted by angiotensin 11 and improve perfusion
Hypoxia stimulates peripheral (carotid) chemoreceptors. A rise in ~ stimulates when pressure is low.
central chemoreceptors and also sensitizes the peripheral chernoreceptors to changes
Autoregulation maintains constant renal blood flow with mean arterial blood pressure
in~. between 80 and 200 mmHg. Mean arterial blood pressure may be roughly calculated as
The oxygen dissociation curve is a sigmoid curve with the x-axis being ~ and the y- diastolic plus one-third of the difference between systolic and diastolic.
axis being either O saturation or concentration of oxygenated haemoglobin. It may be The kidneys filter plasma rather than blood. Plasma volume = blood volume x (1-
2
displaced to the left or right as well as 'stretched' vertically when cl&scribing oxyhae-
haematocrit). Renal plasma flow can be measured using Fick's principle by measuring
moglobin concentration (02 capacity) with haemoglobin fully saturated. the amount of a given substance removed per unit time divided by the arteriovenous
The curve is shifted to the left Oncreased O 2 affinity) by a rise in pH (decreased [H+}- difference in concentration.
the Bohr effect), a fall in temperature and a fall in the levels of 2,3-diphosphoglycerate Para-aminohippuric acid is useful in calculating renal blood flow as it is filtered by the
(2,3-DPG) in the red blood cells. The curve is shifted to the right with the opposite
glomerulus and further secreted into the proximal convoluted tubule. " is also reliable
conditions. because at low-dose infusions 90% is cleared in each single renal circulation.
2,3-DPG is the product of anaerobic glycolysis and is found in the red blood cells. It
 Physiology Answers 73
Physiology AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ngfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 22 A = False B = True C = True D = False E = True
20 A = True B = False C = False D = False E = True F = False G = True
Sodium reabsorption does not occur on the descending loop of Henle. Seventy per
The glomerular filtration rate in a nonnal adult is approximately 125 mVmin (both cent of sodium is reabsorbed In the proximal convoluted tubule actively due to the
kidneys}. It is proportional to body surface area. As renal plasma flow is approximately basolateral Na+W ATPase pump. CI- and H 20 follow by secondary active transport
700 ml/min, GFR is calculated as being 20% of renal plasma flow. GFR of 125 mVmin is and an osmotic gradient respectively, resulting In isotonic resorption.
equivalent to 180 Uday and 99% of this is reabsorbed in the tubules to produce In the thick ascending loop, a further 20% Is reabsorbed by the basolateral Na+K+
approximately 1 L of urine per day. Twenty pe!' cent of GFR would be 36 L of urine a ATPase pump, creating a sodium gradient for sodium to enter from the luminal sida.
day, which is clearly not seen. The sodium enters the thick ascending loop tubule cells via a carrier channel, the Na+-
Diabetes insipidus is a result of the absence or ineffective action of AOH acting on K+ and 2CI- channel by a process of secondary active co-transport. Loop diuretics
the distal convoluting tubule and collecting ducts. inhibit this channel and in doing so prevent a concentration gradient being created in
Blood urea concentration is a poor test of glomerular function, because althoUgh a the renal medulla.
normal concentration relies on renal excretion. it also depeOdSon dietary protein intake. Carbonic anhydrase inhibitors are useful diuretic agents. They inhibit the reversible
Inulin clearance is useful in measuring the GFR because it is freely filtered by the HC03 - +W +:! CO 2 +H 2 0.
glomerulus and is not bound to plasma protein. It is not reabsorbed or secreted by Filtered HC03 - is normally converted to CO 2 and H 20 by luminal brush border
tubule cells and is not stored or me~bo\ized. It is non-toxic. does not actuallY effect the carbonic anhydrase at the proximal convoluted tubule. The C~ and H 2 0 passively
glomerular filtration rate and is relatively easy to measure in both plasma and urine. enter the tubUle cells and carbonic anhydrase in the tubl:llar cells produces HC03 - and
W again. W may be excreted coupled to sodium reabsorption and HC03 - is reab-
sorbed into the circulation by secondary active transport. Inhibition of carbonic anhy-
drase essentially inhibits this process. This reduces the sodium reabsorption that is
21 A = True B = True C = True D = False E = False coupled with W excretion, but more importantly inhibits HCO:!- reabsorption. Reduced
W excretion results in increased potassium excretion as potassium and W compete
o-Glucose is reabsorbed only in the proximal convoluted tubule mainly in the early part. with each other.
The mechanism is by secondary active co-transport whereby it is coupled with Na+ Aldosterone, by acting on DNA and modifying protein synthesis at the distal con-
transport into the cell. Na+ transport into the cell is along a concentration gradient voluted tubule, collecting ducts and to a small degree the bladder, increases sodium
created by the Na+K+ ATPase pump situated, on the baSOlateral membrane of the reabsorption within 30 min.
tubular epithelium.
Uric acid is predominantly reabsorbed at the proximal convoluted tubule; however,
small quantities of uric acid. endogenouS substances such as glucororides. and exo-
genous substances such as PAH and penicillin and other drugs are actively secreted 23 A = True B = True C = True D = False E = True
into the proximal convoluted tubule.
Potassium and W ions are actively secreted in both proximal and distal convoluted The weight of a 70 kg man is made up of 60% water (42 W and 40% proteins. minerals
tubules and the collecting ducts. Creatinine is actively secreted in small amounts by the and fat. Of the body water content, two-thirds (40% total weight or 28 L) is intracellular
proximal convoluted tubules and increases total creatinine in urine by up to 20%. and one-third (20% weight or 14 L) is extracellular. Of the extracellular fluid, three-
luted
The tubular epithelium is impermeable to urea except for the proximal conllO quarters (15% weight or approximately 10.5 L) is in the interstitial space, whereas
tubule and the medullary portion of the collecting ducts. where urea passively moves one-quarter (5% weight or approximately 3.5 L) makes up plasma volume.
out along an osmotic gradient. Intracellular and extracellular fluid osmolality is 290 mOsmlkg H 2 0. Extracellular fluid
Although natural penicillins are metabolized to a small extent to the inactive peni- osmolality is tightly controlled by hypothalamic osmoreceptors which stimulate
cilloic acid by hydrolysis of the [3-lactam ring in either the gastrointestlnal tract or the hypothalamic production and posterior pituitary release of ADH, with effects on the
liver, they are mainly and rapidly excreted in urine by tubular secretion. target organ, the kidney.
Two-thirds of a single intramuscular or intravenous dose of penicillin G is excreted A rise of 3 mOsm/kg H 2 0 (1%) is all that is needed to increase AOH release. Pain
mainly unchanged within 6 h. Over 90% of this is by active tubular secretion and 10% also increases AOH release. ADH release is inhibited by intake of hypotonic fluid such
by glomerular filtration. as water. causing a fall in osmolality. Reduced sodium intake resulting in reduced
Approximately half of a single oral dose of penicillin V is excreted In urine within 8 h Osmolality may briefly reduce ADH release. Alcohol inhibits AOH release.
and approximately 30% is excreted in faeces.
 Physiology Answers 73
Physiology AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ngfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 22 A = False B = True C = True D = False E = True
20 A = True B = False C = False D = False E = True F = False G = True
Sodium reabsorption does not occur on the descending loop of Henle. Seventy per
The glomerular filtration rate in a nonnal adult is approximately 125 mVmin (both cent of sodium is reabsorbed In the proximal convoluted tubule actively due to the
kidneys}. It is proportional to body surface area. As renal plasma flow is approximately basolateral Na+W ATPase pump. CI- and H 20 follow by secondary active transport
700 ml/min, GFR is calculated as being 20% of renal plasma flow. GFR of 125 mVmin is and an osmotic gradient respectively, resulting In isotonic resorption.
equivalent to 180 Uday and 99% of this is reabsorbed in the tubules to produce In the thick ascending loop, a further 20% Is reabsorbed by the basolateral Na+K+
approximately 1 L of urine per day. Twenty pe!' cent of GFR would be 36 L of urine a ATPase pump, creating a sodium gradient for sodium to enter from the luminal sida.
day, which is clearly not seen. The sodium enters the thick ascending loop tubule cells via a carrier channel, the Na+-
Diabetes insipidus is a result of the absence or ineffective action of AOH acting on K+ and 2CI- channel by a process of secondary active co-transport. Loop diuretics
the distal convoluting tubule and collecting ducts. inhibit this channel and in doing so prevent a concentration gradient being created in
Blood urea concentration is a poor test of glomerular function, because althoUgh a the renal medulla.
normal concentration relies on renal excretion. it also depeOdSon dietary protein intake. Carbonic anhydrase inhibitors are useful diuretic agents. They inhibit the reversible
Inulin clearance is useful in measuring the GFR because it is freely filtered by the HC03 - +W +:! CO 2 +H 2 0.
glomerulus and is not bound to plasma protein. It is not reabsorbed or secreted by Filtered HC03 - is normally converted to CO 2 and H 20 by luminal brush border
tubule cells and is not stored or me~bo\ized. It is non-toxic. does not actuallY effect the carbonic anhydrase at the proximal convoluted tubule. The C~ and H 2 0 passively
glomerular filtration rate and is relatively easy to measure in both plasma and urine. enter the tubUle cells and carbonic anhydrase in the tubl:llar cells produces HC03 - and
W again. W may be excreted coupled to sodium reabsorption and HC03 - is reab-
sorbed into the circulation by secondary active transport. Inhibition of carbonic anhy-
drase essentially inhibits this process. This reduces the sodium reabsorption that is
21 A = True B = True C = True D = False E = False coupled with W excretion, but more importantly inhibits HCO:!- reabsorption. Reduced
W excretion results in increased potassium excretion as potassium and W compete
o-Glucose is reabsorbed only in the proximal convoluted tubule mainly in the early part. with each other.
The mechanism is by secondary active co-transport whereby it is coupled with Na+ Aldosterone, by acting on DNA and modifying protein synthesis at the distal con-
transport into the cell. Na+ transport into the cell is along a concentration gradient voluted tubule, collecting ducts and to a small degree the bladder, increases sodium
created by the Na+K+ ATPase pump situated, on the baSOlateral membrane of the reabsorption within 30 min.
tubular epithelium.
Uric acid is predominantly reabsorbed at the proximal convoluted tubule; however,
small quantities of uric acid. endogenouS substances such as glucororides. and exo-
genous substances such as PAH and penicillin and other drugs are actively secreted 23 A = True B = True C = True D = False E = True
into the proximal convoluted tubule.
Potassium and W ions are actively secreted in both proximal and distal convoluted The weight of a 70 kg man is made up of 60% water (42 W and 40% proteins. minerals
tubules and the collecting ducts. Creatinine is actively secreted in small amounts by the and fat. Of the body water content, two-thirds (40% total weight or 28 L) is intracellular
proximal convoluted tubules and increases total creatinine in urine by up to 20%. and one-third (20% weight or 14 L) is extracellular. Of the extracellular fluid, three-
luted
The tubular epithelium is impermeable to urea except for the proximal conllO quarters (15% weight or approximately 10.5 L) is in the interstitial space, whereas
tubule and the medullary portion of the collecting ducts. where urea passively moves one-quarter (5% weight or approximately 3.5 L) makes up plasma volume.
out along an osmotic gradient. Intracellular and extracellular fluid osmolality is 290 mOsmlkg H 2 0. Extracellular fluid
Although natural penicillins are metabolized to a small extent to the inactive peni- osmolality is tightly controlled by hypothalamic osmoreceptors which stimulate
cilloic acid by hydrolysis of the [3-lactam ring in either the gastrointestlnal tract or the hypothalamic production and posterior pituitary release of ADH, with effects on the
liver, they are mainly and rapidly excreted in urine by tubular secretion. target organ, the kidney.
Two-thirds of a single intramuscular or intravenous dose of penicillin G is excreted A rise of 3 mOsm/kg H 2 0 (1%) is all that is needed to increase AOH release. Pain
mainly unchanged within 6 h. Over 90% of this is by active tubular secretion and 10% also increases AOH release. ADH release is inhibited by intake of hypotonic fluid such
by glomerular filtration. as water. causing a fall in osmolality. Reduced sodium intake resulting in reduced
Approximately half of a single oral dose of penicillin V is excreted In urine within 8 h Osmolality may briefly reduce ADH release. Alcohol inhibits AOH release.
and approximately 30% is excreted in faeces.
 Physiology Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers 75
74gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
1 thyroxine-binding globulin (TBG), which atthough present in small concentrations
24 A = True B = True C = False D = True E = False
binds 67% of T4;
Renin Is an enzyme produced and stored as pro-renin by the juxtaglomerular cells of 2 thyroxine-binding pre-albumin (TBPA), which binds 15% of T4;
the kidney (but also produced in the brain, heart and adrenal gland). It is released as 3 albumin, which binds 13% of T4.
renin and cleaves angiotensinogen (from the liver) to produce angiotensin I (a decaPep- Thyroid hormones enter cells without binding to receptors or channels. They bind to
tide). Angiotensin I is converted to the active angiotensin 11 by converting enzymes nuclear membrane receptors and the resulting thyroid receptor complex then binds to
found in the lungs, kidneys and elsewhere. Angiotensin 11 acts to elevate arterial blood DNA altering gene expression. The change in mRNA produced causes production of
pressure both by rapid vasoconstriction at the level of the arterioles and by reducing enzymes that are able to atter cell function. T3 and T4 are able to cross the blood-brain
salt and water excretion by the kidneyS. barrier and are found in grey matter. CSF protein levels are raised in hypothyroidism
Angiotensin 11 acts on the kidneys both directly and indirectly. Directly. its mechanism and lowered in hyperthyroidism.
is thought to be vasoconstriction of renal vasculature and a weak effect on tubules The half-life of TSH is 1 h. TSH is secreted in a pulsatile form. It begins to increase
increasing reabsorption of sodium and water. Indirectly, angiotensin 11 stimulates from 21.00 hours and peaks at approximately midnight. declining during the day.
increased aldosterone production at the zona glomerulosa of the edrenal cortex. Regulation of thyroid secretion is by a negative feedback mechanism. TRH from the
Aldosterone acts mainly to increase sodium and water reabsorption at the dlstal hypothalamus directly stimulates TSH release from the anterior pituitary. TSH increases
convoluted tubules and collecting ducts of the kidney. This causes a rise illl extracellular iodide uptake and T3fT4 production by the thyroid gland. Free T3 and T4 in the
volume and helps to maintain raised arterial blood pressure. circulation directly inhibit both TRH production by the hypothalamus and TSH produc-
Hypoaldosteronism results in hyponatraemia and hyperkalaemia; however, hyperal- tion by the anterior pituitary. T3 is more active than T4, as it binds more readily and acts
dosteronism results in a normal sodium concentration as a result of the consequent more rapidly and effectively than T4 on the nuclear recaptor. T4 is converted in the
water reabSOrption, and instead, hypokalaemia as a result of increased potassium periphery to T3 by deiodination.
excretion.EDCBA

27 A = True B = True C = True 0 = True E = False

f n d o c r in o lo g y Glucagon is a catabolic hormone produced in the A cells In the Islets of Langerhans as

pre-proglucagon. It is useful in mobilizing stores of glucose, fatty acids and amino
25 A = True B = True C = True D = True E = True acids. It is made up of a single polypeptide chain and its structure is the same in all
mammals. It has a half-life of 5-10 min and is destroyed in the liver.
Iodine deficiency (and paradoxically excess as well) inhibits thyroid function, leading to
primary hypothyroidism where TSH secretion increases due to the lack of negative
feedback. Thyroxine increases oxygen uptake and consumption in most cells of the
28 A = False B = True C = False 0 = False E = False
body. Although not essential to life, it is necessary for normal growth and development
and regulates lipid and carbohydrate metabolism. Insulin is a 51 amino acid dipeptide with a half-life of 10-30 min. Its actions are generally
Hypercholesterolaemia is seen in hypothyroidism. This is thought to be because
anabolic, increasing glucose, fatty acid and amino acid stores. It does not increase glucose
thyroxine increases low density lipoprotein (LOll receptor formation in the liver, thus
uptake in the brain, kidney, gastrointestinal mucosa and the red blood cells. Its actions also
facilitating removal of circulating cholesterol. include a rapid increase in the number of membrane glucose transporter proteins that
Iodide is taken up by TSH-independently in the salivary glands, gastric mucosa,
facilitate glucose uptake into cells. Its Immediate effects include increased protein synth-
ciliary body of the eye, choroid plexus, placenta and mammary glands. esis, glycogenesis and reduced protein breakdown. Its delayed effect is to increase
The half-life of thyroxine is approximately 6-7 days. lipogenesis and decrease lipolysis. Insulin inhibits gluconeogenesis in the liver.

29 A = False B = False C = False D = False E = True

26 A = True B = False C = True D = True E = True F = False

ADH (vasopressin) is a neural hormone from the neurohypophysis. It is produced in the

Ninety-nine per cent of circulating T4 is bound either to plasma or tissue proteins.
cell bodies of the magnocellular neurones In the supraoptic and paraventricular nuclei
These plasma proteins include:
 Physiology Answers yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers 75
74gfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
1 thyroxine-binding globulin (TBG), which atthough present in small concentrations
24 A = True B = True C = False D = True E = False
binds 67% of T4;
Renin Is an enzyme produced and stored as pro-renin by the juxtaglomerular cells of 2 thyroxine-binding pre-albumin (TBPA), which binds 15% of T4;
the kidney (but also produced in the brain, heart and adrenal gland). It is released as 3 albumin, which binds 13% of T4.
renin and cleaves angiotensinogen (from the liver) to produce angiotensin I (a decaPep- Thyroid hormones enter cells without binding to receptors or channels. They bind to
tide). Angiotensin I is converted to the active angiotensin 11 by converting enzymes nuclear membrane receptors and the resulting thyroid receptor complex then binds to
found in the lungs, kidneys and elsewhere. Angiotensin 11 acts to elevate arterial blood DNA altering gene expression. The change in mRNA produced causes production of
pressure both by rapid vasoconstriction at the level of the arterioles and by reducing enzymes that are able to atter cell function. T3 and T4 are able to cross the blood-brain
salt and water excretion by the kidneyS. barrier and are found in grey matter. CSF protein levels are raised in hypothyroidism
Angiotensin 11 acts on the kidneys both directly and indirectly. Directly. its mechanism and lowered in hyperthyroidism.
is thought to be vasoconstriction of renal vasculature and a weak effect on tubules The half-life of TSH is 1 h. TSH is secreted in a pulsatile form. It begins to increase
increasing reabsorption of sodium and water. Indirectly, angiotensin 11 stimulates from 21.00 hours and peaks at approximately midnight. declining during the day.
increased aldosterone production at the zona glomerulosa of the edrenal cortex. Regulation of thyroid secretion is by a negative feedback mechanism. TRH from the
Aldosterone acts mainly to increase sodium and water reabsorption at the dlstal hypothalamus directly stimulates TSH release from the anterior pituitary. TSH increases
convoluted tubules and collecting ducts of the kidney. This causes a rise illl extracellular iodide uptake and T3fT4 production by the thyroid gland. Free T3 and T4 in the
volume and helps to maintain raised arterial blood pressure. circulation directly inhibit both TRH production by the hypothalamus and TSH produc-
Hypoaldosteronism results in hyponatraemia and hyperkalaemia; however, hyperal- tion by the anterior pituitary. T3 is more active than T4, as it binds more readily and acts
dosteronism results in a normal sodium concentration as a result of the consequent more rapidly and effectively than T4 on the nuclear recaptor. T4 is converted in the
water reabSOrption, and instead, hypokalaemia as a result of increased potassium periphery to T3 by deiodination.
excretion.EDCBA

27 A = True B = True C = True 0 = True E = False

f n d o c r in o lo g y Glucagon is a catabolic hormone produced in the A cells In the Islets of Langerhans as

pre-proglucagon. It is useful in mobilizing stores of glucose, fatty acids and amino
25 A = True B = True C = True D = True E = True acids. It is made up of a single polypeptide chain and its structure is the same in all
mammals. It has a half-life of 5-10 min and is destroyed in the liver.
Iodine deficiency (and paradoxically excess as well) inhibits thyroid function, leading to
primary hypothyroidism where TSH secretion increases due to the lack of negative
feedback. Thyroxine increases oxygen uptake and consumption in most cells of the
28 A = False B = True C = False 0 = False E = False
body. Although not essential to life, it is necessary for normal growth and development
and regulates lipid and carbohydrate metabolism. Insulin is a 51 amino acid dipeptide with a half-life of 10-30 min. Its actions are generally
Hypercholesterolaemia is seen in hypothyroidism. This is thought to be because
anabolic, increasing glucose, fatty acid and amino acid stores. It does not increase glucose
thyroxine increases low density lipoprotein (LOll receptor formation in the liver, thus
uptake in the brain, kidney, gastrointestinal mucosa and the red blood cells. Its actions also
facilitating removal of circulating cholesterol. include a rapid increase in the number of membrane glucose transporter proteins that
Iodide is taken up by TSH-independently in the salivary glands, gastric mucosa,
facilitate glucose uptake into cells. Its Immediate effects include increased protein synth-
ciliary body of the eye, choroid plexus, placenta and mammary glands. esis, glycogenesis and reduced protein breakdown. Its delayed effect is to increase
The half-life of thyroxine is approximately 6-7 days. lipogenesis and decrease lipolysis. Insulin inhibits gluconeogenesis in the liver.

29 A = False B = False C = False D = False E = True

26 A = True B = False C = True D = True E = True F = False

ADH (vasopressin) is a neural hormone from the neurohypophysis. It is produced in the

Ninety-nine per cent of circulating T4 is bound either to plasma or tissue proteins.
cell bodies of the magnocellular neurones In the supraoptic and paraventricular nuclei
These plasma proteins include:
 Physiology Answers 77
Physiology Answers
76 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA tea

of the hypothalamus. AOH is transferred by axoplasmic flow in granules down the

axons of these nerves to their nerve endings in the posterior pituitary where they are
stored and released in response to an action potential. Its main effects are of water
retention by increasing water permeability at the collecting ducts of the kidney. In vitro It
causes vasoconstriction. It decreases cardiac output when injectedEDCBA
in v iv o by acting on
32 A '" True B = True C = False D = True E = False
the area postrem a.
AOH also acts on the liver to cause glycogenolySis and on the anterior pituitary to
A 70 kg adult contains approximately 1.1 kg of calcium. 99% of which is in the skeletal
increase ACTH release. cortex. Calcitonin is produced by the parafollicular C cells of the thyroid gland and is
AOH release Is Increased by a fall in extracellular fluid volume. pain and an increase in
secreted in response to hypercalcaemia.
plasma osmolality of 3 mOsmIkg H 20.
Parathyroid hormone increases renal tubular reabsorption of calcium and loss of
phosphate, It also increases cortical bone reabsorption and by stimulating 1a-
hydroxylase activity in the kidney. it increases hydroxylation of 25-0H vitamin 0 to
30 A = False B = False C = True D = True E = False 1.2S-(0Hl2 vitamin D.
Oestrogen is known to inhibit osteoclast acitivity in bone; however. no oestrogen
The adrenal medulla is not under regulation of the pituitary. It is supplied by pregan-
receptors have been found in bone.
glionic sympathetic fibres and is also influenced by the adrenal cortex. Aldosterone is
important in the regulation of salt balance and extracellular volume. It is not directly
controlled by the pituitary and hypophYSectomy does not effect aldosterone release in
33 A = True B = False C = False D = True E = True F = true G = True
the same way as cortisol and sex hormones are affected where atrophy of the zona
fasciculata and zona reticularls of the adrenal gland is seen. ne Renal effects of glucocorticoids include a mineralocorticoid effect of increased sodium
ACTH is a 39 amino acid peptide hormone derived from the prohormo pro- reabsorption at the distal convoluted tubule and collecting duct and an increase in the
opiometanocortin (pOMC). It has a half-life of 10 min and is secreted by the anterior GFR. causing a conflicting increased sodium load.
pituitary in pulsatile bursts with a mean peak at around 6 am. Unlike aldosterone. glucocorticoids in circulation are mostly bound to an a-globulin
Hypertension due to excess growth hormone is caused by increased heart size known as transcortin or corticosteroid binding globulin (CBG). Some is also bound to
resulting in increased stroke volume and cardiac output. albumin.
LH. FSH. TSH and HCG are two-unit structures made up of an a and a fJ subunit. Effects of glucocorticoids on the immune system include inhibition of Iymphocyte
ACTH. prolactin and growth hormone have a single-unit chain peptide structure. formation and so reduction in B and T Iymphocytes. reduction in eoslnophils, reduction
in protein synthesis. reducing production of arachidonic acid derivatives and mem-
brane stabilization reducing histamine release. Phaoochromocytoma describes an
adrenal medullary tumour that usually secrates noradrenaline. but can be found to
31 A '" True B = True C = True D '" False E = False
secrete mainly adrenaline.
Hypercalcaemia has many causes. In the presence of reduced serum phosphete. The aldosterone receptor. being a steroid hormone recaptor, is intracellular.
causes can include primary hyperparathyroidism. tertiary hyperparathyroidism or ecto- The adrenal cortex secretes 21-carbon and 19-carbon steroids. Aldosterone (zona
pic parathyroid secretiOn. Hypercalcaemia associated with raised serum phosphate glomerulosa) and cortisol (zona fasciculata) are 21-carbon steroids and so both have
may be due to excess vitamin 0 (due to over-administration. sarcOidosis or idiopathic). mineralocorticoid activity. Aldosterone has a hydroxyl group at position 18 and so is
malignancy of bone ~ncluding osteolytic bone metastases. secretion of pTH-like pep- known as an 18-hydroxycorticosteroid.
tide. and myeloma). thiazide diuretic therapy (that promotes calcium absorption) or

hyperthyroidism.
Effects of hypercalcaemia include cardiovascular (increased digoxin toxicity. sudden 34 A = True B = True C = False 0 = False E = False
arrest. hypertension). gastrointestinal (gastric ulcers. constipation. abdominal pain).
neurological (depression. anorexia. nausea and vomiting) and renal (polyuria) effects. Synthesis of noradrenaline and adrenaline involves the conversion of phenylalanine to
Hypocalce associated with hyperphosphataemia may be due to primary hypo- tyroSine to DOPA to dopamine and to noradrenaline. and then to adrenaline. The half-
emia life of noradrenaline and adrenaline in plasma circulation is approximately 2 min.
parathyroidism as a result of Surgery to the thyroid or parathyrolds. It may also be due
to chronic renal failure or be seen in shock with hypoalbuminaemia. It may be asso-
 Physiology Answers 77
Physiology Answers
76 yxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA tea

of the hypothalamus. AOH is transferred by axoplasmic flow in granules down the

axons of these nerves to their nerve endings in the posterior pituitary where they are
stored and released in response to an action potential. Its main effects are of water
retention by increasing water permeability at the collecting ducts of the kidney. In vitro It
causes vasoconstriction. It decreases cardiac output when injectedEDCBA
in v iv o by acting on
32 A '" True B = True C = False D = True E = False
the area postrem a.
AOH also acts on the liver to cause glycogenolySis and on the anterior pituitary to
A 70 kg adult contains approximately 1.1 kg of calcium. 99% of which is in the skeletal
increase ACTH release. cortex. Calcitonin is produced by the parafollicular C cells of the thyroid gland and is
AOH release Is Increased by a fall in extracellular fluid volume. pain and an increase in
secreted in response to hypercalcaemia.
plasma osmolality of 3 mOsmIkg H 20.
Parathyroid hormone increases renal tubular reabsorption of calcium and loss of
phosphate, It also increases cortical bone reabsorption and by stimulating 1a-
hydroxylase activity in the kidney. it increases hydroxylation of 25-0H vitamin 0 to
30 A = False B = False C = True D = True E = False 1.2S-(0Hl2 vitamin D.
Oestrogen is known to inhibit osteoclast acitivity in bone; however. no oestrogen
The adrenal medulla is not under regulation of the pituitary. It is supplied by pregan-
receptors have been found in bone.
glionic sympathetic fibres and is also influenced by the adrenal cortex. Aldosterone is
important in the regulation of salt balance and extracellular volume. It is not directly
controlled by the pituitary and hypophYSectomy does not effect aldosterone release in
33 A = True B = False C = False D = True E = True F = true G = True
the same way as cortisol and sex hormones are affected where atrophy of the zona
fasciculata and zona reticularls of the adrenal gland is seen. ne Renal effects of glucocorticoids include a mineralocorticoid effect of increased sodium
ACTH is a 39 amino acid peptide hormone derived from the prohormo pro- reabsorption at the distal convoluted tubule and collecting duct and an increase in the
opiometanocortin (pOMC). It has a half-life of 10 min and is secreted by the anterior GFR. causing a conflicting increased sodium load.
pituitary in pulsatile bursts with a mean peak at around 6 am. Unlike aldosterone. glucocorticoids in circulation are mostly bound to an a-globulin
Hypertension due to excess growth hormone is caused by increased heart size known as transcortin or corticosteroid binding globulin (CBG). Some is also bound to
resulting in increased stroke volume and cardiac output. albumin.
LH. FSH. TSH and HCG are two-unit structures made up of an a and a fJ subunit. Effects of glucocorticoids on the immune system include inhibition of Iymphocyte
ACTH. prolactin and growth hormone have a single-unit chain peptide structure. formation and so reduction in B and T Iymphocytes. reduction in eoslnophils, reduction
in protein synthesis. reducing production of arachidonic acid derivatives and mem-
brane stabilization reducing histamine release. Phaoochromocytoma describes an
adrenal medullary tumour that usually secrates noradrenaline. but can be found to
31 A '" True B = True C = True D '" False E = False
secrete mainly adrenaline.
Hypercalcaemia has many causes. In the presence of reduced serum phosphete. The aldosterone receptor. being a steroid hormone recaptor, is intracellular.
causes can include primary hyperparathyroidism. tertiary hyperparathyroidism or ecto- The adrenal cortex secretes 21-carbon and 19-carbon steroids. Aldosterone (zona
pic parathyroid secretiOn. Hypercalcaemia associated with raised serum phosphate glomerulosa) and cortisol (zona fasciculata) are 21-carbon steroids and so both have
may be due to excess vitamin 0 (due to over-administration. sarcOidosis or idiopathic). mineralocorticoid activity. Aldosterone has a hydroxyl group at position 18 and so is
malignancy of bone ~ncluding osteolytic bone metastases. secretion of pTH-like pep- known as an 18-hydroxycorticosteroid.
tide. and myeloma). thiazide diuretic therapy (that promotes calcium absorption) or

hyperthyroidism.
Effects of hypercalcaemia include cardiovascular (increased digoxin toxicity. sudden 34 A = True B = True C = False 0 = False E = False
arrest. hypertension). gastrointestinal (gastric ulcers. constipation. abdominal pain).
neurological (depression. anorexia. nausea and vomiting) and renal (polyuria) effects. Synthesis of noradrenaline and adrenaline involves the conversion of phenylalanine to
Hypocalce associated with hyperphosphataemia may be due to primary hypo- tyroSine to DOPA to dopamine and to noradrenaline. and then to adrenaline. The half-
emia life of noradrenaline and adrenaline in plasma circulation is approximately 2 min.
parathyroidism as a result of Surgery to the thyroid or parathyrolds. It may also be due
to chronic renal failure or be seen in shock with hypoalbuminaemia. It may be asso-
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 79
78
In the dorsal column pathway, the sacral and lumbar fibres lie medial to the thoracic
The effects of adrenaline on the circulation are mediated by both a- and J}-receptors.
and cervical fibres. In the spinothalamic tract, the sacral and lumbar fibres are dis-
These effects include increased myocardial contractility, heart rate and excitability. At
placed more laterally to the thoracic and cervical fibres. It is important to remember this
low concentrations adrenaline causes vasodilation in skeletal muscle and liver vessels
when diagnosing extrinsic and intrinsic spinal tumours causing spinal compression.
and as a result reduces peripheral vascular resistance. Adrenaline also causes an
The descending corticospinal tract largely decussates at the medullary pyramids and
increased cardiac output and wider pulse pressure by increasing systolic and decreas-
80% is from then on known as the lateral corticospinal tract that synapses with anterior
ing diastolic arterial blood pressure (mixed a- and J}-receptor activity).
hom cells to innervate distallimb musculature. Approximately 20% of the corticospinal
The effect of circulating noradrenaline on the heart is similar, but noradrenaline
tract does not decussate at the medulla and continues as the anterior corticospinal
causes generalized vasoconstriction (a-recaptor activity). This results in a rise in
tract. This tract plays an important role in controlling the truncal limb musculature.
mean arterial blood pressure by increasing both systolic and diastolic pressure. Sec-
The Babinski sign is a dorsiflexion response of the toes along with some fanning on
ondary to baroceptor stimulation, a compensatory reduction in the heart rate may be
scratching the outer aspects of the sole of the foot. In a normal individual the response
seen. should be plantarfiexion due to control by the lateral corticospinal tract. The Babinski
Circulating adrenaline and noradrenaline are mainly broken down In the liver to met-
sign indicates damage to the lateral corticospinal tract, but its true significance is not
products, conjugates and VMA (3-metho-4-hydroxymandelic acid). Almost 50% of clear.
these breakdown products are excreted In urine as met-products, 35% as VMA and
small amounts of free noradrenaline and adrenaline are also seen. ,
5-HIAA (5-hydroxyindoleacetic adc!) is the main urinary metabolyte of 5-HT (serotonin).
Adrenalectomy results in reduced plasma levels of adrenaline but not of noradrena-
37 A = False B = True C = True 0 = True E = False

line, whose levels are extremely low and rarely reach those that cause cardiovascular
The knee and ankle jerks are examples of monosynaptic stretch reflexes elicited by
effect. The effects of noradrenaline are mainly due to local release from postganglionic
stretch of intratusal muscle spindle fibres.
sympathetic nerve endings.
A direct synapse on to the ipsilateral a-motor neurone innervating the regular con-
tracting extratusal muscle fibres causes muscle contraction. The muscle spindles lie
parallel to the rest of the muscle fibres and reduce firing when the extratusal fibres
eNS contract.
During fine motor control r-motor innervation of the intratusal spindle fibres allows
35 A = False B = False C = True 0 = True E = True F = True G = False
the muscle spindle to diSCharge and remain sensitive throughout muscle contraction.
This becomes a polysynaptic pathway of feedback control and is described as 'a-y eo-
Absorption of CSF at the arachnoid villi is due to hydrostatic pressure and bulk flow.
activation' .
CSF protein content is approximately 20-40 mg/100 ml, resulting in a CSF/plasma
Golgi tendon organs are sensory nerve endings amongst tendon fascicles that are in
ratio of approximately 0.3%. The 1'co? of CSF is approximately 50 mmHg, 10 mmHg
series with muscle fibres. They are therefore stimulated by anything that produces
higher than that of plasma. tension in the muscle (passive stretch and active muscle contraction). They regUlate
CSF is produced by the choroid plexus around blood vessels in the lateral ventricles
muscle force and form part of a protective reflex arc. The afferent fibres from the Golgi
as well as in the walls of the third and fourth ventricles.
tendon organs synapse on to spinal cord inhibitory interneurones that synapse on to
Normal lumbar CSF pressure is between 7 and 18 cmCSF. The pH of CSF is 7.33.
the muscle motor neurone to cause inhibition. Excitatory innervation of antagonists
may also be seen. This reflex is at least disynaptic.

36 A = True B = True C = True 0 = False E = False F = True

The anterolateral spinothalamic tract carries information of contralateral touch, noci-
38 A = False B = False C = True 0 = Fa/se E = False F = False
ception and temperature. In general, but not exclusively, the anterior spinothalamic
The cerebellum has three tunctional parts:
tract conveys touch and the lateral one conveys information about noxious stimuli and

temperature. 1 The ipsilateral nodulus (on the vermis) and the flocculus form, the flocculonodular
Fibres that signal proprioception and fine touch run in the ascending dorsal (poster- lobe (vestibulocerebellum). This receives vestibular afferent input and is involved in
ior) columns to the gracile and cuneate nuclei In the medulla. After synapsing there, the equilibrium.
second-order fibres decussate to project in the medlallemniscal pathway to the ventral 2 The remainder of the vermis and the medial hemispheres form the spinocerebellum
posterior nucleus of the thalamus.
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 79
78
In the dorsal column pathway, the sacral and lumbar fibres lie medial to the thoracic
The effects of adrenaline on the circulation are mediated by both a- and J}-receptors.
and cervical fibres. In the spinothalamic tract, the sacral and lumbar fibres are dis-
These effects include increased myocardial contractility, heart rate and excitability. At
placed more laterally to the thoracic and cervical fibres. It is important to remember this
low concentrations adrenaline causes vasodilation in skeletal muscle and liver vessels
when diagnosing extrinsic and intrinsic spinal tumours causing spinal compression.
and as a result reduces peripheral vascular resistance. Adrenaline also causes an
The descending corticospinal tract largely decussates at the medullary pyramids and
increased cardiac output and wider pulse pressure by increasing systolic and decreas-
80% is from then on known as the lateral corticospinal tract that synapses with anterior
ing diastolic arterial blood pressure (mixed a- and J}-receptor activity).
hom cells to innervate distallimb musculature. Approximately 20% of the corticospinal
The effect of circulating noradrenaline on the heart is similar, but noradrenaline
tract does not decussate at the medulla and continues as the anterior corticospinal
causes generalized vasoconstriction (a-recaptor activity). This results in a rise in
tract. This tract plays an important role in controlling the truncal limb musculature.
mean arterial blood pressure by increasing both systolic and diastolic pressure. Sec-
The Babinski sign is a dorsiflexion response of the toes along with some fanning on
ondary to baroceptor stimulation, a compensatory reduction in the heart rate may be
scratching the outer aspects of the sole of the foot. In a normal individual the response
seen. should be plantarfiexion due to control by the lateral corticospinal tract. The Babinski
Circulating adrenaline and noradrenaline are mainly broken down In the liver to met-
sign indicates damage to the lateral corticospinal tract, but its true significance is not
products, conjugates and VMA (3-metho-4-hydroxymandelic acid). Almost 50% of clear.
these breakdown products are excreted In urine as met-products, 35% as VMA and
small amounts of free noradrenaline and adrenaline are also seen. ,
5-HIAA (5-hydroxyindoleacetic adc!) is the main urinary metabolyte of 5-HT (serotonin).
Adrenalectomy results in reduced plasma levels of adrenaline but not of noradrena-
37 A = False B = True C = True 0 = True E = False

line, whose levels are extremely low and rarely reach those that cause cardiovascular
The knee and ankle jerks are examples of monosynaptic stretch reflexes elicited by
effect. The effects of noradrenaline are mainly due to local release from postganglionic
stretch of intratusal muscle spindle fibres.
sympathetic nerve endings.
A direct synapse on to the ipsilateral a-motor neurone innervating the regular con-
tracting extratusal muscle fibres causes muscle contraction. The muscle spindles lie
parallel to the rest of the muscle fibres and reduce firing when the extratusal fibres
eNS contract.
During fine motor control r-motor innervation of the intratusal spindle fibres allows
35 A = False B = False C = True 0 = True E = True F = True G = False
the muscle spindle to diSCharge and remain sensitive throughout muscle contraction.
This becomes a polysynaptic pathway of feedback control and is described as 'a-y eo-
Absorption of CSF at the arachnoid villi is due to hydrostatic pressure and bulk flow.
activation' .
CSF protein content is approximately 20-40 mg/100 ml, resulting in a CSF/plasma
Golgi tendon organs are sensory nerve endings amongst tendon fascicles that are in
ratio of approximately 0.3%. The 1'co? of CSF is approximately 50 mmHg, 10 mmHg
series with muscle fibres. They are therefore stimulated by anything that produces
higher than that of plasma. tension in the muscle (passive stretch and active muscle contraction). They regUlate
CSF is produced by the choroid plexus around blood vessels in the lateral ventricles
muscle force and form part of a protective reflex arc. The afferent fibres from the Golgi
as well as in the walls of the third and fourth ventricles.
tendon organs synapse on to spinal cord inhibitory interneurones that synapse on to
Normal lumbar CSF pressure is between 7 and 18 cmCSF. The pH of CSF is 7.33.
the muscle motor neurone to cause inhibition. Excitatory innervation of antagonists
may also be seen. This reflex is at least disynaptic.

36 A = True B = True C = True 0 = False E = False F = True

The anterolateral spinothalamic tract carries information of contralateral touch, noci-
38 A = False B = False C = True 0 = Fa/se E = False F = False
ception and temperature. In general, but not exclusively, the anterior spinothalamic
The cerebellum has three tunctional parts:
tract conveys touch and the lateral one conveys information about noxious stimuli and

temperature. 1 The ipsilateral nodulus (on the vermis) and the flocculus form, the flocculonodular
Fibres that signal proprioception and fine touch run in the ascending dorsal (poster- lobe (vestibulocerebellum). This receives vestibular afferent input and is involved in
ior) columns to the gracile and cuneate nuclei In the medulla. After synapsing there, the equilibrium.
second-order fibres decussate to project in the medlallemniscal pathway to the ventral 2 The remainder of the vermis and the medial hemispheres form the spinocerebellum
posterior nucleus of the thalamus.
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
80 81

and receive proprioceptive afferent input from the ipsilateral body as well as afferent 41 A = False B = True C = False 0 = True E = True
input from the motor cortex. It is Important in feedback coordination of movements
In order for the lipid layer of the tear film to be liquid at ocular surface temperature.
and action.
3 The lateral hemispheres are called the neocerebellum and these interact with the properties of meibum include a lower melting temperature than normal skin sebaceous
secretion.
motor cortex in planning and programming motor commands.
Three-quarters of tear volume is eliminated by the lacrimal drainage system. one-
It is worth noting that the mid-line cerebellum controls axial and proximal limb muscles quarter is evaporated. Of that drained. two-thirds is drained by the lower canaliculus
and lesions result in truncal ataxia. whereas the lateral hemispheres control distal and one-third by the upper canaliculus.
muscles and lesions result in distal ataxia. Lesions of the motor cortex must involve The majority of oxygen used by the cornea is derived by diffusion from the tear film
and not from the anterior chamber. In view of the above figures. it is clear that contact
deep nuclei to produce ataxia.
In cerebellar lesions. stretch reflexes such as the knee jerk become hypotonic. lenses of low oxygen permeability can reduce oxygen availability below critical levels.
Cerebellar lesions are generally manifest with movement. Tremor is not seen at rest. causing epithelial and stromal oedema along with endothelial changes.

but during voluntary work ~ntention tremor). ,

The eyelids

Ocular physiology 42 A = False B = False C = False 0 = True E = True

The tears The eyelids are made up of six layers: skin. subcutaneous tissue, obicularis. submus-
cular connective tissue (containing vessels and nerves), fibrous tarsal plate and the
39 A = True B = False C = False 0 = True E = False palpebral conjunctiva.
Cilia are normally replaced every 3-5 months. but are replaced in two months if
Lacrimal secretion contains four principal antibacterial proteins: lysozyme. a low mole- forcibly removed.
cular weight enzyme that attacks bacterial cell walls. betalysin. lactoferrin. an iron Bell's phenomenon is the upward rotation of the globe during forced closure of the
binding protein that also has free radical scavenger properties. and secretary immu- eyelid. that is. when the patient is asked to close his eyes whilst the eyelids are held
0
noglobulin A (lgA). open. The A-P axis rotates 15 above the horizontal. It is not seen in reflex blink closure.
Aqueous tear production decreases with age. However. it is asymptomatic until a 0
where there is rotation of 1-2 towards the primary direction of gaze. and approximately
critical level is reached. Basal tear production is 1.2 mVmin. 1 mm retraction of the globe. Bell's phenomenon is absent in 10% of the population.
The mucin layer is a two-layer structure with an inner tight glycocalyx secreted by The excitability of a nerve can be described by the weakest stimulus that elicits an
corneal epithelial cells. and a looser outer 'mucus blanket' produced by palpebral and action potential it applied for an infinite time. This is known as the rheobase. Chronaxie
bulbar conjunctiva goblet cells. The comea has no goblet cells. is defined as the time taken to elicit an action potential if a current twice the rheobase is
applied. Chronaxie is a measure of excitability of a muscle. The palpebral portion of
obicularis oculi has a chronaxie half that of the orbital portion.
Spontaneous blinking is blinking occurring on a regular basis without an apparent
40 A = True B = True C = False 0 = True E = False
external stimulus. It is constant for an individual in a specific environment. but may
Change with visual acuity, increase with emotional stress. dry air and wind and
PrlH:orneal tear film is made of three layers: lipid. aqueous and mucin layers. with a
decrease in rate during stressful visual tasks and with alcohol. It is absent until the
thickness of up to 10 urn, The outer lipid layer Is produced mainly by the meibomian
third month of life. and some suggest that men and women have similar rates.
glands of the upper and lower eyelids. with a small component from the glands of Zeiss
and Moll. The aqueous layer forms 90% of the thickness of the tear film and is usually
slightly hypotonic. Tears are predominantly produced by the orbital and palpebral parts
of the main lacrimal gland. and small amounts are produced by accessory glands of
43 A = True B = False C = False 0 = True E = True

Krause and Wo/fring. All aqueous production is stimulus driven and is seen to decrease
Corneal blink reflex consists of an ipsilateral disynaptic fast phase with a latency of 10-
during sleep and general anaesthesia. The lacrimal gland is a tubuloacinar gland with
15 ms and a second slower bilateral multisynaptic phase with a 20-35 ms latency and
granular acinar cells forming around 80% of the gland's substance. It produces serous
a POOrly understood fast multisynaptic bilateral phase. Pathways involved include the
fluid and a small amount of mucus.
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
80 81

and receive proprioceptive afferent input from the ipsilateral body as well as afferent 41 A = False B = True C = False 0 = True E = True
input from the motor cortex. It is Important in feedback coordination of movements
In order for the lipid layer of the tear film to be liquid at ocular surface temperature.
and action.
3 The lateral hemispheres are called the neocerebellum and these interact with the properties of meibum include a lower melting temperature than normal skin sebaceous
secretion.
motor cortex in planning and programming motor commands.
Three-quarters of tear volume is eliminated by the lacrimal drainage system. one-
It is worth noting that the mid-line cerebellum controls axial and proximal limb muscles quarter is evaporated. Of that drained. two-thirds is drained by the lower canaliculus
and lesions result in truncal ataxia. whereas the lateral hemispheres control distal and one-third by the upper canaliculus.
muscles and lesions result in distal ataxia. Lesions of the motor cortex must involve The majority of oxygen used by the cornea is derived by diffusion from the tear film
and not from the anterior chamber. In view of the above figures. it is clear that contact
deep nuclei to produce ataxia.
In cerebellar lesions. stretch reflexes such as the knee jerk become hypotonic. lenses of low oxygen permeability can reduce oxygen availability below critical levels.
Cerebellar lesions are generally manifest with movement. Tremor is not seen at rest. causing epithelial and stromal oedema along with endothelial changes.

but during voluntary work ~ntention tremor). ,

The eyelids

Ocular physiology 42 A = False B = False C = False 0 = True E = True

The tears The eyelids are made up of six layers: skin. subcutaneous tissue, obicularis. submus-
cular connective tissue (containing vessels and nerves), fibrous tarsal plate and the
39 A = True B = False C = False 0 = True E = False palpebral conjunctiva.
Cilia are normally replaced every 3-5 months. but are replaced in two months if
Lacrimal secretion contains four principal antibacterial proteins: lysozyme. a low mole- forcibly removed.
cular weight enzyme that attacks bacterial cell walls. betalysin. lactoferrin. an iron Bell's phenomenon is the upward rotation of the globe during forced closure of the
binding protein that also has free radical scavenger properties. and secretary immu- eyelid. that is. when the patient is asked to close his eyes whilst the eyelids are held
0
noglobulin A (lgA). open. The A-P axis rotates 15 above the horizontal. It is not seen in reflex blink closure.
Aqueous tear production decreases with age. However. it is asymptomatic until a 0
where there is rotation of 1-2 towards the primary direction of gaze. and approximately
critical level is reached. Basal tear production is 1.2 mVmin. 1 mm retraction of the globe. Bell's phenomenon is absent in 10% of the population.
The mucin layer is a two-layer structure with an inner tight glycocalyx secreted by The excitability of a nerve can be described by the weakest stimulus that elicits an
corneal epithelial cells. and a looser outer 'mucus blanket' produced by palpebral and action potential it applied for an infinite time. This is known as the rheobase. Chronaxie
bulbar conjunctiva goblet cells. The comea has no goblet cells. is defined as the time taken to elicit an action potential if a current twice the rheobase is
applied. Chronaxie is a measure of excitability of a muscle. The palpebral portion of
obicularis oculi has a chronaxie half that of the orbital portion.
Spontaneous blinking is blinking occurring on a regular basis without an apparent
40 A = True B = True C = False 0 = True E = False
external stimulus. It is constant for an individual in a specific environment. but may
Change with visual acuity, increase with emotional stress. dry air and wind and
PrlH:orneal tear film is made of three layers: lipid. aqueous and mucin layers. with a
decrease in rate during stressful visual tasks and with alcohol. It is absent until the
thickness of up to 10 urn, The outer lipid layer Is produced mainly by the meibomian
third month of life. and some suggest that men and women have similar rates.
glands of the upper and lower eyelids. with a small component from the glands of Zeiss
and Moll. The aqueous layer forms 90% of the thickness of the tear film and is usually
slightly hypotonic. Tears are predominantly produced by the orbital and palpebral parts
of the main lacrimal gland. and small amounts are produced by accessory glands of
43 A = True B = False C = False 0 = True E = True

Krause and Wo/fring. All aqueous production is stimulus driven and is seen to decrease
Corneal blink reflex consists of an ipsilateral disynaptic fast phase with a latency of 10-
during sleep and general anaesthesia. The lacrimal gland is a tubuloacinar gland with
15 ms and a second slower bilateral multisynaptic phase with a 20-35 ms latency and
granular acinar cells forming around 80% of the gland's substance. It produces serous
a POOrly understood fast multisynaptic bilateral phase. Pathways involved include the
fluid and a small amount of mucus.
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
82 83

ipsilateral trigeminal nucleus, the pontomedullary 'blink' premotor areas (superior col- 'Hassal-Henle warts' are the product of excess basal lamina material produced by
liculus, red nucleus and pretectal nucleus) and finally the facial nucleus. There are also the corneal endothelium and are common up to the edge of the comeosclerallimbus. In
imputs from the cortex and cerebellum, linking coordination, behaviour and learnt the centre they are known as guttata.

responses.
Due to its high elasticity and loose connection to the undertying muscle, the dermis
or corium of the skin of the eyelid is easily distended by oedema or haematoma that 46 A = True B = False C = False D = False E = True
commonly collects here and lifts it away from the underlying orbicularis muscle.
AnEDCBA
a v e r a g e of two glands of Zeiss empty into each follicle. The modified apocrine Normal healthy corneal endothelium consists of up to 80% hexagonal cells. Any
sweat glands of Moll are less plentiful and average less than one per follicle. In contrast decrease in this lellel (an increase of different shapes cells) is known as pleomorphism
to the glands of Zeiss, the glands of Moll have no definite function. They may be and can indicate endothelial instability or stress.
considered analogous to the pheromone-producing apocrine glands of the axilla. Comeal 'temperature reversal' describes how the cornea malntains its hydration and
The conjunctiva consist largely of non-keratinized stratified columnar epithelium thickness by a metabolically active process that is impaired and allows swelling as
except at the limbus and the mucocutaneous junction where it is non-keratinized surrounding temperature falls. Transendothelial potential is 0.5 mV (500 /lV ) . It is main-
stratified squamous epithelium. Muller's muscle is better developed in the upper rather tained by a basolateral Na+K+ ATPase pump, basolateral amiloride-sensitille Na+/W
than the lower lid, where it attaches to the lower border of the tarsus and is thought to eXChange,and energy-dependent apical Na+/HC03 - transport. Although in vitro stu-
be merely a fibrous extension of the inferior rectus sheath. dies with carbonic anhydrase inhibitors have shown corneal swelling, acetazolamide
has shown no effect on corneal hydration.
Aqueous sodium concentration is 143 mmoVl and the stromal sodium concentration
44 A = True B = False C = False 0 = False E = False is approximately 160-170 mmoVl. However, due to binding with negatively charged
glycosaminoglycans, the activity of sodium in the stroma is reduced to 134 mEqII.
Myokymia (fibrillary twitching of the eyelids) is seen commonly due to irritation within The difference between mmoVl and mEqII relates to the presence of charged partl-
the VII cranial nerve. It is often idiopathic, but is associated with fatigue, thyrotoxicosis, cIes. One equivalent (Eq) is 1 mol of an ionized substance divided by its valency.
stress and refractive errors.
The skin layer of the eyelid is the thinnest of the body and contains fine, microscopic
lanugo hair. The 100-150 cilia of the upper lid and 50-75 cilia of the lower lid are 47 A = False B = False C = True D = True E = False F = True
innervated at their follicles by a neural plexus and have an extremely low threshold for
The corneal stroma consists of 78% water or 3.45 parts weight of water to one part
tactile sensation.
At photopic levels, blinking of up to 3 ms duration shows no discontinuity of visual solid. As its hydration increases. the ability to swell decreases. The force needed to
prevent stromal swelling, also known as swelling pressure, decreases almost exponen-
perception.
The sebaceous glands of Zeiss have short, wide ducts lined with stratified squamous tially with increasing stromal hydration and thickness. The normal value of swelling
epithelium that empty into follicles. They produce sebum from the degeneration of pressure is approximately 55 mmHg. Water entering the stroma is influenced by nega-
slowly proliferating basal cells and serve to lubricate the eyelashes and prevent them tively charged glycosaminoglycans and fluid viscosity. Water leaving the stroma is due
from becoming dry and brittle. to the 'endothelial pump' mechanism and an established osmotic gradient.
Evaporation occurs during the day whilst the eyes are open, and it Is noted that
corneal oedema is greater in the mornings due to a lack of nocturnal evaporation.
In response to stromal WOUnding, polymorphonuclear leukocytes and then macro-
Cornea
phages may appear and fibroblast transformation is seen. Stromal keratocytes hyper-
45 A = False B = True C = False D = True E = True trophy and proliferate before refonning and reconnecting gap junctions. Tensile strength
may take years to improve. Central corneal injuries heal slower than peripheral wounds.
With eyes closed during sleep, the palpebral conjunctiva (usually superior) is respon-
sible for oxygen delillery to the cornea.
Symptoms of epithelial oedema include 'haloes' and 'rainbows', increased glare 48 A = False B = False C = True D = False E = True F = True
sensitillity and decreased contrast sensitivity,
The centre of the cornea is the most sensitille area of the eye, followed by the corneal Immediate events after corneal abrasion include a cessation of mitosis and loss of
periphery, the eyelids, the caruncle and the conlunctiva. hemidesmosomal attachment of cells at the wound edge to the underiying basement
 Physiology Physiology Answers
AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
82 83

ipsilateral trigeminal nucleus, the pontomedullary 'blink' premotor areas (superior col- 'Hassal-Henle warts' are the product of excess basal lamina material produced by
liculus, red nucleus and pretectal nucleus) and finally the facial nucleus. There are also the corneal endothelium and are common up to the edge of the comeosclerallimbus. In
imputs from the cortex and cerebellum, linking coordination, behaviour and learnt the centre they are known as guttata.

responses.
Due to its high elasticity and loose connection to the undertying muscle, the dermis
or corium of the skin of the eyelid is easily distended by oedema or haematoma that 46 A = True B = False C = False D = False E = True
commonly collects here and lifts it away from the underlying orbicularis muscle.
AnEDCBA
a v e r a g e of two glands of Zeiss empty into each follicle. The modified apocrine Normal healthy corneal endothelium consists of up to 80% hexagonal cells. Any
sweat glands of Moll are less plentiful and average less than one per follicle. In contrast decrease in this lellel (an increase of different shapes cells) is known as pleomorphism
to the glands of Zeiss, the glands of Moll have no definite function. They may be and can indicate endothelial instability or stress.
considered analogous to the pheromone-producing apocrine glands of the axilla. Comeal 'temperature reversal' describes how the cornea malntains its hydration and
The conjunctiva consist largely of non-keratinized stratified columnar epithelium thickness by a metabolically active process that is impaired and allows swelling as
except at the limbus and the mucocutaneous junction where it is non-keratinized surrounding temperature falls. Transendothelial potential is 0.5 mV (500 /lV ) . It is main-
stratified squamous epithelium. Muller's muscle is better developed in the upper rather tained by a basolateral Na+K+ ATPase pump, basolateral amiloride-sensitille Na+/W
than the lower lid, where it attaches to the lower border of the tarsus and is thought to eXChange,and energy-dependent apical Na+/HC03 - transport. Although in vitro stu-
be merely a fibrous extension of the inferior rectus sheath. dies with carbonic anhydrase inhibitors have shown corneal swelling, acetazolamide
has shown no effect on corneal hydration.
Aqueous sodium concentration is 143 mmoVl and the stromal sodium concentration
44 A = True B = False C = False 0 = False E = False is approximately 160-170 mmoVl. However, due to binding with negatively charged
glycosaminoglycans, the activity of sodium in the stroma is reduced to 134 mEqII.
Myokymia (fibrillary twitching of the eyelids) is seen commonly due to irritation within The difference between mmoVl and mEqII relates to the presence of charged partl-
the VII cranial nerve. It is often idiopathic, but is associated with fatigue, thyrotoxicosis, cIes. One equivalent (Eq) is 1 mol of an ionized substance divided by its valency.
stress and refractive errors.
The skin layer of the eyelid is the thinnest of the body and contains fine, microscopic
lanugo hair. The 100-150 cilia of the upper lid and 50-75 cilia of the lower lid are 47 A = False B = False C = True D = True E = False F = True
innervated at their follicles by a neural plexus and have an extremely low threshold for
The corneal stroma consists of 78% water or 3.45 parts weight of water to one part
tactile sensation.
At photopic levels, blinking of up to 3 ms duration shows no discontinuity of visual solid. As its hydration increases. the ability to swell decreases. The force needed to
prevent stromal swelling, also known as swelling pressure, decreases almost exponen-
perception.
The sebaceous glands of Zeiss have short, wide ducts lined with stratified squamous tially with increasing stromal hydration and thickness. The normal value of swelling
epithelium that empty into follicles. They produce sebum from the degeneration of pressure is approximately 55 mmHg. Water entering the stroma is influenced by nega-
slowly proliferating basal cells and serve to lubricate the eyelashes and prevent them tively charged glycosaminoglycans and fluid viscosity. Water leaving the stroma is due
from becoming dry and brittle. to the 'endothelial pump' mechanism and an established osmotic gradient.
Evaporation occurs during the day whilst the eyes are open, and it Is noted that
corneal oedema is greater in the mornings due to a lack of nocturnal evaporation.
In response to stromal WOUnding, polymorphonuclear leukocytes and then macro-
Cornea
phages may appear and fibroblast transformation is seen. Stromal keratocytes hyper-
45 A = False B = True C = False D = True E = True trophy and proliferate before refonning and reconnecting gap junctions. Tensile strength
may take years to improve. Central corneal injuries heal slower than peripheral wounds.
With eyes closed during sleep, the palpebral conjunctiva (usually superior) is respon-
sible for oxygen delillery to the cornea.
Symptoms of epithelial oedema include 'haloes' and 'rainbows', increased glare 48 A = False B = False C = True D = False E = True F = True
sensitillity and decreased contrast sensitivity,
The centre of the cornea is the most sensitille area of the eye, followed by the corneal Immediate events after corneal abrasion include a cessation of mitosis and loss of
periphery, the eyelids, the caruncle and the conlunctiva. hemidesmosomal attachment of cells at the wound edge to the underiying basement
84 Physiology AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers 85
membrane. This allows cells to enlarge to some degree Qncrease cell water content) endothelium into the aqueous, or is metabolized via the Embden-Meyerhoff pathway in
and migrate at a rapid rate over any epithelial defect. Mitosis then resumes after wound the stroma.
closure. Cell movement Is dependent on calcium calmodulin and cAMP. The effect of The anterior surface of the comea is the major refractive surface of the eye, providing
cholera toxin is to prevent breakdown of cAMP. 48 dioptres. Posterior surface provides -5 dioptres.
The outer membrane of the superficial cell layer accounts for 60% of total comeal The precomeal tear film possesses an inner mucin layer which partly consists of a
resistance to ion flow due to high paracellular resistance. A transepithelial potential of glycocalyx (known as the buffy coat) that interacts with the thick layer of microvilli
between 10 and 35 mV exists. It is the difference between stromal potential and tear projecting from the superficial cells of the comeal epithelium.
potential. Endothelial cell density at birth is approximately 3500-4000 cellslmm 2• The adult
Q.hloride (CI-) transport into the epithelium is dependent on secondary active eo- cornea has a cell density between 1400 and 2500 cellslmm 2 . Comeal transplants may
transport Oinked to the sodium gradient) from the stroma and passive diffusion along have less than 1000 cells/mm 2 and still remain clear with normal functions. The critical
the concentration gradient to the tears, regulated by cAMP. The sodium gradient is level for adequate comeal function is between 400 and 700 cellslmm 2 approximately.
created by the ubiquitous Na+K+ ATPase pump on the basolateral membrane.
Due to an intact barrier formed by junctional complexes, the normal corneal epithelial
surface is impermeable to fluorescein dye and stains very little or not at all with this
anionic molecule. 51 A = False B = True C = False 0 = False E = True

Bowman's layer is an acellular structureless layer that, when viewed under electron
49 A = False B = True C = True D = False E = True microscopy, can be seen to consist of randomly arranged collagen fibril. It has a
thickness of 12 urn and so is approximately one-fifth of the 50-60 pm thick comeal
The comea is made up of five layers: epithelium, Bowman's membranes, stroma, epithelium. The basement membrane of the comeal epithelium consists mainly of type
Descemet's membrane and endothelium. It transmits radiation from 310 nm (in UV) VII collagen known as anchoring fibrils which penetrate into the stroma in order to
to 2500 nm Qnfrared). It is most sensitive to UV radiation at 270 nm which can result in anchor the overlying basal cells. Type rv collagen exists, however, only in the periphery.
photokeratitis. The stroma makes up 90% of the comeal thickness. Descemet's membrane has a
Comeal epithelial wing cells contain abundant intracellular tonofilaments made up of
thickness of 1(}-15 I-lm.
keratin subunits. They are rich in 64 kD a keratin specific to corneal epithelium. How-
ever, the comeal epithelium is non-keratinized because it is unlike the comlfied struc-
ture of the skin epithelium. In vitamin A deficiency, the comeal epithelium expresses
keratins normally found in skin epidermiS (xerophthalmia). 52 A = False B = True C = True 0 = False E = True
Comeal epithelial turnover is within 7 days (once a week).
Comeal epithelium consists of a basal layer forming a single layer of cuboidal cells,
Long-term contact lens use is associated with pleomorphism (change in endothelial
over which lie 2-3 layers of wing-shaped cells, and a final outermost, terminally
cell shape) and polymegathism (change in cell size). However, cell loss has not been
differentiated, degenerating, irregular polygonal superficial layer of cells covered with
observed.
a dense coat of microvilli. Descemet's membrane is 1(}-15 pm thick and consists of two layers: an anterior
Collagen forms 71 % of the dry weight of the corneal stroma and is mainly type I.
layer, which is fetal in origin, and the posterior layer, which is secreted by the endothe-
There are, however, lesser amounts of type Ill, type rv, type V and type VI collagen also
lium and increases in thickness throughout life. Due to Descemet's membrane having a
present. high resistance to proteolytic enzymes and degradation, it can remain intact even in the
presence of severe comeal ulceration.
Endothelial cells possess tight junctions in deep layers, but are also interconnected
50 A = False B = True C = False 0 = True E = True by gap junctions and act as a relatively leaky barrier between aqueous humour and
stroma. Control of comeal hydration is dependent on an active 'endothelial pump'
Corneal endothelium is a single layer of non-vascular cells with a high metabolic
mechanism.
activity. Although aerobic metabolism in the form of the pentose phosphate shunt
It has been observed that corneal denervation increases the risk of comeal erosion
system and Krebs cycle is present in the corneal epithelium, stroma and endothelium,
and ulceration (neurotrophic). The absence of Implicated neuropeptides such as sub-
the comea derives most of its energy from anaerobic metabolism. Over three-quarters
stance P and CGRP from comeal nerve terminals has a delaying effect on comeal
of glucose is metabolized to lactate which either diffuses slowly across the stroma and
wound healing.
84 Physiology AnswersyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Physiology Answers 85
membrane. This allows cells to enlarge to some degree Qncrease cell water content) endothelium into the aqueous, or is metabolized via the Embden-Meyerhoff pathway in
and migrate at a rapid rate over any epithelial defect. Mitosis then resumes after wound the stroma.
closure. Cell movement Is dependent on calcium calmodulin and cAMP. The effect of The anterior surface of the comea is the major refractive surface of the eye, providing
cholera toxin is to prevent breakdown of cAMP. 48 dioptres. Posterior surface provides -5 dioptres.
The outer membrane of the superficial cell layer accounts for 60% of total comeal The precomeal tear film possesses an inner mucin layer which partly consists of a
resistance to ion flow due to high paracellular resistance. A transepithelial potential of glycocalyx (known as the buffy coat) that interacts with the thick layer of microvilli
between 10 and 35 mV exists. It is the difference between stromal potential and tear projecting from the superficial cells of the comeal epithelium.
potential. Endothelial cell density at birth is approximately 3500-4000 cellslmm 2• The adult
Q.hloride (CI-) transport into the epithelium is dependent on secondary active eo- cornea has a cell density between 1400 and 2500 cellslmm 2 . Comeal transplants may
transport Oinked to the sodium gradient) from the stroma and passive diffusion along have less than 1000 cells/mm 2 and still remain clear with normal functions. The critical
the concentration gradient to the tears, regulated by cAMP. The sodium gradient is level for adequate comeal function is between 400 and 700 cellslmm 2 approximately.
created by the ubiquitous Na+K+ ATPase pump on the basolateral membrane.
Due to an intact barrier formed by junctional complexes, the normal corneal epithelial
surface is impermeable to fluorescein dye and stains very little or not at all with this
anionic molecule. 51 A = False B = True C = False 0 = False E = True

Bowman's layer is an acellular structureless layer that, when viewed under electron
49 A = False B = True C = True D = False E = True microscopy, can be seen to consist of randomly arranged collagen fibril. It has a
thickness of 12 urn and so is approximately one-fifth of the 50-60 pm thick comeal
The comea is made up of five layers: epithelium, Bowman's membranes, stroma, epithelium. The basement membrane of the comeal epithelium consists mainly of type
Descemet's membrane and endothelium. It transmits radiation from 310 nm (in UV) VII collagen known as anchoring fibrils which penetrate into the stroma in order to
to 2500 nm Qnfrared). It is most sensitive to UV radiation at 270 nm which can result in anchor the overlying basal cells. Type rv collagen exists, however, only in the periphery.
photokeratitis. The stroma makes up 90% of the comeal thickness. Descemet's membrane has a
Comeal epithelial wing cells contain abundant intracellular tonofilaments made up of
thickness of 1(}-15 I-lm.
keratin subunits. They are rich in 64 kD a keratin specific to corneal epithelium. How-
ever, the comeal epithelium is non-keratinized because it is unlike the comlfied struc-
ture of the skin epithelium. In vitamin A deficiency, the comeal epithelium expresses
keratins normally found in skin epidermiS (xerophthalmia). 52 A = False B = True C = True 0 = False E = True
Comeal epithelial turnover is within 7 days (once a week).
Comeal epithelium consists of a basal layer forming a single layer of cuboidal cells,
Long-term contact lens use is associated with pleomorphism (change in endothelial
over which lie 2-3 layers of wing-shaped cells, and a final outermost, terminally
cell shape) and polymegathism (change in cell size). However, cell loss has not been
differentiated, degenerating, irregular polygonal superficial layer of cells covered with
observed.
a dense coat of microvilli. Descemet's membrane is 1(}-15 pm thick and consists of two layers: an anterior
Collagen forms 71 % of the dry weight of the corneal stroma and is mainly type I.
layer, which is fetal in origin, and the posterior layer, which is secreted by the endothe-
There are, however, lesser amounts of type Ill, type rv, type V and type VI collagen also
lium and increases in thickness throughout life. Due to Descemet's membrane having a
present. high resistance to proteolytic enzymes and degradation, it can remain intact even in the
presence of severe comeal ulceration.
Endothelial cells possess tight junctions in deep layers, but are also interconnected
50 A = False B = True C = False 0 = True E = True by gap junctions and act as a relatively leaky barrier between aqueous humour and
stroma. Control of comeal hydration is dependent on an active 'endothelial pump'
Corneal endothelium is a single layer of non-vascular cells with a high metabolic
mechanism.
activity. Although aerobic metabolism in the form of the pentose phosphate shunt
It has been observed that corneal denervation increases the risk of comeal erosion
system and Krebs cycle is present in the corneal epithelium, stroma and endothelium,
and ulceration (neurotrophic). The absence of Implicated neuropeptides such as sub-
the comea derives most of its energy from anaerobic metabolism. Over three-quarters
stance P and CGRP from comeal nerve terminals has a delaying effect on comeal
of glucose is metabolized to lactate which either diffuses slowly across the stroma and
wound healing.
86JIHGFEDCBA P h y s io lo g y Answers P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
87

53 A = True B = True C = True 0 = False E = True F = False pressures. It is said to be 'skewed' to the right. Strenuous exercise can briefly lower
intraocular pressure, pemaps due to metabolic changes. such as acidosis or extra-
The stromal plexus of myelinated and unmyelinated axons enter mdially Into the comea cellular fluid volume changes. Inspiration causes an increase in negative intrapleural
at the limbus and within 1 mm become unmyelinated whilst retaining a Schwann cell pressure. This reduces central venous pressure, allowing increased venous return to
covering. the heart. Reduced central venous pressure reduces episcleral venous pressure and
Collagen fibrils of the stroma have a diameter of 24-30 nm and a lamellar arrange- increases outflow of the aqueous. Inspiration Is thus seen to cause a brief fall in
ment with a macroperiodicity of 64 nm. intraocular pressure. Valsalva manoeuvre however, causes a positive intrapleural pres-
Corneal sensitivity is up to four times greater in blue-eyed individuals than in those sure and increases central venous pressure. The result is a rise in intraocular pressure.
with brown eyes. Albinos with an absence of pigment show a reduced sensitivity. There
is no explanation for this observation.
The corneal epithelium has pain and cold receptors as well as chemical receptors for 56 A = True B = False C = False 0 = True E = False
low pH and hypertonic solutions. This information is carried by AS fibres.
Although measurement of endothelial cell density is useful in assessing corneal Small quantities of complement C2. C6 and C7 are found in normal (primary) aqueous.
endothelium stability. it must be measured alongside endothelial cell size and shape. The trabecular meshwork is divided into an inner uveal layer. a comeoscleral layer and
The size is measured by the area of the apical surface of a cell population. From an outer juxtacanalicular layer of endothelial cells. The juxtacanalicular layer offers
repeated calculations, mean cell size and standard deviations can be derived. An most resistance to aqueous outflow. The aqueous enters these endothelial cells and
increase/decrease in size is known as polymegathism. For a given cell density. there by a process of vacuolation is exocytosed into Schlemm's canal.
may be widely varying degrees of polymegathism and pleomorphism. The uveoscleral drainage of aqueous reaches the suprachoroidal space and either
passes across the sclera or follows the large vessels piercing the sclera.
The pulsatile nature of intraocular pressure is due to the pulsatile arterial ocular blood
Aqueous and ciliary epithelium flow of the choroidal circulation, which is much larger than the central retinal artery
circulation.
54 A = False B = False C = True 0 = False E = False

Aqueous production is between 2 and 2.5 ~Vmin. 57 A = False B = True C = False 0 = True E = False
The non-pigmented Ciliary epithelium plays the major role in aqueous formation due
to the presence of active enzyme systems in the clefts. including the Na+K+ ATPase, IgG is the only detectable immunoglobulin in the aqueous. IgA and IgM are found to be
carbonic anhydrase and adenylate cyclase. Active secretion accounts for over 70% of present in conditions such as uveitis where there is breakdown of the blood-aqueous
aqueous production with ultrafiltration prodUCing up to 15% and passive diffusion barrier.
largely accounting for the remainder. Aqueous flow decreases by up to 40% during Plasma protein concentration is of the order of 6-7 gl100 ml. Aqueous protein con-
sleep. centration is between 5 and 15 mg/1oo ml in humans. Of the coagulation/fibrinolytic
The corneal endothelium pumps fluid into the anterior chamber at a rate of 10 pVh. proteins, only plasminogen and plasminogen proactivator are found in significant
This amounts to approximately 8% of the aqueous production rate. amounts in the aqueous. Insulin levels in the aqueous are 3% of those in plasma
and increase by a factor of 10 postprandially.
Although active aqueous secretion is Independent of changes in intraocular pressure,
55 A = True B = False C = False 0 = False E = False it is however, found to decrease sharply with intraocular pressures greater than 50-
60 mmHg. approaching that of ciliary artery pressure.
The main pathway for aqueous outflow is via the pressure- and resistance-dependent
trabecular meshwork pathway. Valsalva manoeuvre increases the central venous pres-
sure, episcleral venous pressure and reduces outflow, causing intraocular pressure to 58 A = True B = True C = False D = False E = True
rise.
The pressure-independent uveoscleral outflow of aqueous appears to show no Water-soluble substances such as glucose, amino acids and metabolic substrates
evidence of an active process. cross the blood-aqueous barrier by carrier-mediated transport. Aqueous production
Intraocular pressure in the general population does not fit the bell-shaped normal and intraocular pressure have a diumal variation with a peak between 7 and 9 am.
Gaussian distribution. There is a greater distribution of the population with higher The rate of aqueous production has been found to fall with age.
86JIHGFEDCBA P h y s io lo g y Answers P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
87

53 A = True B = True C = True 0 = False E = True F = False pressures. It is said to be 'skewed' to the right. Strenuous exercise can briefly lower
intraocular pressure, pemaps due to metabolic changes. such as acidosis or extra-
The stromal plexus of myelinated and unmyelinated axons enter mdially Into the comea cellular fluid volume changes. Inspiration causes an increase in negative intrapleural
at the limbus and within 1 mm become unmyelinated whilst retaining a Schwann cell pressure. This reduces central venous pressure, allowing increased venous return to
covering. the heart. Reduced central venous pressure reduces episcleral venous pressure and
Collagen fibrils of the stroma have a diameter of 24-30 nm and a lamellar arrange- increases outflow of the aqueous. Inspiration Is thus seen to cause a brief fall in
ment with a macroperiodicity of 64 nm. intraocular pressure. Valsalva manoeuvre however, causes a positive intrapleural pres-
Corneal sensitivity is up to four times greater in blue-eyed individuals than in those sure and increases central venous pressure. The result is a rise in intraocular pressure.
with brown eyes. Albinos with an absence of pigment show a reduced sensitivity. There
is no explanation for this observation.
The corneal epithelium has pain and cold receptors as well as chemical receptors for 56 A = True B = False C = False 0 = True E = False
low pH and hypertonic solutions. This information is carried by AS fibres.
Although measurement of endothelial cell density is useful in assessing corneal Small quantities of complement C2. C6 and C7 are found in normal (primary) aqueous.
endothelium stability. it must be measured alongside endothelial cell size and shape. The trabecular meshwork is divided into an inner uveal layer. a comeoscleral layer and
The size is measured by the area of the apical surface of a cell population. From an outer juxtacanalicular layer of endothelial cells. The juxtacanalicular layer offers
repeated calculations, mean cell size and standard deviations can be derived. An most resistance to aqueous outflow. The aqueous enters these endothelial cells and
increase/decrease in size is known as polymegathism. For a given cell density. there by a process of vacuolation is exocytosed into Schlemm's canal.
may be widely varying degrees of polymegathism and pleomorphism. The uveoscleral drainage of aqueous reaches the suprachoroidal space and either
passes across the sclera or follows the large vessels piercing the sclera.
The pulsatile nature of intraocular pressure is due to the pulsatile arterial ocular blood
Aqueous and ciliary epithelium flow of the choroidal circulation, which is much larger than the central retinal artery
circulation.
54 A = False B = False C = True 0 = False E = False

Aqueous production is between 2 and 2.5 ~Vmin. 57 A = False B = True C = False 0 = True E = False
The non-pigmented Ciliary epithelium plays the major role in aqueous formation due
to the presence of active enzyme systems in the clefts. including the Na+K+ ATPase, IgG is the only detectable immunoglobulin in the aqueous. IgA and IgM are found to be
carbonic anhydrase and adenylate cyclase. Active secretion accounts for over 70% of present in conditions such as uveitis where there is breakdown of the blood-aqueous
aqueous production with ultrafiltration prodUCing up to 15% and passive diffusion barrier.
largely accounting for the remainder. Aqueous flow decreases by up to 40% during Plasma protein concentration is of the order of 6-7 gl100 ml. Aqueous protein con-
sleep. centration is between 5 and 15 mg/1oo ml in humans. Of the coagulation/fibrinolytic
The corneal endothelium pumps fluid into the anterior chamber at a rate of 10 pVh. proteins, only plasminogen and plasminogen proactivator are found in significant
This amounts to approximately 8% of the aqueous production rate. amounts in the aqueous. Insulin levels in the aqueous are 3% of those in plasma
and increase by a factor of 10 postprandially.
Although active aqueous secretion is Independent of changes in intraocular pressure,
55 A = True B = False C = False 0 = False E = False it is however, found to decrease sharply with intraocular pressures greater than 50-
60 mmHg. approaching that of ciliary artery pressure.
The main pathway for aqueous outflow is via the pressure- and resistance-dependent
trabecular meshwork pathway. Valsalva manoeuvre increases the central venous pres-
sure, episcleral venous pressure and reduces outflow, causing intraocular pressure to 58 A = True B = True C = False D = False E = True
rise.
The pressure-independent uveoscleral outflow of aqueous appears to show no Water-soluble substances such as glucose, amino acids and metabolic substrates
evidence of an active process. cross the blood-aqueous barrier by carrier-mediated transport. Aqueous production
Intraocular pressure in the general population does not fit the bell-shaped normal and intraocular pressure have a diumal variation with a peak between 7 and 9 am.
Gaussian distribution. There is a greater distribution of the population with higher The rate of aqueous production has been found to fall with age.
88 P h y s io lo g y Answers
AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y 89

Glucose concentration in CSF is approximately two-thirds that of plasma. Concen- constant in an individual and can increase, decrease, or reverse sides in a matter of
tration of glucose in aqueous is 80% of that in plasma. hours. In the presence of unequal pupils the reaction to changes in light and accom-
modation are of crucial importance.
The reaction to light has a relatively long latent period that is expected with smooth
59 A = False B = True C = True D = True E = True muscle. In bright light it is 0.2 s and in dimmed light it is prolonged up to 0.5 s.
A tonic pupil is one of the many causes of an efferent pupillary defect, where the pupil
The blood-aqueous barrier is formed by apical tight junctions of the non-pigmented reacts poorly to light and appears fixed and dilated. It refers to any postganglionic
ciliary epithelial cells and by the tight junctions between the capillary endothelial calls of parasympathetic denervation of the intraocular muscles, and implies damage to the
the non-fenestrated iris vessels. Urea passes slowly across the blood-aqueous barrier ciliary ganglion or short ciliary nerves by orbital trauma, viral infection, neoplasm or
and is excreted slowly by the kidney. It is more effective than mannitol in acutely other causes.
reducing intraocular pressure. Urea causes local complications of phlebitis and slough- Although damage to the third nerve by space-occupyinq lesion can cause an efferent
ing as well as systemic complications, and therefore the use of mannitol is considered pupillary defect, it is not referred to as a tonic pupil.
more effective and popular.

6 3 A = True B = True C = True D = False E = True

60 A = False B = True C = True 1) = False E = False
Following pupillary dilation, patients experience blurred vision due to spherical aberra-
The ciliary body is made up of a smooth pars plana posteriorly and a pars plicata tions highlighted by the large pupil aperture. Furthermore, accommodation may be
anteriorly. The apical aspects of the pigmented ciliary epithelial cell faces the apical impaired with the use of cycloplegic drugs.
aspect of the non-pigmented epithelial cells. Pupillary dilation is a therapeutic procedure in cases of anterior uveitis in order to
Tight junctions exist between the apices of the inner non-pigmented ciliary epithelial prevent synechiae and ciliary spasm.
cells. Gap junctions exist between pigmented ciliary epithelial cells and also between Cycloplegic mydriatics carry a risk of raising intraocular pressure, especially in long-
pigmented and non-pigmented ciliary epithelial cells. Capillaries of the ciliary body are term use.
fenestrated and thin walled, whereas those of the liver sinusoids are discontinuous,
allowing easy passage of blood cells through capillary walls.

64 A = True B = True C = True D = True E = True

61 A = False B = True C = True D = False E = True
Factors influencing the size of a pupil may be categoriZed into mechanical, extrinsic
In the mature eye pigmented epithelial cells are cuboidal and non-pigmented cells are and intrinsic factors. Sphincter pupillae has a stronger influence than dilater pupillae on
columnar. By inhibiting carbonic anhydrase and the synthesis of bicarbonate, aceta- pupil size. Mechanical factors include iris pigment. A brown iris is associated with a
zolamide has been found to reduce aqueous production by up to 50%. smaller pupil than a blue iris. Lesions to the iris musculature also affect pupil size and
Ciliary epithelia secrete primary aqueous humour. Secondary aqueous humour refers shape.
to the leakage of plasma-like (or plasmoid) aqueous through destabilization of the Extrinsic factors include light or dark adaptation, distance of the object of fixation
blood-aqueous barrier. Prostaglandins E and F disrupt the 6pical tight junctions of and the degree of change in illumination presented to the retina.
the non-pigmented epithelial cells. Intrinsic factors include sympathetic tone causing mydriasis, parasympathetic tone
causing miosis, age, emotion and sleep.
Sleep, fatigue and drowsiness are associated with reduced sympathetic tone and
Pupil reduced inhibition of the Edinger-Westphal nucleus, causing miosis.

62 A = False B = True C = False D = True E = False

6 5 A = False B = True C = True D = False E = False
Pupil diameter can range from 1 mm to 9 mm when fully dilated. Pupil size gradually
decreases with age, but is largest in adolescence. It is common to have unequal pupil Dense lens opacities do not cause afferent pupillary defects. An efferent pupillary
sizes, and simply physiological anisocoria is present in 20% of the population. It is not defect describes a fixed dilated pupil and can be caused by any defect in the pathway
88 P h y s io lo g y Answers
AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y 89

Glucose concentration in CSF is approximately two-thirds that of plasma. Concen- constant in an individual and can increase, decrease, or reverse sides in a matter of
tration of glucose in aqueous is 80% of that in plasma. hours. In the presence of unequal pupils the reaction to changes in light and accom-
modation are of crucial importance.
The reaction to light has a relatively long latent period that is expected with smooth
59 A = False B = True C = True D = True E = True muscle. In bright light it is 0.2 s and in dimmed light it is prolonged up to 0.5 s.
A tonic pupil is one of the many causes of an efferent pupillary defect, where the pupil
The blood-aqueous barrier is formed by apical tight junctions of the non-pigmented reacts poorly to light and appears fixed and dilated. It refers to any postganglionic
ciliary epithelial cells and by the tight junctions between the capillary endothelial calls of parasympathetic denervation of the intraocular muscles, and implies damage to the
the non-fenestrated iris vessels. Urea passes slowly across the blood-aqueous barrier ciliary ganglion or short ciliary nerves by orbital trauma, viral infection, neoplasm or
and is excreted slowly by the kidney. It is more effective than mannitol in acutely other causes.
reducing intraocular pressure. Urea causes local complications of phlebitis and slough- Although damage to the third nerve by space-occupyinq lesion can cause an efferent
ing as well as systemic complications, and therefore the use of mannitol is considered pupillary defect, it is not referred to as a tonic pupil.
more effective and popular.

6 3 A = True B = True C = True D = False E = True

60 A = False B = True C = True 1) = False E = False
Following pupillary dilation, patients experience blurred vision due to spherical aberra-
The ciliary body is made up of a smooth pars plana posteriorly and a pars plicata tions highlighted by the large pupil aperture. Furthermore, accommodation may be
anteriorly. The apical aspects of the pigmented ciliary epithelial cell faces the apical impaired with the use of cycloplegic drugs.
aspect of the non-pigmented epithelial cells. Pupillary dilation is a therapeutic procedure in cases of anterior uveitis in order to
Tight junctions exist between the apices of the inner non-pigmented ciliary epithelial prevent synechiae and ciliary spasm.
cells. Gap junctions exist between pigmented ciliary epithelial cells and also between Cycloplegic mydriatics carry a risk of raising intraocular pressure, especially in long-
pigmented and non-pigmented ciliary epithelial cells. Capillaries of the ciliary body are term use.
fenestrated and thin walled, whereas those of the liver sinusoids are discontinuous,
allowing easy passage of blood cells through capillary walls.

64 A = True B = True C = True D = True E = True

61 A = False B = True C = True D = False E = True
Factors influencing the size of a pupil may be categoriZed into mechanical, extrinsic
In the mature eye pigmented epithelial cells are cuboidal and non-pigmented cells are and intrinsic factors. Sphincter pupillae has a stronger influence than dilater pupillae on
columnar. By inhibiting carbonic anhydrase and the synthesis of bicarbonate, aceta- pupil size. Mechanical factors include iris pigment. A brown iris is associated with a
zolamide has been found to reduce aqueous production by up to 50%. smaller pupil than a blue iris. Lesions to the iris musculature also affect pupil size and
Ciliary epithelia secrete primary aqueous humour. Secondary aqueous humour refers shape.
to the leakage of plasma-like (or plasmoid) aqueous through destabilization of the Extrinsic factors include light or dark adaptation, distance of the object of fixation
blood-aqueous barrier. Prostaglandins E and F disrupt the 6pical tight junctions of and the degree of change in illumination presented to the retina.
the non-pigmented epithelial cells. Intrinsic factors include sympathetic tone causing mydriasis, parasympathetic tone
causing miosis, age, emotion and sleep.
Sleep, fatigue and drowsiness are associated with reduced sympathetic tone and
Pupil reduced inhibition of the Edinger-Westphal nucleus, causing miosis.

62 A = False B = True C = False D = True E = False

6 5 A = False B = True C = True D = False E = False
Pupil diameter can range from 1 mm to 9 mm when fully dilated. Pupil size gradually
decreases with age, but is largest in adolescence. It is common to have unequal pupil Dense lens opacities do not cause afferent pupillary defects. An efferent pupillary
sizes, and simply physiological anisocoria is present in 20% of the population. It is not defect describes a fixed dilated pupil and can be caused by any defect in the pathway
90 P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 91

of the mid-brain (third cranial nerve, ciliary ganglion) to the iris. It may also be caused by
mydriatic drugs, including anticholinergic or adrenergic agents. Cocaine causes mydriasis by preventing rouptake of noradrenaline back into nerve
Adie's tonic pupil is an idiopathic tonic pupil associated with benign tendon are- terminals. Its duration is variable and no rebound miosis is seen. It also causes
flexia. Pupillary response to light is poor, but pupillary response to near vision is anaesthesia and vasoconstriction that results in conjunctival blanching.
strong and tonic with delayed accommodation of distant objects and symptoms of Thymoxamine is a competitive a-adrenergic antagonist and causes miosis. It
blurred vision. It is suggested that these strong pupillary responses to near vision reverses phenylephrine and hydroxyamphetamine mydriasis. It does not reverse
may be due to aberrant regenerating nerve fibres from the ciliary muscle to the mydriasis of anticholenergic drugs, and has no apparent affect on the ciliary body
constrictor pupillae muscle. Cholinergic hypersensitivity is seen, implying a defect and thus accommodation.
in the ciliary ganglion. The condition usually affects young women unilaterally, but
may become bilateral.
Argyll-Robertson pupils describe lesions to the relay paths in the tectum between 68 A = True B = True C = False D = False E = False
afferent and efferent tracks. It was originally associated with tabes dorsalis. In distinc-
tion to the Adie's pupil, the pupils are small (spinal miosis) and the accommodation Johann Friedrich Homer described a case report of a preganglionic lesion in 1869. The
reflex is preserved ~"-!!obertson Eupll = ~commodation !!eflex Ereserved). sympathetic pathway can be divided into a central, preganglionic and postganglionic
Whereas a tonic pupil dilates well with atropine, Argyll-Robertson pupils dilate poorly. parts, and this forms a classification of the aetiology of Homer's syndrome. Clinical
signs include ptosis, miosis, facial anhydrosis On preganglionic Horner's), dilation lag
and, initially, conjunctival hyperaemia may be seen. Congenital or neonatal Homer's
66 A = True B = False C = False D = False E = True denies normal pigmentation of the iris. Homer's after the age of 2 years usually does
not cause heterochromia.
Botulinum toxin blocks the release of acetylcholine at both preganglionic and post- Cocaine prevents rouptake of noradrenaline and any interruption in the sympathetic
ganglionic levels. Atropine is a competitive antimuscarinic antagonist of acetylcholine pathway will reduce the noradrenaline released from nerve endings. As a rule, therefore,
at the post synaptic cell membrane. Reversible acetylcholine esterase inhibitors such cocaine dilation is reduced in all Homer's pupils.
as pyridostigmine (rnesthinon), edrophonium (tensilon), neostigmine and physostigmine Based on the principle of denervation hypersansitivity, postganglionic Homer's pupils
(eserine) cause miosis by potenliating acetylcholine. can dilate with low concentrations of adrenaline.
Drugs such as noradrenaline, adrenaline, phenylephrine and methoxamine are direct Pancoast's syndrome describes lung carcinoma associated with ipsilateral pregan-
a-adrenergic agonists causing mydriasis without cycloplegia They do not affect the glionic Horner's syndrome due to invasion of the cervical sympathetic plexus in the
pupillary light reflex or accommodation. region of the stellate ganglion. Hydroxyamphetamine is an indirect a-adrenergic ago-
Central nervous system depressants such as barbituates (phenobarbitone) act by the nist that only dilates the pupil in the presence of presynaptic noradrenaline. It therefore
GABA system to potenliate neural inhibition of the Edinger-Westphal nucleus. Barbi- produces mydriasis in central and preganglionic Homer's, but fails to dilate the eye in
turate poisoning results in Sluggish pupillary light reflexes. lesions of the postganglionic sympathetic pathway. The hydroxyamphetamine test is
said to have a diagnostic accuracy of 84% for postganglionic lesions and 97% for
central or preganglionic lesions.

67 A = True B = True C = True D = False E = True

Histamine acts directly on smooth muscle causing it to contract. As sphincter pupillae The /ens
is stronger than dilator pupillae, the result is a powerful miosis.
Morphine acting directly on smooth muscle causes constriction, and so its direct 69 A = False B = True C = True D = False E = False
action on sphincter pupillae results in miosis. The classical pinpoint pupil seen mor-
phine overdose, however, is probably due to central nervous system depression and so The lens absorbs short-wave length blue/ultraviolet light.
reduced cortical inhibition of the Edinger-Westphal nucleus. The acellular capsule is analogous to basement membrane. It stains positive with
Pilocarpine is a complex rather than simple direct acting muscarinic cholinergic PAS reagents. It is therefore probably the thickest basement membrane in.the body and
agonist. As well as causing miosis, it has a puzzling effect of reducing, or even is made up of type IV collagen and 10% glycosaminoglycan. It is synthesized by the
abolishing the pupillary light reflex for many hours after miosis disappears, thus coun- epithelium and the most superficial lens fibres posteriorly.
teracting naturally released acetylcholine. Compared to other tissue, the lens is unique in being made up of one-third protein
and two-thirds water. This high protein content is thought to be essential for the high
90 P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 91

of the mid-brain (third cranial nerve, ciliary ganglion) to the iris. It may also be caused by
mydriatic drugs, including anticholinergic or adrenergic agents. Cocaine causes mydriasis by preventing rouptake of noradrenaline back into nerve
Adie's tonic pupil is an idiopathic tonic pupil associated with benign tendon are- terminals. Its duration is variable and no rebound miosis is seen. It also causes
flexia. Pupillary response to light is poor, but pupillary response to near vision is anaesthesia and vasoconstriction that results in conjunctival blanching.
strong and tonic with delayed accommodation of distant objects and symptoms of Thymoxamine is a competitive a-adrenergic antagonist and causes miosis. It
blurred vision. It is suggested that these strong pupillary responses to near vision reverses phenylephrine and hydroxyamphetamine mydriasis. It does not reverse
may be due to aberrant regenerating nerve fibres from the ciliary muscle to the mydriasis of anticholenergic drugs, and has no apparent affect on the ciliary body
constrictor pupillae muscle. Cholinergic hypersensitivity is seen, implying a defect and thus accommodation.
in the ciliary ganglion. The condition usually affects young women unilaterally, but
may become bilateral.
Argyll-Robertson pupils describe lesions to the relay paths in the tectum between 68 A = True B = True C = False D = False E = False
afferent and efferent tracks. It was originally associated with tabes dorsalis. In distinc-
tion to the Adie's pupil, the pupils are small (spinal miosis) and the accommodation Johann Friedrich Homer described a case report of a preganglionic lesion in 1869. The
reflex is preserved ~"-!!obertson Eupll = ~commodation !!eflex Ereserved). sympathetic pathway can be divided into a central, preganglionic and postganglionic
Whereas a tonic pupil dilates well with atropine, Argyll-Robertson pupils dilate poorly. parts, and this forms a classification of the aetiology of Homer's syndrome. Clinical
signs include ptosis, miosis, facial anhydrosis On preganglionic Horner's), dilation lag
and, initially, conjunctival hyperaemia may be seen. Congenital or neonatal Homer's
66 A = True B = False C = False D = False E = True denies normal pigmentation of the iris. Homer's after the age of 2 years usually does
not cause heterochromia.
Botulinum toxin blocks the release of acetylcholine at both preganglionic and post- Cocaine prevents rouptake of noradrenaline and any interruption in the sympathetic
ganglionic levels. Atropine is a competitive antimuscarinic antagonist of acetylcholine pathway will reduce the noradrenaline released from nerve endings. As a rule, therefore,
at the post synaptic cell membrane. Reversible acetylcholine esterase inhibitors such cocaine dilation is reduced in all Homer's pupils.
as pyridostigmine (rnesthinon), edrophonium (tensilon), neostigmine and physostigmine Based on the principle of denervation hypersansitivity, postganglionic Homer's pupils
(eserine) cause miosis by potenliating acetylcholine. can dilate with low concentrations of adrenaline.
Drugs such as noradrenaline, adrenaline, phenylephrine and methoxamine are direct Pancoast's syndrome describes lung carcinoma associated with ipsilateral pregan-
a-adrenergic agonists causing mydriasis without cycloplegia They do not affect the glionic Horner's syndrome due to invasion of the cervical sympathetic plexus in the
pupillary light reflex or accommodation. region of the stellate ganglion. Hydroxyamphetamine is an indirect a-adrenergic ago-
Central nervous system depressants such as barbituates (phenobarbitone) act by the nist that only dilates the pupil in the presence of presynaptic noradrenaline. It therefore
GABA system to potenliate neural inhibition of the Edinger-Westphal nucleus. Barbi- produces mydriasis in central and preganglionic Homer's, but fails to dilate the eye in
turate poisoning results in Sluggish pupillary light reflexes. lesions of the postganglionic sympathetic pathway. The hydroxyamphetamine test is
said to have a diagnostic accuracy of 84% for postganglionic lesions and 97% for
central or preganglionic lesions.

67 A = True B = True C = True D = False E = True

Histamine acts directly on smooth muscle causing it to contract. As sphincter pupillae The /ens
is stronger than dilator pupillae, the result is a powerful miosis.
Morphine acting directly on smooth muscle causes constriction, and so its direct 69 A = False B = True C = True D = False E = False
action on sphincter pupillae results in miosis. The classical pinpoint pupil seen mor-
phine overdose, however, is probably due to central nervous system depression and so The lens absorbs short-wave length blue/ultraviolet light.
reduced cortical inhibition of the Edinger-Westphal nucleus. The acellular capsule is analogous to basement membrane. It stains positive with
Pilocarpine is a complex rather than simple direct acting muscarinic cholinergic PAS reagents. It is therefore probably the thickest basement membrane in.the body and
agonist. As well as causing miosis, it has a puzzling effect of reducing, or even is made up of type IV collagen and 10% glycosaminoglycan. It is synthesized by the
abolishing the pupillary light reflex for many hours after miosis disappears, thus coun- epithelium and the most superficial lens fibres posteriorly.
teracting naturally released acetylcholine. Compared to other tissue, the lens is unique in being made up of one-third protein
and two-thirds water. This high protein content is thought to be essential for the high
 92JIHGFEDCBA P h y s io lo g y Answers 93
P h y s io lo g y Answers
refractive index, and also affords a good buffering capacity. The pH of the lens has Active transport mechanisms of amino acids into the lens are dependent on the
been measured at 6.9.
sodium gradient set up by the Na+K+ ATPase pump.
Lens proteins have very little helical structure. Crystallin configuration is mainly f3- The sorbitol pathway serves as a protective buffer that can reduce hypertonicity of
sheet. The fibres of the lens are closely packed with a distance of 100/200 A between the lens due to high glucose levels in the aqueous as a result of short-term hypergly-
adjacent cells. Lens transparency is thought to be achieved by the close packing caemia. This is based on the observation that a rapid rise is in serum glucose (Le. 5-
(reducing light scattering), the regular arrangement and the small differences in 1 5 mM)can markedly dehydrate the lens. Excess glucose is converted to sorbitol and
refracted index between light-scattering components.
then to fructose which diffuses out of the lens.
In 1978, Stevens et al. put forward the proposal that sustained activity of the sorbitol
pathway in diabetes was not the major cause of diabetic cataract It was suggested
70 A = True B = True C = False 0 = True E = False that glycosylation of lens proteins was the cause. Calcium levels in the lens are of the
order of 0.3 mEqlkg lens water. Efflux of Ca2+ is an active process independent of Na+-
2
In the lens, a potassium concentration of 1 2 5 mmoVl and a sodium concentration of Ca2+ exchange or external levels of Na+. The mechanism may due to a ea + ATPase
20 mmolll is maintained by the Na+K+ ATPase pump actively pumping sodium out and pump.
potassium in.
Of the extremely high 33% protein content of the lens, 90% are water-soluble
structural proteins or crystallins. 73 A = True B = True C = False D'= True E = False
Glutathione, a tripeptide, is present in the lens in concentrations 1000 times greater
than that of the aqueous. It is continually synthesized and maintained in its reduced Alpha, beta and gamma crystallins are the only crystallins found in humans. Alpha
form (GSH) by NADPH from the hexose monophosphate (HMp) shunt In the presence crystallin has been found in the heart, brain and lung. Alpha crystallins are related to
of cataract, glutathione levels are found to be reduced. 'heat shock' proteins, protective proteins that bind any denatured proteins made in
response to unusual rises in temperature.
Alpha crystallin is the largest crystallin and is mainly found in the cortex. It comprises
of 35% of lens crystallins. Beta crystallin is the most common crystallin, making up
71 A = False B = True C = True 0 = False E = True
55% of lens crystallins. Gamma crystallin forms 10% of lens crystallins. It is the
smallest crystallin and is monomeric, unlike the others. Gamma crystallins are found
Central lens epithelial cells are cuboidal. At the equator they elongate and differentiate
mainly at the central core region, the fetal nucleus of the lens. It is the area of highest
into lens fibres. Functions of the lens epithelial cells include ceU division, especially in
refractive index and the lowest water content of the lens. Due to very low protein
the equatorial and pre-equatorial regions, synthesis of crystallin proteins, active cation
transport and secretion of the capsule. tu mover here, the lifetime of the gamma crystallin molecule is the same as that of
the mammal. Due to cysteine-, methionine- and sulphur-containing residues, it is
Lens fibre nuclei are lost at the deep cortical/nuclear stage. Nucleated lens fibre cells
containing organelles are usually 'hidden' behind the iris and not in the optical path. susceptible to oxidative processes and nuclear cataract fonnation.
The Na+K+ ATPase pump is mainly found on the apicolateral surface of the lens
epithelium.
The lens interior has an osmolality similar to that of aqueous humour. 74 A = True B = False C = True 0 = True E = True

A cataract is usually defined as an opacification of the lens. Increased levels of lens

calcium is associated with deposits of calcium oxalate and cortical cataracts. Hypo-
72 A = True B = True C = True 0 = True E = True calcaemia (as a result of hypoparathyroidism) is also associated with outer cortical lens
opacification. Other metabolic disorders that cause catarect include diabetes, galac-
Insulin levels in the aqueous humour are 3% of that in serum. The lens has insulin
tosaemia, Wilson's disease and homocystinuria.
receptors, although glucose enters the lens by insulin-independent facilitated diffusion.
In cataract, both methionine and cysteine are found to be oxidized.
Although 80% of lens glucose is metabolized by anaerobic glycolysis, and 4% is
Photosensitizing drugs such as psoralen given in combination with brief exposures
metabolized by aerobic glycolysis, due to a yield of two ATP molecules per glucose
to UV radiation (32Q-340 nm) are able to photochemically change and modify nearby
molecule, anaerobic glycolysis produces 60% of lens energy and aerobic glycolysis
tissue molecules. PUVA is widely used by dennatologists to treat psoriasis. The most
produces up to 40% of lens energy (yielding 36 ATP per glucose molecule). Ffrteen per
commonly affected tissues are the skin and the eye. Formation of cataracts is well
cent of glucose is metabolized via the pentose (HMP) shunt.
documented.
 92JIHGFEDCBA P h y s io lo g y Answers 93
P h y s io lo g y Answers
refractive index, and also affords a good buffering capacity. The pH of the lens has Active transport mechanisms of amino acids into the lens are dependent on the
been measured at 6.9.
sodium gradient set up by the Na+K+ ATPase pump.
Lens proteins have very little helical structure. Crystallin configuration is mainly f3- The sorbitol pathway serves as a protective buffer that can reduce hypertonicity of
sheet. The fibres of the lens are closely packed with a distance of 100/200 A between the lens due to high glucose levels in the aqueous as a result of short-term hypergly-
adjacent cells. Lens transparency is thought to be achieved by the close packing caemia. This is based on the observation that a rapid rise is in serum glucose (Le. 5-
(reducing light scattering), the regular arrangement and the small differences in 1 5 mM)can markedly dehydrate the lens. Excess glucose is converted to sorbitol and
refracted index between light-scattering components.
then to fructose which diffuses out of the lens.
In 1978, Stevens et al. put forward the proposal that sustained activity of the sorbitol
pathway in diabetes was not the major cause of diabetic cataract It was suggested
70 A = True B = True C = False 0 = True E = False that glycosylation of lens proteins was the cause. Calcium levels in the lens are of the
order of 0.3 mEqlkg lens water. Efflux of Ca2+ is an active process independent of Na+-
2
In the lens, a potassium concentration of 1 2 5 mmoVl and a sodium concentration of Ca2+ exchange or external levels of Na+. The mechanism may due to a ea + ATPase
20 mmolll is maintained by the Na+K+ ATPase pump actively pumping sodium out and pump.
potassium in.
Of the extremely high 33% protein content of the lens, 90% are water-soluble
structural proteins or crystallins. 73 A = True B = True C = False D'= True E = False
Glutathione, a tripeptide, is present in the lens in concentrations 1000 times greater
than that of the aqueous. It is continually synthesized and maintained in its reduced Alpha, beta and gamma crystallins are the only crystallins found in humans. Alpha
form (GSH) by NADPH from the hexose monophosphate (HMp) shunt In the presence crystallin has been found in the heart, brain and lung. Alpha crystallins are related to
of cataract, glutathione levels are found to be reduced. 'heat shock' proteins, protective proteins that bind any denatured proteins made in
response to unusual rises in temperature.
Alpha crystallin is the largest crystallin and is mainly found in the cortex. It comprises
of 35% of lens crystallins. Beta crystallin is the most common crystallin, making up
71 A = False B = True C = True 0 = False E = True
55% of lens crystallins. Gamma crystallin forms 10% of lens crystallins. It is the
smallest crystallin and is monomeric, unlike the others. Gamma crystallins are found
Central lens epithelial cells are cuboidal. At the equator they elongate and differentiate
mainly at the central core region, the fetal nucleus of the lens. It is the area of highest
into lens fibres. Functions of the lens epithelial cells include ceU division, especially in
refractive index and the lowest water content of the lens. Due to very low protein
the equatorial and pre-equatorial regions, synthesis of crystallin proteins, active cation
transport and secretion of the capsule. tu mover here, the lifetime of the gamma crystallin molecule is the same as that of
the mammal. Due to cysteine-, methionine- and sulphur-containing residues, it is
Lens fibre nuclei are lost at the deep cortical/nuclear stage. Nucleated lens fibre cells
containing organelles are usually 'hidden' behind the iris and not in the optical path. susceptible to oxidative processes and nuclear cataract fonnation.
The Na+K+ ATPase pump is mainly found on the apicolateral surface of the lens
epithelium.
The lens interior has an osmolality similar to that of aqueous humour. 74 A = True B = False C = True 0 = True E = True

A cataract is usually defined as an opacification of the lens. Increased levels of lens

calcium is associated with deposits of calcium oxalate and cortical cataracts. Hypo-
72 A = True B = True C = True 0 = True E = True calcaemia (as a result of hypoparathyroidism) is also associated with outer cortical lens
opacification. Other metabolic disorders that cause catarect include diabetes, galac-
Insulin levels in the aqueous humour are 3% of that in serum. The lens has insulin
tosaemia, Wilson's disease and homocystinuria.
receptors, although glucose enters the lens by insulin-independent facilitated diffusion.
In cataract, both methionine and cysteine are found to be oxidized.
Although 80% of lens glucose is metabolized by anaerobic glycolysis, and 4% is
Photosensitizing drugs such as psoralen given in combination with brief exposures
metabolized by aerobic glycolysis, due to a yield of two ATP molecules per glucose
to UV radiation (32Q-340 nm) are able to photochemically change and modify nearby
molecule, anaerobic glycolysis produces 60% of lens energy and aerobic glycolysis
tissue molecules. PUVA is widely used by dennatologists to treat psoriasis. The most
produces up to 40% of lens energy (yielding 36 ATP per glucose molecule). Ffrteen per
commonly affected tissues are the skin and the eye. Formation of cataracts is well
cent of glucose is metabolized via the pentose (HMP) shunt.
documented.
94 P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 95

The mechanism for steroid-induced cataract is unclear and amongst many theories The vitreous serves as a repository of nutrients (Including amino acids) for the retina.
Urban and Cotlier ( 1 9 8 6 ) proposed that steroids react with amino groups of lens It has been known for over 5 0 years that the vitreous has active water movement
crystallins to precipitate the formation of disulphide bonds leading to protein aggre- important for transport of solutes in the eye. Fifty per cent of labelled water is seen
gation. Posterior subcapsular cataracts are commonly caused by topical and sys-
to turn over every 1 0 -1 5 min.
temic corticosteroid. Chlorpromazine is the only phenothiazine Implicated in causing
cataract.

78 A = False B = True C = True D = False E = True

75 I t = True B = True C = True 0 = False E = True
Collagen density is greatest in the vitreous base, followed by the posterior vitreous
cortex and then the anterior vitreous cortex behind the lens.
The lens is insensitive to touch or pain due to the absence of sensory innervation.
Cloquet's canal, the former site of the hyaloid artery, Is devoid of collagen fibrils and
Increase of thickness and also equatorial growth of the human lens occurs at approxi-
mately 0 .0 2 mm per year. The variation in the anterior radius of curvature is between 8.4 consists of fenestrated sheaths of basal laminae. It opens posteriorly into the optic
and 1 3 .8 mm with an average of 1 0 mm. The posterior radius of curvature is between disc.
4.6 and 7.5 mm with an average of 6 mm. These figures are age related. The vitreous is made up of 99% water. Hydrated hyaluronic acid has a volume 3000

During accommodation, the anteriOr surface of the lens moves forward towards the times greater than when dehydrated. The vitreous Is susceptible to osmotic dehydra-
cornea, and the posterior surface back, but to a much smaller extent than the anterior tion and reduction in volume from mannitol therapy.
surface. The dense vitreous cortex Is absent over the optic disc and is thin over the macula.
The lens capsule continues to grow throughout life and a young adult's capsule Hyalocytes are mononuclear ceUs found in the region of greatest hyaluronic acid
measures approximately 1 3 J.lmanteriorly and approximately 4 J.lmposteriorly. concentration in a single layer anterior to the inner limiting layer of the retina.

VItTeous 79 A = False B = False C = False D = True E = False

76 A = True B = False C = False D = False E = True The vitreous transmits up to 90% of visible light between 300 and 1400 nm. It does not
transmit light below 3 0 0 nm.
Due to a low diffusion gradient, high molecular weight molecules are carried in the
Vitreous osmolality has been measured to range between 288 and 322 mOsmlkg,
vitreous by convective bulk flow.
slightly higher than that of serum.
Hyaluronic acid provides greatest resistance to flow of water in the vitreous, espe-
Due to active pumping of potassium from the aqueous into the lens and then passive
cially in the cortex. Collagen provides resistance to bulk flow.
diffusion into the anterior vitreous, potassium levels in the vitreous can be used to give
Hyaluronic acid has an anionic charge which allows it to interact with mobile ions and
an accurate time of death within the first 3 - 4 days.
influence osmotic pressure, ion transport and vitreal electric potential.
Vrtreous to plasma ascorbic acid ratio is 9 :1 , probably due to active ciliary body
Although zonule fibres are similar to vitreous collagen fibrils they differ in certain
aspects: they are tightly packed and resist collagenase, whereas vitreous collagen pumping into the aqueous and then passive diffusion into the vitreous.
fibres are loosely arranged and are susceptible to collagenase activity.
Uquefaction describes an increase in the liquid volume of the vitreous. Age-related
liquefaction of the vitreous begins in the central vitreous and by the age of 5 0 , up to 80 A = False B = True C = False D = False E = True
2 5 % of individuals have a significant degree of liquefaction.
The vitreous forms 80% of the globe. The refractive Index of the vitreous is 1 .3 3 4 9 .
Collagen is the major structural protein of the vitreous. Over 90% of the collagen is of
77 A = True B = False C = True D = True E = True type 11.Collagen and hyaluronic acid are the major structural molecules of the vitr-
eous. In humans, hyaluronic acid content in the vitreous is very low in the prenatal
Fibroblasts are mainly found in the vitreous base and adjacent to the optic disc and period. Hyalocytes synthesize glycosaminoglycans after birth and maximum levels of
ciliary processes. The vitreous has marked haemostatic properties and has been vitreous hyaluronic acid are reached by adulthood and are concerrtrated mainly in the
shown to shorten the partial thromboplastin time and cause platelet aggregation. cortex.
94 P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 95

The mechanism for steroid-induced cataract is unclear and amongst many theories The vitreous serves as a repository of nutrients (Including amino acids) for the retina.
Urban and Cotlier ( 1 9 8 6 ) proposed that steroids react with amino groups of lens It has been known for over 5 0 years that the vitreous has active water movement
crystallins to precipitate the formation of disulphide bonds leading to protein aggre- important for transport of solutes in the eye. Fifty per cent of labelled water is seen
gation. Posterior subcapsular cataracts are commonly caused by topical and sys-
to turn over every 1 0 -1 5 min.
temic corticosteroid. Chlorpromazine is the only phenothiazine Implicated in causing
cataract.

78 A = False B = True C = True D = False E = True

75 I t = True B = True C = True 0 = False E = True
Collagen density is greatest in the vitreous base, followed by the posterior vitreous
cortex and then the anterior vitreous cortex behind the lens.
The lens is insensitive to touch or pain due to the absence of sensory innervation.
Cloquet's canal, the former site of the hyaloid artery, Is devoid of collagen fibrils and
Increase of thickness and also equatorial growth of the human lens occurs at approxi-
mately 0 .0 2 mm per year. The variation in the anterior radius of curvature is between 8.4 consists of fenestrated sheaths of basal laminae. It opens posteriorly into the optic
and 1 3 .8 mm with an average of 1 0 mm. The posterior radius of curvature is between disc.
4.6 and 7.5 mm with an average of 6 mm. These figures are age related. The vitreous is made up of 99% water. Hydrated hyaluronic acid has a volume 3000

During accommodation, the anteriOr surface of the lens moves forward towards the times greater than when dehydrated. The vitreous Is susceptible to osmotic dehydra-
cornea, and the posterior surface back, but to a much smaller extent than the anterior tion and reduction in volume from mannitol therapy.
surface. The dense vitreous cortex Is absent over the optic disc and is thin over the macula.
The lens capsule continues to grow throughout life and a young adult's capsule Hyalocytes are mononuclear ceUs found in the region of greatest hyaluronic acid
measures approximately 1 3 J.lmanteriorly and approximately 4 J.lmposteriorly. concentration in a single layer anterior to the inner limiting layer of the retina.

VItTeous 79 A = False B = False C = False D = True E = False

76 A = True B = False C = False D = False E = True The vitreous transmits up to 90% of visible light between 300 and 1400 nm. It does not
transmit light below 3 0 0 nm.
Due to a low diffusion gradient, high molecular weight molecules are carried in the
Vitreous osmolality has been measured to range between 288 and 322 mOsmlkg,
vitreous by convective bulk flow.
slightly higher than that of serum.
Hyaluronic acid provides greatest resistance to flow of water in the vitreous, espe-
Due to active pumping of potassium from the aqueous into the lens and then passive
cially in the cortex. Collagen provides resistance to bulk flow.
diffusion into the anterior vitreous, potassium levels in the vitreous can be used to give
Hyaluronic acid has an anionic charge which allows it to interact with mobile ions and
an accurate time of death within the first 3 - 4 days.
influence osmotic pressure, ion transport and vitreal electric potential.
Vrtreous to plasma ascorbic acid ratio is 9 :1 , probably due to active ciliary body
Although zonule fibres are similar to vitreous collagen fibrils they differ in certain
aspects: they are tightly packed and resist collagenase, whereas vitreous collagen pumping into the aqueous and then passive diffusion into the vitreous.
fibres are loosely arranged and are susceptible to collagenase activity.
Uquefaction describes an increase in the liquid volume of the vitreous. Age-related
liquefaction of the vitreous begins in the central vitreous and by the age of 5 0 , up to 80 A = False B = True C = False D = False E = True
2 5 % of individuals have a significant degree of liquefaction.
The vitreous forms 80% of the globe. The refractive Index of the vitreous is 1 .3 3 4 9 .
Collagen is the major structural protein of the vitreous. Over 90% of the collagen is of
77 A = True B = False C = True D = True E = True type 11.Collagen and hyaluronic acid are the major structural molecules of the vitr-
eous. In humans, hyaluronic acid content in the vitreous is very low in the prenatal
Fibroblasts are mainly found in the vitreous base and adjacent to the optic disc and period. Hyalocytes synthesize glycosaminoglycans after birth and maximum levels of
ciliary processes. The vitreous has marked haemostatic properties and has been vitreous hyaluronic acid are reached by adulthood and are concerrtrated mainly in the
shown to shorten the partial thromboplastin time and cause platelet aggregation. cortex.
% P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 97

81 A = False B = True C = False 0 = True E = True The retinal pigment epithelium maintains the blood-retinal barrier, phagocytoses
photoreceptor outer segments, nutritionally supports the photoreceptors, transports
The central retinal artery receives sympathetic innervation up to the lamina cribrosa and solutes, stores photopigment and absorbs light. The retinal pigment epithelial cens are
not beyond. Despite this fact, the retinal vessels appear to constrict in vitro on expo- encircled by zonulae occludentes (tight junctions) as well as zonulae adherentes (inter-
sure to noradrenaline outside the vessel wall. They appear to display both a ,- and a 2 - mediate junctions) and a few gap junctions on the apicolateral surface.
•
receptors. Sympathetic innervation of the choroidal circulation serves to reduce blood Retinol enters the retinal pigment epithelium from the bloodstream, assisted by a
flow by vasoconstriction without affecting the retinal circulation. In this way stable binding protein. It is immediately esterified to prevent accumulation and toxicity to
blood How is maintained during sudden changes in systemic blood pressure. The membranes in the retina. The enzymatic isomerization of the resulting A11-trans-retinyl
role of parasympathetic innervation to the retina is unclear. Both retinal and choroidal ester to 11-cis-retinol is followed by oxidation of this product to 11-cis-Retinaldehyde.
vessels vasodilate in the presence of hypoxia or hypercapnia Qncreased ~. l1-cis-Retinaldehyde enters the photoreceptor and binds with opsin to form rhodopsin.

82 A = False B = True C = True 0 = False E = False 85 A = False B = False C = False 0 = False E = False
Muller cells are a form of ependymal cell. The retina lacks the presence of oligoden-
cGMP levels are high in the dark and fall on exposure to light due to activation of
drocytes as ganglion cell axons are unmyelinated. phosphodiesterase. The 'triad' was first described by Mlsotten In 1962 and describes
The peak shedding period of cone discs is inconsistent, but shedding of rod discs the invagination into a cone pedicle of a bipolar cell dendrite flanked by two horizontal
occurs mainly in the morning.
cell processes, one on each side.
Evidence suggests that the foveola is deficient in blue cones.
The retinal pigment epithelium consists of a single layer of cells with a predominantly
The external limiting membrane is a term referring to the staining of the zonula
hexagonal arrangement. Photoreceptor tips are kept in adherence to the retinal pig-
adherens Ontermediate junction) attaching the plasma membrMes of photoreceptors
ment epithelial processes by the viscous interphotoreceptor matrix. There are no
and adjacent Muller cells. It separates the photoreceptor layer from the outer nuclear
junctional complexes.
layer.
The central retinal artery is lined with continuous epithelium and supplies the inner
two-thirds of the retina, including the inner nuclear layer. The fenestrated choriocapil-
laris supplies nutrients to the outer third of the retina, including the photoreceptors. 86 A = False B = False C = False 0 = True E = True

Rhodopsin has a half-life of 4 2 0 years.

The 'dark current' refers to the sodium influx entering the outer segment of the
83 A = False B = False C = True 0 = True E = True
photoreceptor from which it reaches the inner segment via the cytoplasm.
8y virtue of the photoreceptor depolarizing to darkness and hyperpolarizing to light, it
Muller cells extend through the entire thickness of the neural retina from the intemal
limiting membrane to beyond the extemallimiting membrane, terminating between the is an OFF cell.
Approximately 15% of glucose metabolism in the retina is via the hexose monopho-
inner segments of the photoreceptors.
sphate shunt pathway for the production of the reducing substrate NADPH and synth-
The ciliary stalk connecting inner and outer segments of the photoreceptor is a
modified cilium with nine pairs of microtubules but no central pair. esis of nucleotides.
The blood flow per gram weight to the retina is up to three times higher than that to
RhodopSin lies across the bllayered phospholipid disc membrane. 11-cis-
the kidney and between 1 0 and 2 0 times higher than that to the grey matter of the brain.
Retina!dehyde is bound to opsin by a Schiff-base linkage and only absorbs light that
Oxygen consumption in the retina is twice that of the cerebral cortex.
meets it perpendicularly. Light arriving at any other angle is not absorbed. The b-wave
of the electroretinogram is a reflection of the potential change In the MOller cell.

87 A = False B = True C = False 0 = True E = True

84 A = False B = True C = True 0 = True E = False
Dietary sources of vitamin A include J}-carotene from carrots and sweet potatoes and
The Gs protein 'transducin' is made up of three subunits, a, fJ and t. and remains retinyl esters from animal sources. These are enzymatically converted to retinol, vitamin
inactive due to the presence of the r subunit. A alcohol and retinoic acid in the gut.
% P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 97

81 A = False B = True C = False 0 = True E = True The retinal pigment epithelium maintains the blood-retinal barrier, phagocytoses
photoreceptor outer segments, nutritionally supports the photoreceptors, transports
The central retinal artery receives sympathetic innervation up to the lamina cribrosa and solutes, stores photopigment and absorbs light. The retinal pigment epithelial cens are
not beyond. Despite this fact, the retinal vessels appear to constrict in vitro on expo- encircled by zonulae occludentes (tight junctions) as well as zonulae adherentes (inter-
sure to noradrenaline outside the vessel wall. They appear to display both a ,- and a 2 - mediate junctions) and a few gap junctions on the apicolateral surface.
•
receptors. Sympathetic innervation of the choroidal circulation serves to reduce blood Retinol enters the retinal pigment epithelium from the bloodstream, assisted by a
flow by vasoconstriction without affecting the retinal circulation. In this way stable binding protein. It is immediately esterified to prevent accumulation and toxicity to
blood How is maintained during sudden changes in systemic blood pressure. The membranes in the retina. The enzymatic isomerization of the resulting A11-trans-retinyl
role of parasympathetic innervation to the retina is unclear. Both retinal and choroidal ester to 11-cis-retinol is followed by oxidation of this product to 11-cis-Retinaldehyde.
vessels vasodilate in the presence of hypoxia or hypercapnia Qncreased ~. l1-cis-Retinaldehyde enters the photoreceptor and binds with opsin to form rhodopsin.

82 A = False B = True C = True 0 = False E = False 85 A = False B = False C = False 0 = False E = False
Muller cells are a form of ependymal cell. The retina lacks the presence of oligoden-
cGMP levels are high in the dark and fall on exposure to light due to activation of
drocytes as ganglion cell axons are unmyelinated. phosphodiesterase. The 'triad' was first described by Mlsotten In 1962 and describes
The peak shedding period of cone discs is inconsistent, but shedding of rod discs the invagination into a cone pedicle of a bipolar cell dendrite flanked by two horizontal
occurs mainly in the morning.
cell processes, one on each side.
Evidence suggests that the foveola is deficient in blue cones.
The retinal pigment epithelium consists of a single layer of cells with a predominantly
The external limiting membrane is a term referring to the staining of the zonula
hexagonal arrangement. Photoreceptor tips are kept in adherence to the retinal pig-
adherens Ontermediate junction) attaching the plasma membrMes of photoreceptors
ment epithelial processes by the viscous interphotoreceptor matrix. There are no
and adjacent Muller cells. It separates the photoreceptor layer from the outer nuclear
junctional complexes.
layer.
The central retinal artery is lined with continuous epithelium and supplies the inner
two-thirds of the retina, including the inner nuclear layer. The fenestrated choriocapil-
laris supplies nutrients to the outer third of the retina, including the photoreceptors. 86 A = False B = False C = False 0 = True E = True

Rhodopsin has a half-life of 4 2 0 years.

The 'dark current' refers to the sodium influx entering the outer segment of the
83 A = False B = False C = True 0 = True E = True
photoreceptor from which it reaches the inner segment via the cytoplasm.
8y virtue of the photoreceptor depolarizing to darkness and hyperpolarizing to light, it
Muller cells extend through the entire thickness of the neural retina from the intemal
limiting membrane to beyond the extemallimiting membrane, terminating between the is an OFF cell.
Approximately 15% of glucose metabolism in the retina is via the hexose monopho-
inner segments of the photoreceptors.
sphate shunt pathway for the production of the reducing substrate NADPH and synth-
The ciliary stalk connecting inner and outer segments of the photoreceptor is a
modified cilium with nine pairs of microtubules but no central pair. esis of nucleotides.
The blood flow per gram weight to the retina is up to three times higher than that to
RhodopSin lies across the bllayered phospholipid disc membrane. 11-cis-
the kidney and between 1 0 and 2 0 times higher than that to the grey matter of the brain.
Retina!dehyde is bound to opsin by a Schiff-base linkage and only absorbs light that
Oxygen consumption in the retina is twice that of the cerebral cortex.
meets it perpendicularly. Light arriving at any other angle is not absorbed. The b-wave
of the electroretinogram is a reflection of the potential change In the MOller cell.

87 A = False B = True C = False 0 = True E = True

84 A = False B = True C = True 0 = True E = False
Dietary sources of vitamin A include J}-carotene from carrots and sweet potatoes and
The Gs protein 'transducin' is made up of three subunits, a, fJ and t. and remains retinyl esters from animal sources. These are enzymatically converted to retinol, vitamin
inactive due to the presence of the r subunit. A alcohol and retinoic acid in the gut.
98 P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 99

Conversion of rhodopsin to bathottlodopsin is a photoreaction. Subsequent conver- Pattem ERG consists of three waves: N35, P50 (partly ganglion cell derived) and N95
sion reactions are thermally driven. (ganglion cell, but secondary phenomenon P50). PSOis abnormal in the presence of
In the dark, the inner segment of the retina, which is supplied by the central retinal macular disease, however the P5OIN95 ratio is normal. In the presence of optic neuro-
artery, is vulnerable to hypoxia due to the high rate of metabolism maintained in the pathy, P50 is usually normal, but N95 may show selective reduction.
dark current. The choroidal circulation supplies the outer segment and has a high rate By using monocular stimulation and comparing left and right hemisphere VEPs, the
of blood flow. difference in latency and scale distribution between normal and abnormal recordings
Mitochondria consist of an outer membrane, inner membrane with cristae and a can be used to predict the location of compressive lesions, as to whether they may be
5
matrix enclosed by the inner membrane. Between the inner and outer membrane is chiasmal, pre- or post-chiasmal. When the retinal is stimulated by a flash of light 10
an intermembrane space. The matrix consists of soluble enzymes absent In the cyto- times brighter than that required for scotopic ERG, an early recaptor potential is seen to
plasm. The inner membrane holds electron-transferring proteins and the enzyme ATP occur before the a-wave. It consists of a positive peak followed by a negative trough
synthase. Acetyl CoA is formed from pyruvate by pyruvate dehydrogenase in the and a second positive peak. It is thought to be generated by cone pigments.
matrix.
In the retina, although 60% of glucose is metabolized anaerobically and only 25% is
metabolized aarobically, due to its high ATP yield, aerobic metabolism accounts for up 90 A = False B = True C = False 0 = False E = True
to 90% of energy production in the retina. Fifteen per cent of glucose is metabolized by
the hexose monophosphate shunt pathway. The ERG is a test of the peripheral retiha and of cells distal to the ganglion cells. The
a-wave of the ERG is produced by photoreceptors which are supplied by the chor-
oidal circulation. Glaucoma is a disease of ganglion cells and the optic nerve and so
88 A = False B = True C = True 0 = True E = False shows a normal ERG. The flicker ERG produces a pure cone response in the form of
a sinusoidal-like wave response. Rods have relatively poor temporal resolution and
Photoreceptors are unable to store glycogen. Muller cells store glycogen and are able are unable to respond to flash frequencies greater than 10-15 Hz. The Arden index
to convert glycogen to glucose due to the presence of glucose-6-phosphatase. refers to the light peak/dark trough in the electro-oculogram. The normal value should
Terminal processas of ON bipolar cells are found in the inner half of the inner plexi- be greater than 170%. This is a reflection of RPElphotoreceptor interaction.
form layer whilst those of OFF bipolar cells are found in the outer half of the inner
plexiform layer. These cells are excited by brightness or darkness respectively and they
form the begiming of parallel pathways reaching the brain. They are directly excltatory 91 A = False B = False C = True 0 = True E = True
to their specific ganglion cells.
In the retina, pyruvate production (regardless of oxygen supply) is greater than The ERG is performed using electrodes placed near the source of the signal close to
pyruvate metabolism. This causes production of lactate. the cornea. This is achieved with contact lens and non-contact lens corneal electrodes.
Due to the reduced partial pressure of oxygen at high altitude, delayed dark adapta- The VEP is recorded by placing electrodes over the occipital scalp in relation to the
tion is seen. visual cortex.
The pattem ERG is useful in detecting ganglion cell abnormalities. It is of no value in
confirming central retinal artery occlusion.
Electrophyslologiesl I n v e s tig a tio n s The flash VEP uses a diffuse stimulus that is clinically useful in patients not fix.ating,
or those with an unknown refractive error. It has individual variability, but is consistent
89 A = True B = True C = True 0 = True E = False between cerebral hemispheres and eyes.
The ERG b-wave is largest when the patient is full dark adapted.
Electroretinography records the summation of retinal potential changes to light. As the
central macula occupies 5% of the photoreceptor population, the ERG may be normal
in the presence of severe macular disease. The ECG is able to assess RPElphoto- The extraocular muscles
receptor interaction by recording corneoretinal potentials with fixed 30· lateral excur-
sions. It consists of a standing potential due to RPE activity and a light-sensitive 92 A = False B = True C = True 0 '" False E '" True
component due to depolarization of the basal membrane of the retinal pigment epithe-
lium. In retinitis pigmentosa the amplitude of the light-sensitive potential falls In early A cross-section of an extraocular muscle such as the rectus. reveals an outer orbital
disease and the standing potential is also seen to fall in advanced stages. layer, a core and an innermost global layer facing the globe.
98 P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s io lo g y Answers 99

Conversion of rhodopsin to bathottlodopsin is a photoreaction. Subsequent conver- Pattem ERG consists of three waves: N35, P50 (partly ganglion cell derived) and N95
sion reactions are thermally driven. (ganglion cell, but secondary phenomenon P50). PSOis abnormal in the presence of
In the dark, the inner segment of the retina, which is supplied by the central retinal macular disease, however the P5OIN95 ratio is normal. In the presence of optic neuro-
artery, is vulnerable to hypoxia due to the high rate of metabolism maintained in the pathy, P50 is usually normal, but N95 may show selective reduction.
dark current. The choroidal circulation supplies the outer segment and has a high rate By using monocular stimulation and comparing left and right hemisphere VEPs, the
of blood flow. difference in latency and scale distribution between normal and abnormal recordings
Mitochondria consist of an outer membrane, inner membrane with cristae and a can be used to predict the location of compressive lesions, as to whether they may be
5
matrix enclosed by the inner membrane. Between the inner and outer membrane is chiasmal, pre- or post-chiasmal. When the retinal is stimulated by a flash of light 10
an intermembrane space. The matrix consists of soluble enzymes absent In the cyto- times brighter than that required for scotopic ERG, an early recaptor potential is seen to
plasm. The inner membrane holds electron-transferring proteins and the enzyme ATP occur before the a-wave. It consists of a positive peak followed by a negative trough
synthase. Acetyl CoA is formed from pyruvate by pyruvate dehydrogenase in the and a second positive peak. It is thought to be generated by cone pigments.
matrix.
In the retina, although 60% of glucose is metabolized anaerobically and only 25% is
metabolized aarobically, due to its high ATP yield, aerobic metabolism accounts for up 90 A = False B = True C = False 0 = False E = True
to 90% of energy production in the retina. Fifteen per cent of glucose is metabolized by
the hexose monophosphate shunt pathway. The ERG is a test of the peripheral retiha and of cells distal to the ganglion cells. The
a-wave of the ERG is produced by photoreceptors which are supplied by the chor-
oidal circulation. Glaucoma is a disease of ganglion cells and the optic nerve and so
88 A = False B = True C = True 0 = True E = False shows a normal ERG. The flicker ERG produces a pure cone response in the form of
a sinusoidal-like wave response. Rods have relatively poor temporal resolution and
Photoreceptors are unable to store glycogen. Muller cells store glycogen and are able are unable to respond to flash frequencies greater than 10-15 Hz. The Arden index
to convert glycogen to glucose due to the presence of glucose-6-phosphatase. refers to the light peak/dark trough in the electro-oculogram. The normal value should
Terminal processas of ON bipolar cells are found in the inner half of the inner plexi- be greater than 170%. This is a reflection of RPElphotoreceptor interaction.
form layer whilst those of OFF bipolar cells are found in the outer half of the inner
plexiform layer. These cells are excited by brightness or darkness respectively and they
form the begiming of parallel pathways reaching the brain. They are directly excltatory 91 A = False B = False C = True 0 = True E = True
to their specific ganglion cells.
In the retina, pyruvate production (regardless of oxygen supply) is greater than The ERG is performed using electrodes placed near the source of the signal close to
pyruvate metabolism. This causes production of lactate. the cornea. This is achieved with contact lens and non-contact lens corneal electrodes.
Due to the reduced partial pressure of oxygen at high altitude, delayed dark adapta- The VEP is recorded by placing electrodes over the occipital scalp in relation to the
tion is seen. visual cortex.
The pattem ERG is useful in detecting ganglion cell abnormalities. It is of no value in
confirming central retinal artery occlusion.
Electrophyslologiesl I n v e s tig a tio n s The flash VEP uses a diffuse stimulus that is clinically useful in patients not fix.ating,
or those with an unknown refractive error. It has individual variability, but is consistent
89 A = True B = True C = True 0 = True E = False between cerebral hemispheres and eyes.
The ERG b-wave is largest when the patient is full dark adapted.
Electroretinography records the summation of retinal potential changes to light. As the
central macula occupies 5% of the photoreceptor population, the ERG may be normal
in the presence of severe macular disease. The ECG is able to assess RPElphoto- The extraocular muscles
receptor interaction by recording corneoretinal potentials with fixed 30· lateral excur-
sions. It consists of a standing potential due to RPE activity and a light-sensitive 92 A = False B = True C = True 0 '" False E '" True
component due to depolarization of the basal membrane of the retinal pigment epithe-
lium. In retinitis pigmentosa the amplitude of the light-sensitive potential falls In early A cross-section of an extraocular muscle such as the rectus. reveals an outer orbital
disease and the standing potential is also seen to fall in advanced stages. layer, a core and an innermost global layer facing the globe.
100
P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
PHARMACOWGY
Extraocular muscles may be broadly classified into singly innervated flbrillenstrukter
fibres and multiply innervated felderstrukter fibres. The fibrillenstrukter fibres are found Questions
in the ort>itaI layer, are thought to be responsible for fallt speed contraction and have a
single large motor end-plate. They have a well-developed sarcoplasmic reticulum and
T-tubule system releasing calcium for excitatiorH:Ontraction coupling. Other varying
types are found elsewhere In the muscle with Inconsistent features. 1 Complications of periocular injections include
The felderstrukter fibres make up most of the core and the global layer of the muscle,
although some are found in the orbital aspect all well. These fibres have multiple grape- A transient reduction in visual acuity
like nerve endings scattered along their length and are tonically active. Due to a poorly B extraocular muscle palsy
developed sarcoplasmic reticulum, calcium release is from the surface membrane and C central retinal artery occlusion
not the sarcoplasmic reticulum. o conjunctival haemorrhage
The orbital layer of the rectus muscles possesses a richer capillary blood supply and E glaucoma and cataract
a greater concentration of mitochondria than the global layer.
Sherrington's law of reciprocal inOOlVationstates that with increased contraction of a
prime mover, there is a decrease in contractile activity of the corresponding antagonist.
Yoke muscles are paired muscles that move both eyes In the same direction and are 2 Which of the following statements are true?

equally innervated (see Hering's law).

Suxamethonlum (succinylcholine) initially depolarizes the end-plate and then remains A The corneal epithelium acts as a depot for drugs released into the aqueous.
bound causing neuromuscular blockade. It acts rapidly, usually for a short duration B The ciliary body provides the largest ocular source of drug-metabolizing enzymes.
(less than 10 min) and is normally hydrolysed by- pseudocholinesterases. In the pre- C Topical neomycin can cause blepharoconjunctivitis.
sence of a cholinesterase inhibiter, this breakdown is diminished. o Topical timolol can cause bronchospasm, bradycardia and systemic hypotension.
E Subconjunctival injection is most commonly performed by passing a needle
through the skin of the lid between the conjunctiva and Tenon's capsule.
93 A = False B = False C = False 0 = False E = False

Amidst growing arguments against the role of proprioception In extraocular muscles,

3 Ocular side-effects of digoxin therapy include
there do, however, exist three main types of nerve endings which are thought to be
sensory. Spiral nerve endings have recently been shown to be motor endings. Scanty
muscles spindles with thin capsules and few intrafusal fibres have a questionable role. A changes in colour vision after day one of administration
A few Golgi tendon organs exist, but these are atypical in morphology and also B impaired dark adaptation
C reduced intraocular pressure
perhaps, in function.
Tertiary positions of gaze involve simultaneous rotations about the X-axis (horizontaQ osnowy vision
and Z-axis (verticaQ. Torsion with rotation about the Y-axis is not a tertiary position of E retrobulbar neuritis
gaze. Extorsion and intorsion by inferior and superior obliques respectively involves
rotation about a fixed point on the lateral limbus and not about the Y-axis. Secondary
positions of gaze involve rotation of the eye along either the vertical Z-axis or the
4 Which of the following statements are correct?
horizontal X-axis.
The isolated agonist model is a well-accepted model of extraocular movement.
A {J-Adrenergic receptors are found in the corneal epithelium.
Medial rectus has a primary action of adduction; lateral rectus: abduction; superior
rectus: elevation (secondary action: abduction and intorsion); inferior rectus: depres- B Topical noradrenaline lowers intraocular pressure mainly by reducing aqueous
production.
sion (secondary action: abduction and extorsion); inferior oblique: extorsion (secondary
reaction: abduction and elevation); and superior oblique: intorsion (secondary action: C Mydriasis due to topical adrenaline is maximal at 2 h after installation and lasts
12 h.
depression and abduction). Due to the insertion of inferior oblique at an angle of 51° to
the saqittal plane, it produces pure extorsion when the eye rotates 39° laterally out of o Phenylephrine is a synthetic amine with mainly a-agonist properties.
E Timolol is administered twice a day.
the sagittal plane.
100
P h y s io lo g y AnswersutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
PHARMACOWGY
Extraocular muscles may be broadly classified into singly innervated flbrillenstrukter
fibres and multiply innervated felderstrukter fibres. The fibrillenstrukter fibres are found Questions
in the ort>itaI layer, are thought to be responsible for fallt speed contraction and have a
single large motor end-plate. They have a well-developed sarcoplasmic reticulum and
T-tubule system releasing calcium for excitatiorH:Ontraction coupling. Other varying
types are found elsewhere In the muscle with Inconsistent features. 1 Complications of periocular injections include
The felderstrukter fibres make up most of the core and the global layer of the muscle,
although some are found in the orbital aspect all well. These fibres have multiple grape- A transient reduction in visual acuity
like nerve endings scattered along their length and are tonically active. Due to a poorly B extraocular muscle palsy
developed sarcoplasmic reticulum, calcium release is from the surface membrane and C central retinal artery occlusion
not the sarcoplasmic reticulum. o conjunctival haemorrhage
The orbital layer of the rectus muscles possesses a richer capillary blood supply and E glaucoma and cataract
a greater concentration of mitochondria than the global layer.
Sherrington's law of reciprocal inOOlVationstates that with increased contraction of a
prime mover, there is a decrease in contractile activity of the corresponding antagonist.
Yoke muscles are paired muscles that move both eyes In the same direction and are 2 Which of the following statements are true?

equally innervated (see Hering's law).

Suxamethonlum (succinylcholine) initially depolarizes the end-plate and then remains A The corneal epithelium acts as a depot for drugs released into the aqueous.
bound causing neuromuscular blockade. It acts rapidly, usually for a short duration B The ciliary body provides the largest ocular source of drug-metabolizing enzymes.
(less than 10 min) and is normally hydrolysed by- pseudocholinesterases. In the pre- C Topical neomycin can cause blepharoconjunctivitis.
sence of a cholinesterase inhibiter, this breakdown is diminished. o Topical timolol can cause bronchospasm, bradycardia and systemic hypotension.
E Subconjunctival injection is most commonly performed by passing a needle
through the skin of the lid between the conjunctiva and Tenon's capsule.
93 A = False B = False C = False 0 = False E = False

Amidst growing arguments against the role of proprioception In extraocular muscles,

3 Ocular side-effects of digoxin therapy include
there do, however, exist three main types of nerve endings which are thought to be
sensory. Spiral nerve endings have recently been shown to be motor endings. Scanty
muscles spindles with thin capsules and few intrafusal fibres have a questionable role. A changes in colour vision after day one of administration
A few Golgi tendon organs exist, but these are atypical in morphology and also B impaired dark adaptation
C reduced intraocular pressure
perhaps, in function.
Tertiary positions of gaze involve simultaneous rotations about the X-axis (horizontaQ osnowy vision
and Z-axis (verticaQ. Torsion with rotation about the Y-axis is not a tertiary position of E retrobulbar neuritis
gaze. Extorsion and intorsion by inferior and superior obliques respectively involves
rotation about a fixed point on the lateral limbus and not about the Y-axis. Secondary
positions of gaze involve rotation of the eye along either the vertical Z-axis or the
4 Which of the following statements are correct?
horizontal X-axis.
The isolated agonist model is a well-accepted model of extraocular movement.
A {J-Adrenergic receptors are found in the corneal epithelium.
Medial rectus has a primary action of adduction; lateral rectus: abduction; superior
rectus: elevation (secondary action: abduction and intorsion); inferior rectus: depres- B Topical noradrenaline lowers intraocular pressure mainly by reducing aqueous
production.
sion (secondary action: abduction and extorsion); inferior oblique: extorsion (secondary
reaction: abduction and elevation); and superior oblique: intorsion (secondary action: C Mydriasis due to topical adrenaline is maximal at 2 h after installation and lasts
12 h.
depression and abduction). Due to the insertion of inferior oblique at an angle of 51° to
the saqittal plane, it produces pure extorsion when the eye rotates 39° laterally out of o Phenylephrine is a synthetic amine with mainly a-agonist properties.
E Timolol is administered twice a day.
the sagittal plane.
 P h a rm a c o lo g y P h a rm a c o lo g y Questions
Q u e s tio n s utsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 103
102
9 Carbachol
5 Which of the following are correct?
A has a direct cholinergic action only
A Topical adrenaline causes cycloplegia. B is a muscarinic and nicotinic agonist
B Adrenaline causes maculopathy in aphakic eyes. C is rapidly hydrolysed by cholinesterases
C Phenylephrine causes a rebound miosis 24 h after installation.
D applied topically is an effective ocular hypotensive agent due to its high lipid
D Guanethidine blocks the effects of hydroxyamphetamine. solubility
E Pilocarpine, adrenaline and timolol are less effective in reducing intraocular pres- E causes vasodilatation
sure in black subjects than white subjects.

10 Which of the following statements about pilocarpine and physostigmine are true?
6 Which of the following statements are true?
A Brown eyes have a greater ocular hypotensive response to pilocarpine than blue
A One per cent topical adrenaline causes conjunctival blanching, reduction in Intrao- eyes.
cular pressure and severe mydriasis. B Ocular side-effects of pilocarpine include accommodative spasm, myopia and
B Adrenaline-induced ocular hypotension is initially enhanced when used in combi- follicular conjunctivitis.
nation with topical Il-blockers. . C Physostigmine acts both centrally and peripherally as an irreversible cholinester-
C Topical cocaine causes anaesthesia, mydriasis and conjunctival blanching. ase inhibitor.
D Timolol applied topically to one eye also reduces the intraocular pressure of the D Physostigmine is both a muscarinic and nicotinic agonist.
unmedicated eye. E Physostigmine solution undergoes a colour change due to oxidation when in
E Combined maintenance therapy of adrenaline and timolol has a strong ocular storage.
hypotensive effect.

" Which of the following are true?

7 Which of the following are correct?
A Physostigmine causes a ptosis, miosis and accommodative spasm.
A Combined oral Il-blocker therapy is contraindicated with topical timolol. B Neostigmine is useful in treatment for Phthirus pubis Infestation.
B Thymoxamine is a competitive a-blocker. C Physostigmine causes brow ache.
C Thymoxamine reduces intraocular pressure. D Edrophonium stimulates muscarinic receptors more than nicotinic receptors.
D Guanethidine potentlates the effects of adrenaline in reducing intraocular E Edrophonium reduces intraocular pressure.
pressure.
E Guanethidine reduces lid retraction found in thyroid eye disease.
12 Which of the following are true?

8 Which of the following are true? A Ecothiopate is a useful diagnostic and therapeutic tool in accommodative
esotropia
A Thymoxamine is of diagnostic value in angle closure glaucoma. B Low levels of plasma and red cell cholinesterase are always found in patients
B Acetylcholine is available as a topical preparation and is effective in causing a with systemic side-effects of cholinesterase inhibitors.
C Systemic absorption of topically applied ocular drugs occurs mainly through
complete miosis.
C Pilocarpine is a direct-acting ocular cholinergic agonist with no systemic side- ciliary vessels and Schlemm's canal.
D Cyclopentolate causes mydriasis that lasts for 48 h.
effects.
D Pilocarpine reduces intraocular pressure mainly by increasing aqueous outflow. E Hyoscine causes mydriasis that lasts up to one week.
E pilocarpine should be given twice daily for control of intraocular pressure.
 P h a rm a c o lo g y P h a rm a c o lo g y Questions
Q u e s tio n s utsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 103
102
9 Carbachol
5 Which of the following are correct?
A has a direct cholinergic action only
A Topical adrenaline causes cycloplegia. B is a muscarinic and nicotinic agonist
B Adrenaline causes maculopathy in aphakic eyes. C is rapidly hydrolysed by cholinesterases
C Phenylephrine causes a rebound miosis 24 h after installation.
D applied topically is an effective ocular hypotensive agent due to its high lipid
D Guanethidine blocks the effects of hydroxyamphetamine. solubility
E Pilocarpine, adrenaline and timolol are less effective in reducing intraocular pres- E causes vasodilatation
sure in black subjects than white subjects.

10 Which of the following statements about pilocarpine and physostigmine are true?
6 Which of the following statements are true?
A Brown eyes have a greater ocular hypotensive response to pilocarpine than blue
A One per cent topical adrenaline causes conjunctival blanching, reduction in Intrao- eyes.
cular pressure and severe mydriasis. B Ocular side-effects of pilocarpine include accommodative spasm, myopia and
B Adrenaline-induced ocular hypotension is initially enhanced when used in combi- follicular conjunctivitis.
nation with topical Il-blockers. . C Physostigmine acts both centrally and peripherally as an irreversible cholinester-
C Topical cocaine causes anaesthesia, mydriasis and conjunctival blanching. ase inhibitor.
D Timolol applied topically to one eye also reduces the intraocular pressure of the D Physostigmine is both a muscarinic and nicotinic agonist.
unmedicated eye. E Physostigmine solution undergoes a colour change due to oxidation when in
E Combined maintenance therapy of adrenaline and timolol has a strong ocular storage.
hypotensive effect.

" Which of the following are true?

7 Which of the following are correct?
A Physostigmine causes a ptosis, miosis and accommodative spasm.
A Combined oral Il-blocker therapy is contraindicated with topical timolol. B Neostigmine is useful in treatment for Phthirus pubis Infestation.
B Thymoxamine is a competitive a-blocker. C Physostigmine causes brow ache.
C Thymoxamine reduces intraocular pressure. D Edrophonium stimulates muscarinic receptors more than nicotinic receptors.
D Guanethidine potentlates the effects of adrenaline in reducing intraocular E Edrophonium reduces intraocular pressure.
pressure.
E Guanethidine reduces lid retraction found in thyroid eye disease.
12 Which of the following are true?

8 Which of the following are true? A Ecothiopate is a useful diagnostic and therapeutic tool in accommodative
esotropia
A Thymoxamine is of diagnostic value in angle closure glaucoma. B Low levels of plasma and red cell cholinesterase are always found in patients
B Acetylcholine is available as a topical preparation and is effective in causing a with systemic side-effects of cholinesterase inhibitors.
C Systemic absorption of topically applied ocular drugs occurs mainly through
complete miosis.
C Pilocarpine is a direct-acting ocular cholinergic agonist with no systemic side- ciliary vessels and Schlemm's canal.
D Cyclopentolate causes mydriasis that lasts for 48 h.
effects.
D Pilocarpine reduces intraocular pressure mainly by increasing aqueous outflow. E Hyoscine causes mydriasis that lasts up to one week.
E pilocarpine should be given twice daily for control of intraocular pressure.
 P h a r m a c o lo g y Questions
P h a r m a c o lo g y QuestionsutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 105

104
18 Ocular effects of corticosteroids include
1 3 How many of the following statements about ecothiopate and atropine are true?
A Increased intraocular pressure
A Ecothiopate produces miosis that lasts for up to 4 weekS. B posterior subcapsular cataract
B Ecothlopate reduCeSintraocular pressure mainly by reducing aqueous production. C neovascularization
e Ecothiopate is associated with anterior subcaPsular cataract. o miosis
E ptosis
o Atropine mydriaSis lasts up to 48 h.
E Atropine is contraindicated in anterior uveitis.

1 9 Whictl of the following statements about J3-blockers are true?

'4 Which of the following are true?

A Atenolol is a P,-selective antagonist
A Atropine-induced maximal mydriasis precedes cycloplegia B Betaxolol is a p,-selective antagonist.
B Homatropine causes mydriasis that is maximal in 40 min. e Levobunolol is a non-selective J3-antagonist.
e Tropicamide causes mydriasis that recovers In 6 h. o Propanolol is a p,-selective antagonist.
o The degree of mydriasis due to tropicamide is independent of iris pigmentation. E TImolol is a non-selective J3-antagOnist.
E Atropine is also an a-adrenergic agonist.

20 Which of the following are true?

'5 Local anaesthetics

A Topical propanolcl causes corneal anaesthesia.
B Timelol is available orally for the treatment of ocular hypertenSion.
A are biphasic weak bases
B act on the cell membrane by maintaining a high permeability to sodium ions e Timolol has an additive ocular hypotenSive effect when combined with
pilocarpine.
e exhibit antimicrobial properties
o administered topically commonly cause desquamatiOl'l of the corneal epithelium o Acetazolamide produces a metabolic alkalosis.
E exhibit marked crossed hypersensitivity between different classes of anaesthetic E Topical acetazolamide penetrates the corneal epithelium poorly.

21 Acetazolamide
16 Glucocorticoids

A reduce numbers of neutrophils A administered intravenously has a maximal ocular hypotensive effect within 5 min
B 50% is found bound to plasma proteins
B increase numbers of basophils
e reduce numbers of circulating red blood cells C when protein bound is responsible for carbonic anhydrase inhibition
o reduce numbers of eosinophils o is metabolized in the liver
E produces acidic urine
E reduce numbers of monocytes

17 Which of these statements about steroids are true? 22 Acetazolamide

A Systemic corticosteroids reduce IgG and IgE titres. A is a sulphonamide derivative

B SteroidS reduce numbers of B Iymphocytes more than they reduce numbers of T B in combined therapy increases serum levels of phenytoin
e is a useful adjunct in the treatment of petit mal epilepsy
Iymphocytes.
C Glucocorticoids enter the cell membrane by recaptor mediator transport. o is detected in the milk of lactating women being treated with acetazolamide
o Plasma cortisol levels are lowest between 6 and 8 am. E therapy causes depression
E Topical ocular corticosteroids cause increased corneal thicknesS.
 P h a r m a c o lo g y Questions
P h a r m a c o lo g y QuestionsutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 105

104
18 Ocular effects of corticosteroids include
1 3 How many of the following statements about ecothiopate and atropine are true?
A Increased intraocular pressure
A Ecothiopate produces miosis that lasts for up to 4 weekS. B posterior subcapsular cataract
B Ecothlopate reduCeSintraocular pressure mainly by reducing aqueous production. C neovascularization
e Ecothiopate is associated with anterior subcaPsular cataract. o miosis
E ptosis
o Atropine mydriaSis lasts up to 48 h.
E Atropine is contraindicated in anterior uveitis.

1 9 Whictl of the following statements about J3-blockers are true?

'4 Which of the following are true?

A Atenolol is a P,-selective antagonist
A Atropine-induced maximal mydriasis precedes cycloplegia B Betaxolol is a p,-selective antagonist.
B Homatropine causes mydriasis that is maximal in 40 min. e Levobunolol is a non-selective J3-antagonist.
e Tropicamide causes mydriasis that recovers In 6 h. o Propanolol is a p,-selective antagonist.
o The degree of mydriasis due to tropicamide is independent of iris pigmentation. E TImolol is a non-selective J3-antagOnist.
E Atropine is also an a-adrenergic agonist.

20 Which of the following are true?

'5 Local anaesthetics

A Topical propanolcl causes corneal anaesthesia.
B Timelol is available orally for the treatment of ocular hypertenSion.
A are biphasic weak bases
B act on the cell membrane by maintaining a high permeability to sodium ions e Timolol has an additive ocular hypotenSive effect when combined with
pilocarpine.
e exhibit antimicrobial properties
o administered topically commonly cause desquamatiOl'l of the corneal epithelium o Acetazolamide produces a metabolic alkalosis.
E exhibit marked crossed hypersensitivity between different classes of anaesthetic E Topical acetazolamide penetrates the corneal epithelium poorly.

21 Acetazolamide
16 Glucocorticoids

A reduce numbers of neutrophils A administered intravenously has a maximal ocular hypotensive effect within 5 min
B 50% is found bound to plasma proteins
B increase numbers of basophils
e reduce numbers of circulating red blood cells C when protein bound is responsible for carbonic anhydrase inhibition
o reduce numbers of eosinophils o is metabolized in the liver
E produces acidic urine
E reduce numbers of monocytes

17 Which of these statements about steroids are true? 22 Acetazolamide

A Systemic corticosteroids reduce IgG and IgE titres. A is a sulphonamide derivative

B SteroidS reduce numbers of B Iymphocytes more than they reduce numbers of T B in combined therapy increases serum levels of phenytoin
e is a useful adjunct in the treatment of petit mal epilepsy
Iymphocytes.
C Glucocorticoids enter the cell membrane by recaptor mediator transport. o is detected in the milk of lactating women being treated with acetazolamide
o Plasma cortisol levels are lowest between 6 and 8 am. E therapy causes depression
E Topical ocular corticosteroids cause increased corneal thicknesS.
 P h a r m a c o lo g y P h a r m a c o lo g y Questions
Q u e s tio n s utsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 107
106
27 AAtlDactenalS: Which of the following statements about arninoglycosides are true?
23 Acetazolamide
A Gentamicin acts by binding to bacterial ribosomes and inhibiting tRNA attachment.
A produces a metallic taste B Gentamicin easily crosses the normal blood-brain barrier.
B therapy is associated with perioral paraesthesia C Aminoglycosides are bactericidal.

C is associated with hypermetropia

o Gentamicin ototoxicity destroys cochlear cells only.
E Neomycin shows good absorption when administered orally.
o is associated with urinary calculi
E is associated with thrombocytopenia
F is safe in patients with liver cirrhosis
28 Antibacterials: How many of these statements about tetracyclines are true?
G is safe in pregnancy
A'Tetracycline binds to bacterial ribosomes and prevents tRNA and mRNA
attachment.
24 Which of the following statements are true? B Tetracycline is useful for the treatment of mycoplasma, Q fever and Chlamydia
C Tetracycline is effective in the treatment of 'corneal melting'.
A Urea exerts its hyperOsmotic effect by remaining in the extracellular space. D Doxycycline is the only tetracycline excreted renally.
B Urea is metabolized by the kidney. E Oral tetracycline is the drug of choice in chlamydial ophthalmia neonatorum.
C Oral mannitol is metabolized by the 'first-pass' phenomenon. F TetracyCline can potentiate Warfarin In combination therapy.
o Seventy-five per cent of mannitol is protein bound in the extracellular space.
E Glycerol has good penetration of the blood-aqueous barrier.
29 Erythromycin
F Glycerol exerts its hyperosmotic effect by inducing glycosuria.
G Glycerol is well absorbed from the gastrointestinal tract.
A is bacteriostatic
B is effective In the treatment of Mycoplasma pneumoniae
C easily crosses the blood-brain barrier and blood-ocular barriers
25 AntibacterialS: Penicillins D is associated with cholestatic jaundice
E administered orally is the drug of choice for chlamydlal ophthalmia neonatorum
A have a bactericidal effect
B inhibit bacterial transpeptidases responsible for cross-linking polysaccharide

chains 30 Chloramphenicol
C and cephalosporins contain a fj-Iactamase ring
o cross the normal blood-<>Cularbarrier easily A easily penetrates the blood-brain and blood-aqueous barrier
E allergy is linked to cephalosporins, with 20% of people allergiC to penicillin B administered topically does not cause aplastic anaemia
having cross-reactivity to cephalosporins C is effective in the treatment of typhoid fever
o is useful in the treatment of pneumonia
E is effective in the treatment of CNS infections due to Bacteroides fragl/is
26 AntibacterialS: Which of the following statements about cephalosponns are true? F is bacteriostatic

A fj-Lactamase-producing StaphylOCOCCUS
aureus Is resistant to cephalosporins.
31 Metronidazole
B Third-generation cephalosporins have good penetration of the bIood-brain

barrier. A acts by inhibiting RNA synthesis

C Third-generation cephalosporins have greater activity against !}-Iactarnase gram-
B may be administered by suppository to achieve satisfactory blood levels
negative bacteria. C is the treatment of choice 10r Trichomonas vagina/is
D Cephadrine and cefadroxil are second-generatlon cephalosporins. D may be prescribed in pregnancy
E Cephalosporins are bacteriostatic.
 P h a r m a c o lo g y P h a r m a c o lo g y Questions
Q u e s tio n s utsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 107
106
27 AAtlDactenalS: Which of the following statements about arninoglycosides are true?
23 Acetazolamide
A Gentamicin acts by binding to bacterial ribosomes and inhibiting tRNA attachment.
A produces a metallic taste B Gentamicin easily crosses the normal blood-brain barrier.
B therapy is associated with perioral paraesthesia C Aminoglycosides are bactericidal.

C is associated with hypermetropia

o Gentamicin ototoxicity destroys cochlear cells only.
E Neomycin shows good absorption when administered orally.
o is associated with urinary calculi
E is associated with thrombocytopenia
F is safe in patients with liver cirrhosis
28 Antibacterials: How many of these statements about tetracyclines are true?
G is safe in pregnancy
A'Tetracycline binds to bacterial ribosomes and prevents tRNA and mRNA
attachment.
24 Which of the following statements are true? B Tetracycline is useful for the treatment of mycoplasma, Q fever and Chlamydia
C Tetracycline is effective in the treatment of 'corneal melting'.
A Urea exerts its hyperOsmotic effect by remaining in the extracellular space. D Doxycycline is the only tetracycline excreted renally.
B Urea is metabolized by the kidney. E Oral tetracycline is the drug of choice in chlamydial ophthalmia neonatorum.
C Oral mannitol is metabolized by the 'first-pass' phenomenon. F TetracyCline can potentiate Warfarin In combination therapy.
o Seventy-five per cent of mannitol is protein bound in the extracellular space.
E Glycerol has good penetration of the blood-aqueous barrier.
29 Erythromycin
F Glycerol exerts its hyperosmotic effect by inducing glycosuria.
G Glycerol is well absorbed from the gastrointestinal tract.
A is bacteriostatic
B is effective In the treatment of Mycoplasma pneumoniae
C easily crosses the blood-brain barrier and blood-ocular barriers
25 AntibacterialS: Penicillins D is associated with cholestatic jaundice
E administered orally is the drug of choice for chlamydlal ophthalmia neonatorum
A have a bactericidal effect
B inhibit bacterial transpeptidases responsible for cross-linking polysaccharide

chains 30 Chloramphenicol
C and cephalosporins contain a fj-Iactamase ring
o cross the normal blood-<>Cularbarrier easily A easily penetrates the blood-brain and blood-aqueous barrier
E allergy is linked to cephalosporins, with 20% of people allergiC to penicillin B administered topically does not cause aplastic anaemia
having cross-reactivity to cephalosporins C is effective in the treatment of typhoid fever
o is useful in the treatment of pneumonia
E is effective in the treatment of CNS infections due to Bacteroides fragl/is
26 AntibacterialS: Which of the following statements about cephalosponns are true? F is bacteriostatic

A fj-Lactamase-producing StaphylOCOCCUS
aureus Is resistant to cephalosporins.
31 Metronidazole
B Third-generation cephalosporins have good penetration of the bIood-brain

barrier. A acts by inhibiting RNA synthesis

C Third-generation cephalosporins have greater activity against !}-Iactarnase gram-
B may be administered by suppository to achieve satisfactory blood levels
negative bacteria. C is the treatment of choice 10r Trichomonas vagina/is
D Cephadrine and cefadroxil are second-generatlon cephalosporins. D may be prescribed in pregnancy
E Cephalosporins are bacteriostatic.
 P h a rm a c o lo g y Questions
P h a r m a c o lo g y Questions 109
108utsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
36 Which of the following antibiotics are bactericidal?
E Is useful In the treatment of anaerobiC bacterial infections
F crosses the blood-brain barrier poorly A rifampicin
B chloramphenicol
32 Which of the following statements about antifungal drugs are true? C tetracycline
D ciprofloxacin
A Nystatin is absOrbed well through mucous membranes. E trimethoprim
B Fluconazole is the drug of choice for CNS InfectionS due to CryptoCOCCUS F sulphonamide
neoformans. G co-trimoxazole
C Flucytosine is usually used in combination with amphotericin B.
o Miconazo\e can be administered topically. subconjunctiVally. orally and parenterally.
E Ketoconazol is known to be toxic to the eye when administered orally.
e

33 Antifungal drugs: Amphotericin B

A acts by altering the selective permeability of fungal cell membranes

B therapy Is usually for 3-4 weeks
C cannot be administered topically
o intravenous administration is usually associated with unpleasant side-effects
E causes hypokalaemia

34 Antiviral drugS: Idoxuridine

A is useful in topical treatment of corneal dendritic ulcers

B treatment must be for at least 3 weeks
C reduces the risk of recurrence of herpesvirus
o is effective in the treatment of herpetic stromal keratitis
E applied systemically is highly toxic

35 Antiviral drugs: Acyclovir

A inhibits RNA polymerase in viral-infected cells

B is effective on itS own against herpes simplex stromal keratitiS
C administered orally is effective in the treatment of herpeS zoster ophthalmicus
o administered Intravenously commonly causes phlebitis at the Injection site
E applied topically is effective In the treatment of genital herpes
 P h a rm a c o lo g y Questions
P h a r m a c o lo g y Questions 109
108utsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
36 Which of the following antibiotics are bactericidal?
E Is useful In the treatment of anaerobiC bacterial infections
F crosses the blood-brain barrier poorly A rifampicin
B chloramphenicol
32 Which of the following statements about antifungal drugs are true? C tetracycline
D ciprofloxacin
A Nystatin is absOrbed well through mucous membranes. E trimethoprim
B Fluconazole is the drug of choice for CNS InfectionS due to CryptoCOCCUS F sulphonamide
neoformans. G co-trimoxazole
C Flucytosine is usually used in combination with amphotericin B.
o Miconazo\e can be administered topically. subconjunctiVally. orally and parenterally.
E Ketoconazol is known to be toxic to the eye when administered orally.
e

33 Antifungal drugs: Amphotericin B

A acts by altering the selective permeability of fungal cell membranes

B therapy Is usually for 3-4 weeks
C cannot be administered topically
o intravenous administration is usually associated with unpleasant side-effects
E causes hypokalaemia

34 Antiviral drugS: Idoxuridine

A is useful in topical treatment of corneal dendritic ulcers

B treatment must be for at least 3 weeks
C reduces the risk of recurrence of herpesvirus
o is effective in the treatment of herpetic stromal keratitis
E applied systemically is highly toxic

35 Antiviral drugs: Acyclovir

A inhibits RNA polymerase in viral-infected cells

B is effective on itS own against herpes simplex stromal keratitiS
C administered orally is effective in the treatment of herpeS zoster ophthalmicus
o administered Intravenously commonly causes phlebitis at the Injection site
E applied topically is effective In the treatment of genital herpes
 P h a rm a c o lo g y Answers 111

PHARMACOLOGY 4 A = True B = False C = True 0 = True E = True

AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Noradrenaline is a water-soluble compound. Due to its polar nature the prior use of
local anaesthetic is needed to increase the permeability of the lipid corneal epithelial
barrier and allow greater penetration. Noradrenaline is a very effective ocular hypoten-
sive agent and its main effect is on the aqueous outflow, perhaps by acting on the
trabecular meshwork. It has very little effect on aqueous humour production. Pheny-
1 AUTSRQPONMLKJIHGFEDCBA
= True B = True C = True 0 = True E = True
lephrine is a synthetic amine similar to adrenaline, and is an a-agonist with no effect of
note on jJ-receptors.
Extraocular muscle palsy, pupillary abnormalities and ptosis occur after retrobulbar
Timelol has a 2 4 h duration of action but is administered 12 hourly to avoid diurnal
injection of local anaesthetic. Impairment of visual acuity is almost always found pressure variations.
transiently. Conjunctival haemorrtlage is common. Periocular administration of cortios-
teroid has been reported to cause glaucoma, cataract, proptosis, Cushing's syndrome,
systemic hypertenSion and retinal and choroidal vessel occlusion. 5 A = False B = True C = True 0 = True E = False

Topical adrenaline causes conjunctival btanching, reduction in intraocular pressure and

mydriasis without cycloplegia and so does not greatly alter visual acuity or reduce
2 A = True B = True C = True 0 = True E = True
refractive Changes. Due to the incidence of cystoid macular oedema, the use of adrena-
line is contraindicated In aphakic eyes. It should also be avoided in subjects with
The corneal epithelium contains approximately two-thirds of the plasma membrane
narrow angles, cardiovascular disease, hyperthyroidism and subjects treated with
mass of the cornea. It therefore acts as a large store for lipophilic drugs whose release
monoamine oxidase inhibitors (MAOls) or tricyclic antidepressants due to the increased
rate into the aqueous depends on their speed in altering to a hydrophilic phase. sensitivity of adrenergic receptors.
The two main phases of detoxification and removal of drugs from the eye occur at the Rebound miosis 24 h after installation of phenylephrine is often seen in patients over
ciliary body. Phase 1 comprises the cytochrome p450 system that produces oxidation- 50 years of age.
reduction products. These are conjugated in phase 2. Melanin granules of the ciliary Hydroxyamphetamine is thought to release noradrenaline from adrenergic nerve
epithelium also provide a role in drug and toxin binding. Topical neomycin ointment can terminals. Guanethidine depletes nerve terminals of noradrenaline and blocks the
adrenergic effect of hydroxyamphetamine.
cause hypersensitivity reactions including blepharoconjunctivitis.
Topical drugs may have systemic side-effects due to their absorption Into the blood- Pilocarpine and adrenaline are less effective in black subjects than white subjects in
reducing intraocular pressure.
stream. Systemic side-effects of p-blockers include bronchospasm, bradycardia and

systemic hypotension.
Subconjunctival injections are usually performed by passing a needle through the 6 A = False B = True C = True 0 = True E = False
skin of the lid or through the inferior fomix. It is most useful in treatment of bacterial
infection and severe uveitiS, allowing high concentrations of antibiotics or steroids Low concentrations (1%) of adrenaline in the normal eye cause a triple response of
conjunctival blanching, reduction of intraocular pressure and only slight mydriasis. The
respectively.
effects can be partly explained by its mixed a and fJ actions and poor corneal penetra-
tion. Combined therapy of adrenaline and timelol has an initial strong ocular hypoten-
sive effect for about two weeks. With maintenance treatment beyond this period, this
3 A = True B = True C = True D = True E = True
combined effect is lost. Combined maintenance therapy of timelol with either pilocar-
pine, dorzolamide, carbachol or acetazolamide, however, has a strong ocular hypoten-
Systemic digoxin therapy commonly causes colour vision disturbances. Although
sive effect. One explanation is that timolol reduces aqueous production and eventually
usually occurring within two weeks, they can occur as soon as day 1. The mechanism actually blocks the effect of adrenaline on outflow facility. Adrenaline is thought to
may be at a retinal level involving inhibition of the Na+K+ATPase pump. This would also increase outflow by jJ-receptor stimulation.
explain the impairment of darl< adaptation and alteration in colour. vision. Digoxin Aqueous flow can be thought of as an inflow and outflow. Both a- and jJ-receptors
therapy has been shown to reduce intraocular pressure by 14% in patients with affect inflow and mainly jJ-receptors affect outflow. a-Receptor stimulation causes
glaucoma. Aqueous formation has been shown to be reduced by 45%.
 P h a rm a c o lo g y Answers 111

PHARMACOLOGY 4 A = True B = False C = True 0 = True E = True

AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Noradrenaline is a water-soluble compound. Due to its polar nature the prior use of
local anaesthetic is needed to increase the permeability of the lipid corneal epithelial
barrier and allow greater penetration. Noradrenaline is a very effective ocular hypoten-
sive agent and its main effect is on the aqueous outflow, perhaps by acting on the
trabecular meshwork. It has very little effect on aqueous humour production. Pheny-
1 AUTSRQPONMLKJIHGFEDCBA
= True B = True C = True 0 = True E = True
lephrine is a synthetic amine similar to adrenaline, and is an a-agonist with no effect of
note on jJ-receptors.
Extraocular muscle palsy, pupillary abnormalities and ptosis occur after retrobulbar
Timelol has a 2 4 h duration of action but is administered 12 hourly to avoid diurnal
injection of local anaesthetic. Impairment of visual acuity is almost always found pressure variations.
transiently. Conjunctival haemorrtlage is common. Periocular administration of cortios-
teroid has been reported to cause glaucoma, cataract, proptosis, Cushing's syndrome,
systemic hypertenSion and retinal and choroidal vessel occlusion. 5 A = False B = True C = True 0 = True E = False

Topical adrenaline causes conjunctival btanching, reduction in intraocular pressure and

mydriasis without cycloplegia and so does not greatly alter visual acuity or reduce
2 A = True B = True C = True 0 = True E = True
refractive Changes. Due to the incidence of cystoid macular oedema, the use of adrena-
line is contraindicated In aphakic eyes. It should also be avoided in subjects with
The corneal epithelium contains approximately two-thirds of the plasma membrane
narrow angles, cardiovascular disease, hyperthyroidism and subjects treated with
mass of the cornea. It therefore acts as a large store for lipophilic drugs whose release
monoamine oxidase inhibitors (MAOls) or tricyclic antidepressants due to the increased
rate into the aqueous depends on their speed in altering to a hydrophilic phase. sensitivity of adrenergic receptors.
The two main phases of detoxification and removal of drugs from the eye occur at the Rebound miosis 24 h after installation of phenylephrine is often seen in patients over
ciliary body. Phase 1 comprises the cytochrome p450 system that produces oxidation- 50 years of age.
reduction products. These are conjugated in phase 2. Melanin granules of the ciliary Hydroxyamphetamine is thought to release noradrenaline from adrenergic nerve
epithelium also provide a role in drug and toxin binding. Topical neomycin ointment can terminals. Guanethidine depletes nerve terminals of noradrenaline and blocks the
adrenergic effect of hydroxyamphetamine.
cause hypersensitivity reactions including blepharoconjunctivitis.
Topical drugs may have systemic side-effects due to their absorption Into the blood- Pilocarpine and adrenaline are less effective in black subjects than white subjects in
reducing intraocular pressure.
stream. Systemic side-effects of p-blockers include bronchospasm, bradycardia and

systemic hypotension.
Subconjunctival injections are usually performed by passing a needle through the 6 A = False B = True C = True 0 = True E = False
skin of the lid or through the inferior fomix. It is most useful in treatment of bacterial
infection and severe uveitiS, allowing high concentrations of antibiotics or steroids Low concentrations (1%) of adrenaline in the normal eye cause a triple response of
conjunctival blanching, reduction of intraocular pressure and only slight mydriasis. The
respectively.
effects can be partly explained by its mixed a and fJ actions and poor corneal penetra-
tion. Combined therapy of adrenaline and timelol has an initial strong ocular hypoten-
sive effect for about two weeks. With maintenance treatment beyond this period, this
3 A = True B = True C = True D = True E = True
combined effect is lost. Combined maintenance therapy of timelol with either pilocar-
pine, dorzolamide, carbachol or acetazolamide, however, has a strong ocular hypoten-
Systemic digoxin therapy commonly causes colour vision disturbances. Although
sive effect. One explanation is that timolol reduces aqueous production and eventually
usually occurring within two weeks, they can occur as soon as day 1. The mechanism actually blocks the effect of adrenaline on outflow facility. Adrenaline is thought to
may be at a retinal level involving inhibition of the Na+K+ATPase pump. This would also increase outflow by jJ-receptor stimulation.
explain the impairment of darl< adaptation and alteration in colour. vision. Digoxin Aqueous flow can be thought of as an inflow and outflow. Both a- and jJ-receptors
therapy has been shown to reduce intraocular pressure by 14% in patients with affect inflow and mainly jJ-receptors affect outflow. a-Receptor stimulation causes
glaucoma. Aqueous formation has been shown to be reduced by 45%.
 P h a rm a c o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
112 P h a rm a c o lo g y Answers
113
vasoconstriction of ciliary vasculature, reducing hydrostatic pressure and so reducing
longitudinal muscles of the Ciliary body affecting the scleral spur, widening the
aqueous production Onflow}. Stimulation of tl-receptors increases aqueous production
trabecular meshwork and so increasing aqueous outflow. Aqueous fonmation may
Onflow} by increasing cAMP in the non-pigmented ciliary epithelium. Stimulation of {J-
also be slightly reduced with long-tenm use. Pilocarpine should be administered 3--4
receptors in the outflow tracks increases outflow facility; stimulation of a-receptors has
times a day. Twice daily use 01 pilocarpine leads to inadequate control, especially if
very little effect on outflow. {J-blockade reduces inflow but has very little effect on compounded by poor compliance.
outfloW.
Cocaine acts as an anaesthetic by blocking conduction of nerve impulses. It has an
adrenergic effect by blocking noradrenaline reuptake and so causes vasoconstriction
9 A = False B = True C = False 0 = False E = True
and mydriasis. Systemically, it causes tachycardia, vasoconstriction and is a well-
known CNS stimulant.
Carbachol is resistant to hydrolysis by cholinesterases and so has a long direct-acting
chOlinergic effect. It also has indirect effect of displacing acetylcholine from nerve
tenminals. It stimulates both muscarinic and nicotinic receptors.
7 A = False B = True C = False 0 = True E = True
Carbachol is a very effective ocular hypotensive agent, but has poor lipid solubility
and therefore requires the addition of 0.03% benzalkonium chloride (BAt<)preservative
Combined therapy with oral tl-blockers is not a contraindication to topical timolol as
to aid corneal penetration or 0.005% BAK along with 1% hydroxypropyl methylcellu-
patients who tolerate /3-blockers do not have problems with additional doses of topical lose to prolong ocular surface contact. .
tirnolol. Carbachol causes brief vasodilation and therefore short-lasting conjunctival and
Thymoxamine produces miosis without any effect on the ciliary body and
ciliary injection. To avoid the risk of increasing inflammation, it is therefore contra-
accommodation. indicated in patients with anterior uveitis and neovascular glaucoma.
Guanethidine interferes with noradrenaline release from postganglionic adrenergic
nerve endings. Its complex action is seen to initially cause noradrenaline release from
nerve tenminals soon followed by inhibition of both release and uptake. A curious
10 A = False B = True C = False 0 = True E = True
hypersensitivity to adrenergic agonists is seen and thereby potentiation of their effects.
Guanethidine is useful in the treatment of glaucoma due to its ability to reduce intrao-
Brown pigmented eyes show a reduced OCUlarhypotensive response to pilocarpine
cular pressure for up to a month by both increasing outflow and reducing aqueous
than blue eyes due to pigment binding. These patients often require higher concentra-
production. tion solutions. Although the hypotensive effect is reduced in pigmented eyes, the
When used in combination with adrenaline it has an enhancing effect of reducing
subsequent release of pilocarpine from the pigment provides a more prolonged
intraocular pressure. Guanethidine is also useful in the treatment of Graves' disease- response.
associated lid retraction. Physostigmine is a highly lipid-soluble reversible cholinesterase inhibitor that is
easily able to cross the blood-brain barrier and so exert both a peripheral and central
effect on both muscarinic and nicotinic receptors.
8 A = True B = False C = False 0 = True E = False Aqueous solutions of physostigmine are usually stored after sterilization with anti-
oxidants at a buffered pH of less than 4. Oxidation is seen to tum the colourless
Due to the fact that thymoxamine causes miosis without affecting intraocular pressure, solution pink and reduce efficacy.
aqueous outflow or aqueous production, it is useful in the diagnosis of acute closed-
angle glaucoma. If by opening the angle of the anterior chamber by miosis, thymox-
amine reduces intraocular pressure to nonmal, then the diagnosis of acute closed-angle 11 A = False B = False C = True 0 = False E = False
glaucoma may be made. If intraocular pressure remains high or is only slightly reduced
the diagnosis may be open-angle glaucoma or perhaps a combination of both. Acet-
Physostigmine causes miosis that begins after 5 min, is maximal at 30 min and lasts for
ylcholine is ineffective when applied topically it is available as a ,:'0 0 preparation for
4 h. It also causes accommodative spasm that begins after 2 0 min and lasts for 3 h. It
use during surgical procedures and must be placed directly on the iris in order to
also causes conjunctival vasodilation and a reduction in intraocular pressure. It does
achieve immediate and complete miosis of short duration. not produce ptosis. Physostigmine has antimicrobial properties related to its antic-
Pilocarpine is an alkaloid of plant origin. It is a direct-acting muscarinic agonist with
holinesterase action againstRQPONMLKJIHGFEDCBA
P h t h ir u s p u b is . Side-effects of physostigmine include lid
cholinergic effects on the cardiovascular system, central nervous system, exocrine twitching (nicotinic receptors), accommodative spasm, myopia, brow ache and allergIc
glands and smooth muscle. It is thought to reduce intraocular pressure by contracting follicular conjunctivitis.
 P h a rm a c o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
112 P h a rm a c o lo g y Answers
113
vasoconstriction of ciliary vasculature, reducing hydrostatic pressure and so reducing
longitudinal muscles of the Ciliary body affecting the scleral spur, widening the
aqueous production Onflow}. Stimulation of tl-receptors increases aqueous production
trabecular meshwork and so increasing aqueous outflow. Aqueous fonmation may
Onflow} by increasing cAMP in the non-pigmented ciliary epithelium. Stimulation of {J-
also be slightly reduced with long-tenm use. Pilocarpine should be administered 3--4
receptors in the outflow tracks increases outflow facility; stimulation of a-receptors has
times a day. Twice daily use 01 pilocarpine leads to inadequate control, especially if
very little effect on outflow. {J-blockade reduces inflow but has very little effect on compounded by poor compliance.
outfloW.
Cocaine acts as an anaesthetic by blocking conduction of nerve impulses. It has an
adrenergic effect by blocking noradrenaline reuptake and so causes vasoconstriction
9 A = False B = True C = False 0 = False E = True
and mydriasis. Systemically, it causes tachycardia, vasoconstriction and is a well-
known CNS stimulant.
Carbachol is resistant to hydrolysis by cholinesterases and so has a long direct-acting
chOlinergic effect. It also has indirect effect of displacing acetylcholine from nerve
tenminals. It stimulates both muscarinic and nicotinic receptors.
7 A = False B = True C = False 0 = True E = True
Carbachol is a very effective ocular hypotensive agent, but has poor lipid solubility
and therefore requires the addition of 0.03% benzalkonium chloride (BAt<)preservative
Combined therapy with oral tl-blockers is not a contraindication to topical timolol as
to aid corneal penetration or 0.005% BAK along with 1% hydroxypropyl methylcellu-
patients who tolerate /3-blockers do not have problems with additional doses of topical lose to prolong ocular surface contact. .
tirnolol. Carbachol causes brief vasodilation and therefore short-lasting conjunctival and
Thymoxamine produces miosis without any effect on the ciliary body and
ciliary injection. To avoid the risk of increasing inflammation, it is therefore contra-
accommodation. indicated in patients with anterior uveitis and neovascular glaucoma.
Guanethidine interferes with noradrenaline release from postganglionic adrenergic
nerve endings. Its complex action is seen to initially cause noradrenaline release from
nerve tenminals soon followed by inhibition of both release and uptake. A curious
10 A = False B = True C = False 0 = True E = True
hypersensitivity to adrenergic agonists is seen and thereby potentiation of their effects.
Guanethidine is useful in the treatment of glaucoma due to its ability to reduce intrao-
Brown pigmented eyes show a reduced OCUlarhypotensive response to pilocarpine
cular pressure for up to a month by both increasing outflow and reducing aqueous
than blue eyes due to pigment binding. These patients often require higher concentra-
production. tion solutions. Although the hypotensive effect is reduced in pigmented eyes, the
When used in combination with adrenaline it has an enhancing effect of reducing
subsequent release of pilocarpine from the pigment provides a more prolonged
intraocular pressure. Guanethidine is also useful in the treatment of Graves' disease- response.
associated lid retraction. Physostigmine is a highly lipid-soluble reversible cholinesterase inhibitor that is
easily able to cross the blood-brain barrier and so exert both a peripheral and central
effect on both muscarinic and nicotinic receptors.
8 A = True B = False C = False 0 = True E = False Aqueous solutions of physostigmine are usually stored after sterilization with anti-
oxidants at a buffered pH of less than 4. Oxidation is seen to tum the colourless
Due to the fact that thymoxamine causes miosis without affecting intraocular pressure, solution pink and reduce efficacy.
aqueous outflow or aqueous production, it is useful in the diagnosis of acute closed-
angle glaucoma. If by opening the angle of the anterior chamber by miosis, thymox-
amine reduces intraocular pressure to nonmal, then the diagnosis of acute closed-angle 11 A = False B = False C = True 0 = False E = False
glaucoma may be made. If intraocular pressure remains high or is only slightly reduced
the diagnosis may be open-angle glaucoma or perhaps a combination of both. Acet-
Physostigmine causes miosis that begins after 5 min, is maximal at 30 min and lasts for
ylcholine is ineffective when applied topically it is available as a ,:'0 0 preparation for
4 h. It also causes accommodative spasm that begins after 2 0 min and lasts for 3 h. It
use during surgical procedures and must be placed directly on the iris in order to
also causes conjunctival vasodilation and a reduction in intraocular pressure. It does
achieve immediate and complete miosis of short duration. not produce ptosis. Physostigmine has antimicrobial properties related to its antic-
Pilocarpine is an alkaloid of plant origin. It is a direct-acting muscarinic agonist with
holinesterase action againstRQPONMLKJIHGFEDCBA
P h t h ir u s p u b is . Side-effects of physostigmine include lid
cholinergic effects on the cardiovascular system, central nervous system, exocrine twitching (nicotinic receptors), accommodative spasm, myopia, brow ache and allergIc
glands and smooth muscle. It is thought to reduce intraocular pressure by contracting follicular conjunctivitis.
 P h a rm a c o lo g y A n s w e rs P h a rm a c o lo g y Answers 115
114 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
14 A = True B '" True C = True D = True E = True
Edrophonium (TenSilon) is a reversible cholinesterase inhibitor. It predominantly
stimulates nicotinic receptors and acts on the neuromuscular junction. Ideal for the
Homatropine is an anticholinergic drug of one-tenth potency of atropine. It causes
diagnosis of myasthenia gravis. it transientty increases muscle strength when adminis-
maximum mydriasis and weaker cycloplegia in 40 min. Recovery is complete within 3
tered intravenously (Tensilon Test). Tonography has shown that edrophonium causes a days.
brief rise in intraocular pressure of up to 5 mmHg. Tropicamide is a preci<'rninantly unionized anticholinergic drug. Its resultant lipid
solubility explains itl. la,> < action. One per cent tropicamide produces maximal mydria-
sis in 2 0 min and maximal cvclopleqia in 3 0 min. Full recovery is within 6 h. Tropica-
12 A = True B = True C = False 0 = False E = True mide-induced mydriasis appears to be independent of iris pigmentation or racial
differences.
Ecothiophate is an irreversible cholinesterase inhibitor. By potentiating acetylcholine it
Atropine is thought to cause mydriasis both by blocking muscarinic receptors on the
allOWSless effort in accommodation and so less accommodative convergence. In
sphincter pupillae muscle and mildly stimulating a-adrenergic receptors on the dilator
patients with esotropia. an accommodative component can be implicated if the patient
pupillae muscle.
corrects his or her visual axis with ecothiopate. Continuing on a lower dose for up to 2
years can be an effective treatment.
Systemic absorption of cholinesterase inhibitors results in low levels of plasma and
15 A = True B = False C = True 0 = True E = False
red cell cholinesterase levels. Normal levels rule out drug-related symptoms.
Systemic absorption of topically applied ocular drugs occurs mainly through con-
Local anaesthetics are locally appli!ld reversible drugs that block nerve conduction
junctival vessels and the nasal mucosa. It is therefore usefUl to manually compress the
resulting In loss of sensation. Structurally. they consist of an aromatic lipophilic portion
lacrimal canaliculi after installation of a drug in order to reduce systemic side-effects.
linked to an intermediate aliphatic chain by an ester or amide linkage. This is followed
Cyclopentolate is a water-soluble anticholinergic drug. One per cent cyclopentolate
by a nitrogen-containing hydrophili:: hydrocarbon chain. They are weak bases with a
causes maximum mydriasis in 3 0 rnin and maximum cycloplegia within 6 0 min. Resi-
plC. between 8 and 9 .
dual accommodation is approximately 1.25 dioptres. Mydriasis and cycloplegia retum
In solution they am .ontzed anc' water soluble. but at a neutral pH they become
to normal within 2 4 h. unionizedRQPONMLKJIHGFEDCBA
a n d penetrate tissue.
Hyoscine (scopolamine) is a potent anticholinergic drug with similar efficacy to
Local anaestbetics hlock nerve conduction by acting on the cell membrane and
atropine. Maximum mydriasis occurs in 20 min. Maximum cycloplegia occurs In
, blocking the rise In permeability i ? sodium io n s . thereby preventing sodium Influx
4 0 min (residual accommodation being 1 .6 dioptres) and returns to normal in 3 days.
IC /'O S S the membrane. Local anaesthetics have been shown to exhibit antimicrobial
Mydriasis returns to normal in 7 days. properties. Tetracaine inhihit~ the growth of S t a p h y lo c o c c u s a u r e u s , C a n d id a a lb ic a n s
and P s e u d o m o n a s .
Local anaesthellcs applied topicaliy to the eye can cause localized or diffuse comeal
13 A = True B = False C = True 0 = False E = False epithelial desquamation wrtnin 5 min.

Ecothiopate is an irreversible cholinesterase inhibitor with poor lipid solubility. Topical

ecothiophate causes miosis from 1 0 to 45 min lasting up to four weeks.
Ecothiopate reduces intraocular pressure for up to 4 days. mainly by increasing
16 A = False B = False C = False 0 = True E = True
aqueous outflow facility. More than other cholinesterases. it is associated with the
onset of cataract. Anterior subcapsular cataracts are commonly associated but nuclear GluCQCorticorticoids cause neutrophilia. but neutrophil migration Is inhibited.
sclerotic and posterior subcapsular cataract may also be accelerated. Atropine. first
isolated frOm the plant Atropa belladonna is a naturally occurring alkaloid. It is one of
the most potent cholinergic antagonists available and causes strong mydriasis maximal 17 A = False B" f alse ~ = False 0 = False E = True
at 3 0 min and lasting up to 1 0 days. It causes cycloplegia that is maximal in 3 hand
IgE may be considered a mediator of the allergic response and IgG may be considered
lasts for 7 days. a mediator of the auioirnrnuna response. Systemic corticosterolds do not affect IgG or
Atropine relaxes ciliary muscle spasm reducing pain. it prevents posterior synechiae
by maximally dilating the pupil and reducing convexity and thickness of the lens. and it IgE titres. Glucocorticoids reduce allergic type 1 hypersensitivity by reducing histamine
also plays a role in reducing the vasodilation and permeability of inflamed leaking and prostaglandin production. Corticosteroids reduce numbers of Iymphocytes with a
greater in reduction T Iymphocytes than in B Iymphocytes.
vessels. It is therefore useful in the treatment of anterior uveitis.
 P h a rm a c o lo g y A n s w e rs P h a rm a c o lo g y Answers 115
114 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
14 A = True B '" True C = True D = True E = True
Edrophonium (TenSilon) is a reversible cholinesterase inhibitor. It predominantly
stimulates nicotinic receptors and acts on the neuromuscular junction. Ideal for the
Homatropine is an anticholinergic drug of one-tenth potency of atropine. It causes
diagnosis of myasthenia gravis. it transientty increases muscle strength when adminis-
maximum mydriasis and weaker cycloplegia in 40 min. Recovery is complete within 3
tered intravenously (Tensilon Test). Tonography has shown that edrophonium causes a days.
brief rise in intraocular pressure of up to 5 mmHg. Tropicamide is a preci<'rninantly unionized anticholinergic drug. Its resultant lipid
solubility explains itl. la,> < action. One per cent tropicamide produces maximal mydria-
sis in 2 0 min and maximal cvclopleqia in 3 0 min. Full recovery is within 6 h. Tropica-
12 A = True B = True C = False 0 = False E = True mide-induced mydriasis appears to be independent of iris pigmentation or racial
differences.
Ecothiophate is an irreversible cholinesterase inhibitor. By potentiating acetylcholine it
Atropine is thought to cause mydriasis both by blocking muscarinic receptors on the
allOWSless effort in accommodation and so less accommodative convergence. In
sphincter pupillae muscle and mildly stimulating a-adrenergic receptors on the dilator
patients with esotropia. an accommodative component can be implicated if the patient
pupillae muscle.
corrects his or her visual axis with ecothiopate. Continuing on a lower dose for up to 2
years can be an effective treatment.
Systemic absorption of cholinesterase inhibitors results in low levels of plasma and
15 A = True B = False C = True 0 = True E = False
red cell cholinesterase levels. Normal levels rule out drug-related symptoms.
Systemic absorption of topically applied ocular drugs occurs mainly through con-
Local anaesthetics are locally appli!ld reversible drugs that block nerve conduction
junctival vessels and the nasal mucosa. It is therefore usefUl to manually compress the
resulting In loss of sensation. Structurally. they consist of an aromatic lipophilic portion
lacrimal canaliculi after installation of a drug in order to reduce systemic side-effects.
linked to an intermediate aliphatic chain by an ester or amide linkage. This is followed
Cyclopentolate is a water-soluble anticholinergic drug. One per cent cyclopentolate
by a nitrogen-containing hydrophili:: hydrocarbon chain. They are weak bases with a
causes maximum mydriasis in 3 0 rnin and maximum cycloplegia within 6 0 min. Resi-
plC. between 8 and 9 .
dual accommodation is approximately 1.25 dioptres. Mydriasis and cycloplegia retum
In solution they am .ontzed anc' water soluble. but at a neutral pH they become
to normal within 2 4 h. unionizedRQPONMLKJIHGFEDCBA
a n d penetrate tissue.
Hyoscine (scopolamine) is a potent anticholinergic drug with similar efficacy to
Local anaestbetics hlock nerve conduction by acting on the cell membrane and
atropine. Maximum mydriasis occurs in 20 min. Maximum cycloplegia occurs In
, blocking the rise In permeability i ? sodium io n s . thereby preventing sodium Influx
4 0 min (residual accommodation being 1 .6 dioptres) and returns to normal in 3 days.
IC /'O S S the membrane. Local anaesthetics have been shown to exhibit antimicrobial
Mydriasis returns to normal in 7 days. properties. Tetracaine inhihit~ the growth of S t a p h y lo c o c c u s a u r e u s , C a n d id a a lb ic a n s
and P s e u d o m o n a s .
Local anaesthellcs applied topicaliy to the eye can cause localized or diffuse comeal
13 A = True B = False C = True 0 = False E = False epithelial desquamation wrtnin 5 min.

Ecothiopate is an irreversible cholinesterase inhibitor with poor lipid solubility. Topical

ecothiophate causes miosis from 1 0 to 45 min lasting up to four weeks.
Ecothiopate reduces intraocular pressure for up to 4 days. mainly by increasing
16 A = False B = False C = False 0 = True E = True
aqueous outflow facility. More than other cholinesterases. it is associated with the
onset of cataract. Anterior subcapsular cataracts are commonly associated but nuclear GluCQCorticorticoids cause neutrophilia. but neutrophil migration Is inhibited.
sclerotic and posterior subcapsular cataract may also be accelerated. Atropine. first
isolated frOm the plant Atropa belladonna is a naturally occurring alkaloid. It is one of
the most potent cholinergic antagonists available and causes strong mydriasis maximal 17 A = False B" f alse ~ = False 0 = False E = True
at 3 0 min and lasting up to 1 0 days. It causes cycloplegia that is maximal in 3 hand
IgE may be considered a mediator of the allergic response and IgG may be considered
lasts for 7 days. a mediator of the auioirnrnuna response. Systemic corticosterolds do not affect IgG or
Atropine relaxes ciliary muscle spasm reducing pain. it prevents posterior synechiae
by maximally dilating the pupil and reducing convexity and thickness of the lens. and it IgE titres. Glucocorticoids reduce allergic type 1 hypersensitivity by reducing histamine
also plays a role in reducing the vasodilation and permeability of inflamed leaking and prostaglandin production. Corticosteroids reduce numbers of Iymphocytes with a
greater in reduction T Iymphocytes than in B Iymphocytes.
vessels. It is therefore useful in the treatment of anterior uveitis.
 P h a rm a c o lo g y Answers 117
P h a rm a c o lo g y Answers
1 1 6 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Timolol (Timoptol) is a non-selective j3-antagonisl Due to the predominance of
/l2-receptors in the eye a i3:!-antagonist effect is seen.
Glucocorticoids pass through cell membranes without the need for receptor-
mediated transport. They bind to intracellular recaptors and signal the nucleus to either
upregulate or downregulate protein synthesis.
Plasma cortisol levels are highest between 6 and 8 am. They are lowest around 20 A = True B = False C = True D = False E = True
midnight.
Propranolol has strong membrane-stabilizing properties and so acts as a local
anaesthetic. Topical application of propranolol causes Significant corneal anaesthesia.
18 A = True B = True C = False D = False E = True Oral timolol has a dose-related ocular hypotensive effect. It is available for the
treatment of systemic hypertension with patients on oral timolol; further reduction in
Ocular effects of corticosteroids include corneal thickening and vasoconstriction of mtraocular pressure is not achieved with combined topical timolol. Miotics such as
conjunctival vessels and the inhibition of both corneal epithelial healing and neovas- pllocarpine have an additive ocular hypotensive effect when combined with timolol.
Both may be administered twice daily.
cularization.
Protein and glucose levels in aqueous and vitreous compartments are elevated with Acetazolamide is a carbonic anhydrase inhibitor. It reduces intraocular pressure by
urea and ascorbic acid levels reduced. lntraocular pressure is raised with a greater rise inhibiting the production of blcarbonate, and reducing the amount of sodium and
in patients with glaucoma than normal subjects. chloride entering into the posterior chamber. This has the effect of reducing aqueous
Corticosteroids are cataractogenic and are associated with an increased incidence of humour production. By inhibiting bicarbonate production. acetazolamide has an effect
posterior subcapsular cataract. An increase in lens hydration is seen with increased on renal function and acid-base equilibrium of a mild metabolic acidosis. Topical
lens sodium levels and reduced potassium. urea and glutathione levels. acetazolamide has poor corneal penetration and only produces a very small reduction
Topical corticosteroids are associated with mild mydriasiS (1 mm) and mild ptosis. in intraocular pressure. Dorzolamide has been recently introduced as a topical carbonic
Brief ocular discomfort is a common complaint with topical steroids. They have also anhydrase inhibitor.
been shown to occasionally cause refractive errors.
superimposed infection by bacteria. fungi and viruses is a recognized and obvious
risk. and if present contraindicates the use of corticosteroids. 21 A = False B = False C = False D = False E = False
The benefits of corticosteroids are evident in ocular Inflammation where they have a
non-specifIC anti-inflammatory effect in reducing capillary permeability and exudate.
Acetazolamide is available in both oral and intravenous forms. Orally. its onset of action
They inhibit neutrophil migration. fibroblast growth and toxic enzyme release to dam-
is in 1 h. maximally reducing Intraocular pressure between 2 and 4 h. and lasting for up
pen inflammation. to 6 h. Intravenously. its onset of action is in 1 min with a maximum reduction within
30 min lasting for up to 4 h. A sustained-release twice daily oral capsule is also
available. which maximally reduces intraocular pressure for up to 1 2 h and lasts up
19 A = True B = True C = True D = False E = True to 18 h. Up to 95% of acetazolamide in the circulation is plasma protein bound. Fifty
per cent of unbound acetazolamide is unionized and is responsible for cell penetration
Atenolol is a selective p,-antagonist administered orally as a 50 mg daily tablet for
the treatment of systemic hypertension. It has been shown to reduce intraocular and carbonic anhydrase inhibition.
pressure by 35% approximately 5 h after ingestion for about 7 h. Betaxolol (Setoptic) Acetazolamide is not metabolized. It is excreted renally by the proximal convoluted

is a f3,-selective antagonist available as ophthalmic drops for topical use only. It tubule into urine.
produces a 30% reduction in intraocular pressure within 2 h and this lasts for up
to 1 2 h. Its selectivity reduces the risk of systemic side-effects of /l2-blockade
(bronchOConstriction and exacerbation of chronic obstructive airways disease (COAD». 22 A = True B = True C = True D = True E = True
Levobunalol (Betagan) is a non-selective j3-antagonist available as an ophthalmiC
solution for topical use only. It has a long duration of action with 26-30% maximal Acetazolamide is a sulphonamide derivative and is contraindicated in patients with
reduction of intraocular pressure lasting up to 2 4 h. It is administered twice daily. sulphonamide hypersensitivity. Combined therapy with phenytoin results in modifica-
Propanolol is a non-selective j3-antagonist available for oral and intravenous use in tion of phenytoin metabolism and increased phenytoin serum levels. One of the indica-
the treatment of systemic hypertension. angina. certain cardiac arrhythmias. hyper- tions of acetazolamide therapy Is adjunct in the treatment of petit mal epilepsy.
trophic cardiomyopathies and migraine headaches. It produces a dose-dependent Acetazolamide is detected in the milk of lactating women being treated with
reduction in intraocular pressures.
 P h a rm a c o lo g y Answers 117
P h a rm a c o lo g y Answers
1 1 6 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Timolol (Timoptol) is a non-selective j3-antagonisl Due to the predominance of
/l2-receptors in the eye a i3:!-antagonist effect is seen.
Glucocorticoids pass through cell membranes without the need for receptor-
mediated transport. They bind to intracellular recaptors and signal the nucleus to either
upregulate or downregulate protein synthesis.
Plasma cortisol levels are highest between 6 and 8 am. They are lowest around 20 A = True B = False C = True D = False E = True
midnight.
Propranolol has strong membrane-stabilizing properties and so acts as a local
anaesthetic. Topical application of propranolol causes Significant corneal anaesthesia.
18 A = True B = True C = False D = False E = True Oral timolol has a dose-related ocular hypotensive effect. It is available for the
treatment of systemic hypertension with patients on oral timolol; further reduction in
Ocular effects of corticosteroids include corneal thickening and vasoconstriction of mtraocular pressure is not achieved with combined topical timolol. Miotics such as
conjunctival vessels and the inhibition of both corneal epithelial healing and neovas- pllocarpine have an additive ocular hypotensive effect when combined with timolol.
Both may be administered twice daily.
cularization.
Protein and glucose levels in aqueous and vitreous compartments are elevated with Acetazolamide is a carbonic anhydrase inhibitor. It reduces intraocular pressure by
urea and ascorbic acid levels reduced. lntraocular pressure is raised with a greater rise inhibiting the production of blcarbonate, and reducing the amount of sodium and
in patients with glaucoma than normal subjects. chloride entering into the posterior chamber. This has the effect of reducing aqueous
Corticosteroids are cataractogenic and are associated with an increased incidence of humour production. By inhibiting bicarbonate production. acetazolamide has an effect
posterior subcapsular cataract. An increase in lens hydration is seen with increased on renal function and acid-base equilibrium of a mild metabolic acidosis. Topical
lens sodium levels and reduced potassium. urea and glutathione levels. acetazolamide has poor corneal penetration and only produces a very small reduction
Topical corticosteroids are associated with mild mydriasiS (1 mm) and mild ptosis. in intraocular pressure. Dorzolamide has been recently introduced as a topical carbonic
Brief ocular discomfort is a common complaint with topical steroids. They have also anhydrase inhibitor.
been shown to occasionally cause refractive errors.
superimposed infection by bacteria. fungi and viruses is a recognized and obvious
risk. and if present contraindicates the use of corticosteroids. 21 A = False B = False C = False D = False E = False
The benefits of corticosteroids are evident in ocular Inflammation where they have a
non-specifIC anti-inflammatory effect in reducing capillary permeability and exudate.
Acetazolamide is available in both oral and intravenous forms. Orally. its onset of action
They inhibit neutrophil migration. fibroblast growth and toxic enzyme release to dam-
is in 1 h. maximally reducing Intraocular pressure between 2 and 4 h. and lasting for up
pen inflammation. to 6 h. Intravenously. its onset of action is in 1 min with a maximum reduction within
30 min lasting for up to 4 h. A sustained-release twice daily oral capsule is also
available. which maximally reduces intraocular pressure for up to 1 2 h and lasts up
19 A = True B = True C = True D = False E = True to 18 h. Up to 95% of acetazolamide in the circulation is plasma protein bound. Fifty
per cent of unbound acetazolamide is unionized and is responsible for cell penetration
Atenolol is a selective p,-antagonist administered orally as a 50 mg daily tablet for
the treatment of systemic hypertension. It has been shown to reduce intraocular and carbonic anhydrase inhibition.
pressure by 35% approximately 5 h after ingestion for about 7 h. Betaxolol (Setoptic) Acetazolamide is not metabolized. It is excreted renally by the proximal convoluted

is a f3,-selective antagonist available as ophthalmic drops for topical use only. It tubule into urine.
produces a 30% reduction in intraocular pressure within 2 h and this lasts for up
to 1 2 h. Its selectivity reduces the risk of systemic side-effects of /l2-blockade
(bronchOConstriction and exacerbation of chronic obstructive airways disease (COAD». 22 A = True B = True C = True D = True E = True
Levobunalol (Betagan) is a non-selective j3-antagonist available as an ophthalmiC
solution for topical use only. It has a long duration of action with 26-30% maximal Acetazolamide is a sulphonamide derivative and is contraindicated in patients with
reduction of intraocular pressure lasting up to 2 4 h. It is administered twice daily. sulphonamide hypersensitivity. Combined therapy with phenytoin results in modifica-
Propanolol is a non-selective j3-antagonist available for oral and intravenous use in tion of phenytoin metabolism and increased phenytoin serum levels. One of the indica-
the treatment of systemic hypertension. angina. certain cardiac arrhythmias. hyper- tions of acetazolamide therapy Is adjunct in the treatment of petit mal epilepsy.
trophic cardiomyopathies and migraine headaches. It produces a dose-dependent Acetazolamide is detected in the milk of lactating women being treated with
reduction in intraocular pressures.
 Pharmacology A n s w e rs
1 1 8 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h a rm a c o lo g y Answers 119

acetazolamide and so is not recommended during breastfeeding. A recognized side- 26 A = False B = True C = True 0 = False E = False
effect with acetazolamide therapy is mild depression.

Cephalosporins are bactericidal antibiotics that interfere with cell wall synthesis by

23 A = True B = True C = False D = True E = True F = False G = False preventing cross-linkinq in a similar way to penicillin. They also contain a j3-lactam ring.
Cephalosporins are usually active against j3-lactamase (penicillinase)-producing Sta-RQPONMLKJIHGFEDC
Acetazolamide has both ocular and systemic side-effects. Ocular side-effects include p h y lo c o c c u s aureus and are inactivated by gram-negative bacteria prodUCing j3-lacta-
myopia, probably due to shallowing of the anterior chamber secondary to forward shift mase. First-generation cephalosporins include cephradine, cephalexin and cefadroxil.
of the lens and iris and caused by ciliary bodY oedema. Systemic side-effects include They have g o o d gram-positive cover and not so good activity against gram-negative
peripheral and perioral paresthesia, metallic taste, malaise, loss of libido, abdominal bacteria. They are easily inactivated by gram-negative bacteria producing j3-lactamase
cramps and metabolic acidosis. and cross the blood-brain barrier poorly.
Acetazolamide causes increased urinal)' bicarbonate levels and decreased urinary
Second-generation cephalosporins include cefuroxime, cefaclor and cefoxitin. They
citrate level, producing alkaline urine. This Increases the risk of calcium phosphate
urinary calculi. Alkalinization of urine reduces excretion of ammonium (NH. "). have greater gram-negative activity and are useful in treating infections due to gram-
Increased blood ammonia lellels carry a risk of hepatiC encephalopathy in patients positive cocci, H a e m o p h ilu s influenzae, E n te r o b a c te r , P r o te u s , E. c o li and K le b s ie lla .
They have some activity against anaerobes such as Bacteroides.
with liller failure.
Although acetazolamide has not been implicated in human congenital defects, it is Unlike first- and second-generation cephalosporins, third-generation cephalosporins
teratogenic in animals and so is not recommended in pregnancy. such as cefotaxime, ceftriaxone, and cefiazidime have good blood-brain and blood-
ocular barrier penetration. Third-generation cephalosporins have reduced activity
against gram-positive bacteria, but have increased resistance to j3-lactamase produced
24 A = False B = False C = False 0 = False E = False F = False G = True
by gram-negative bacteria. They are extremely useful in treating gram-negative infec-

Due to its solubility, urea is distributed all oiler the body, including the eye. It is found in tions due to P s e u d o m o n a s , E . c o li, K le b s ie lla , P r o te u s , H a e m o p h ilu s in flu e n z a e , E n te r -

both intra- and extracellular spaces and both intra- and extravascular spaces. It is obacter and S e r r a tia , which include gram-negative bacillary meningitis, abdominal or
excreted by the kidney and urine. Mannitol is a hyperosmolar agent that remains pelvic infections, lower respiratory tract infections and septicaemia.
unbound to protein in the extracelluar fluid compartment and produces diuresis and
cellular dehydration. It is excreted 90% unchanged by the kidney in urine. Oral mannitol
is not absolbed by the gastrointestinal tract. 27 A = True B = False C = True 0 = False E = False
Glycerol is an orally administered hyperosmotic agent. It penetrates poorly the unin-
flamed blood-aqueous barrier. It has a calorific value and can cause hyperglycaemia in
Aminoglycosides such as gentamicin prevent protein synthesis by binding to bacterial
patients with diabetes. Hyperosmotic agents are effective In reducing intraocular pres-
ribosomes and inhibiting tRNA and mRNA binding as well as causing codon-misreading.
sure. They cause a rapid rise In plasma osmolality, thereby resulting in a fluid shift from
Gentamicin is useful for treatment of gram-negative bacillary infections. It crosses the
the vitreous and aqueous into the plasma.
inflamed blood-brain barrier and is useful in the treatment of meningitis. Due to its
water solubility it crosses the normal blood-brain barrier poorly and does not penetrate
25 A = True B = True C = False D = False E = False the normal cornea well. It is therefore extremely useful in the treatment of external
bacterial eye disease and bacterial corneal ulcers. Gentamicin ototoxicity affects both
Penicillins are bactericidal by inhibiting bacterial cell wall synthesis. Along with cepha- cochlea cells (tinnitus, pressure sensation) and vestibular cells (nystagmus, vertigo,
Iosporins they are /3-lactam-containing antibiotics and have variable susceptibility to J3- nausea, vomiting).
lactamases produced by certain bacteria. Nephrotoxicity in the form of acute tubular necrosis occurs with very high concentrations.
Penicillins along with first- and second-generation cephalosporins' do not easily
cross the normal blood-brain or b100d-0cular barriers. They do, howeller, cross the Neomycin is one of the most toxic aminoglycosides. It has very few indications for
Inflamed blood-brain barrier easily. They are actively transported out of the aqueous by intravenous administration. Due to its poor gut absorption, oral administration is useful
in bowel preparation for surgery or in the treatment of hepatic encephalopathy. It is
the ciliary body.
Ten per cent of people allergic to penicillin have cross-reactivity to cephalosporins. commonly administered topically for external ear and skin bacterial infections.
 Pharmacology A n s w e rs
1 1 8 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h a rm a c o lo g y Answers 119

acetazolamide and so is not recommended during breastfeeding. A recognized side- 26 A = False B = True C = True 0 = False E = False
effect with acetazolamide therapy is mild depression.

Cephalosporins are bactericidal antibiotics that interfere with cell wall synthesis by

23 A = True B = True C = False D = True E = True F = False G = False preventing cross-linkinq in a similar way to penicillin. They also contain a j3-lactam ring.
Cephalosporins are usually active against j3-lactamase (penicillinase)-producing Sta-RQPONMLKJIHGFEDC
Acetazolamide has both ocular and systemic side-effects. Ocular side-effects include p h y lo c o c c u s aureus and are inactivated by gram-negative bacteria prodUCing j3-lacta-
myopia, probably due to shallowing of the anterior chamber secondary to forward shift mase. First-generation cephalosporins include cephradine, cephalexin and cefadroxil.
of the lens and iris and caused by ciliary bodY oedema. Systemic side-effects include They have g o o d gram-positive cover and not so good activity against gram-negative
peripheral and perioral paresthesia, metallic taste, malaise, loss of libido, abdominal bacteria. They are easily inactivated by gram-negative bacteria producing j3-lactamase
cramps and metabolic acidosis. and cross the blood-brain barrier poorly.
Acetazolamide causes increased urinal)' bicarbonate levels and decreased urinary
Second-generation cephalosporins include cefuroxime, cefaclor and cefoxitin. They
citrate level, producing alkaline urine. This Increases the risk of calcium phosphate
urinary calculi. Alkalinization of urine reduces excretion of ammonium (NH. "). have greater gram-negative activity and are useful in treating infections due to gram-
Increased blood ammonia lellels carry a risk of hepatiC encephalopathy in patients positive cocci, H a e m o p h ilu s influenzae, E n te r o b a c te r , P r o te u s , E. c o li and K le b s ie lla .
They have some activity against anaerobes such as Bacteroides.
with liller failure.
Although acetazolamide has not been implicated in human congenital defects, it is Unlike first- and second-generation cephalosporins, third-generation cephalosporins
teratogenic in animals and so is not recommended in pregnancy. such as cefotaxime, ceftriaxone, and cefiazidime have good blood-brain and blood-
ocular barrier penetration. Third-generation cephalosporins have reduced activity
against gram-positive bacteria, but have increased resistance to j3-lactamase produced
24 A = False B = False C = False 0 = False E = False F = False G = True
by gram-negative bacteria. They are extremely useful in treating gram-negative infec-

Due to its solubility, urea is distributed all oiler the body, including the eye. It is found in tions due to P s e u d o m o n a s , E . c o li, K le b s ie lla , P r o te u s , H a e m o p h ilu s in flu e n z a e , E n te r -

both intra- and extracellular spaces and both intra- and extravascular spaces. It is obacter and S e r r a tia , which include gram-negative bacillary meningitis, abdominal or
excreted by the kidney and urine. Mannitol is a hyperosmolar agent that remains pelvic infections, lower respiratory tract infections and septicaemia.
unbound to protein in the extracelluar fluid compartment and produces diuresis and
cellular dehydration. It is excreted 90% unchanged by the kidney in urine. Oral mannitol
is not absolbed by the gastrointestinal tract. 27 A = True B = False C = True 0 = False E = False
Glycerol is an orally administered hyperosmotic agent. It penetrates poorly the unin-
flamed blood-aqueous barrier. It has a calorific value and can cause hyperglycaemia in
Aminoglycosides such as gentamicin prevent protein synthesis by binding to bacterial
patients with diabetes. Hyperosmotic agents are effective In reducing intraocular pres-
ribosomes and inhibiting tRNA and mRNA binding as well as causing codon-misreading.
sure. They cause a rapid rise In plasma osmolality, thereby resulting in a fluid shift from
Gentamicin is useful for treatment of gram-negative bacillary infections. It crosses the
the vitreous and aqueous into the plasma.
inflamed blood-brain barrier and is useful in the treatment of meningitis. Due to its
water solubility it crosses the normal blood-brain barrier poorly and does not penetrate
25 A = True B = True C = False D = False E = False the normal cornea well. It is therefore extremely useful in the treatment of external
bacterial eye disease and bacterial corneal ulcers. Gentamicin ototoxicity affects both
Penicillins are bactericidal by inhibiting bacterial cell wall synthesis. Along with cepha- cochlea cells (tinnitus, pressure sensation) and vestibular cells (nystagmus, vertigo,
Iosporins they are /3-lactam-containing antibiotics and have variable susceptibility to J3- nausea, vomiting).
lactamases produced by certain bacteria. Nephrotoxicity in the form of acute tubular necrosis occurs with very high concentrations.
Penicillins along with first- and second-generation cephalosporins' do not easily
cross the normal blood-brain or b100d-0cular barriers. They do, howeller, cross the Neomycin is one of the most toxic aminoglycosides. It has very few indications for
Inflamed blood-brain barrier easily. They are actively transported out of the aqueous by intravenous administration. Due to its poor gut absorption, oral administration is useful
in bowel preparation for surgery or in the treatment of hepatic encephalopathy. It is
the ciliary body.
Ten per cent of people allergic to penicillin have cross-reactivity to cephalosporins. commonly administered topically for external ear and skin bacterial infections.
120 P h a rm a c o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h a rm a c o lo g y Answers
121
28 A = True B = True C = True D = False E = False F = True
sion causing anaemia, reduced erythrocyte iron uptake end raised serum iron levels.
Tetracycline inhibits protein synthesis in human and bacterial cells by ribosomal bind- Patients taking systemic or topical chloramphenicol carry a very small risk of the mora
ing. It is not taken up actively in human cells. serious idiosyncratic side-effect of aplastic anaemia. This occurs months after c0m-
Tetracyclines have a broad spectrum of action against gram-positive, gram-negative pletion and results in irreversible pancytopenia. It is worth noting that the topical dose
and both aerobic and anaerobic bacteria. They are useful in the treatment ofRQPONMLKJIHGFEDCBA
M yco- of chloramphenicol is a fraction of the oral dose.
p la s m a p n e u m o n ia e infection, rickettsial infections (typhus and a fever) and chlamydial

infections ( C . t r a c h o m a t is ) .
Tetracycline has an effective roie in the treatment of sterile non-infected corneal
3 1 A = False B = True C = True D = False E = True F = False
ulcers ('corneal melting1 in which stromal necrosis is thought to be due to collagenase
activity. Tetracycline is thought to have anticollagenase properties.
Doxycycline is the only tetracycline excreted mainly by the gastrointestinal tract. Metronidazole is a nitroimidazole with a bactericidal action against anaerobic bacteria
The majority of tetracyclines are excreted renally and are contraindicated in renal such as B a c t e r o id e s . It is also the drug of choice in the treatment of amoebiasis,
T r ic h o m o n a s v a g in a lis and giardiasis. It acts by inhibiting microbial DNA synthesis.
impairment.
Tetracyclines may be used topically in the treatment of chlamydial ophthalmia neo- Although metronidazole has not been proven to be teratogenic in humans, animal
natorum but systemic erythromycin is the drug of choice. In children below the age of 8 experiments have shown nitroimidazoles to be carcinogenic, and so the use is contra-
years tetracycline slows bone growth and causes changes in dentition including dis- indicated in pregnancy. It is recommended that alcohol be avoided whilst taking
coloration and dysgenesis due to the formation of tetracycline-calcium phosphate metronidazole due to the interaction with ethanol producing an unpleasant acetalde-
hyde intoxication and histamine release.
complexes.
Metronidazole has excellent penetration of the blood-brain barrier.

29 A = False B = True C = False D = True E = True

32 A = False B = True C = True 0 = true E = False
Erythromycin is a bactericidal antibiotic. It is effective in the treatment of atypical
pneumonias such as that caused by M y c o p la s m a p n e u m o n ia e , C o x ie lla b u m e t li, Nystatin ~ew york STATe) is useful in the treatment of oral, enteric and vaginal
L e g io n e lla p n e u m o p h ila , or as an altemative to penicillin in streptococcal infections. candidiasis. Hypersensitivity, mucous membrane irritation, blood interactions or ser-
Erythromycin crosses the blood-brain and blood-ocular barriers poorly. Cholestatic ious systemic side-effects have not been reported.
jaundice is a rare but recognized complication of erythromycin therapy. Fluconazole is an imidazole antifungal agent active against aerobic organisms. It
penetrates the blood-brain barrier well and is useful in the treatment of infections due
to Cryptococcus n e o f o n n a n s .
30 A = True B = False C = True 0 = True E = True r = True Flucytosine is a fluorinated pyrimidine derivative that is converted to fluorouracil in
fungal cells end not in host cells. Useful in infections by C r y p t o c o c c u s neoformans and
Chloramphenicol is a bacteriostatic antibiotic containing the key toxic element nitro- C a n d id a (including endophthalmitis), it is used in combination with amphotericin B due
benzene. It acts by competing with mRNA for binding on to bacterial ribosomes and to the high incidence of resistance. It has good blood-brain barrier penetration but can
inhibiting protein synthesis. It has a broad spectrum of gram-positive and gram-nega- be hepatotoxic as well as causing bone marrow suppression.
tive activity and is effective against H a e m o p h ilu s in f lu e n z a e , N a ls s e r ia , Y e r s ln ia p e s t is Miconazole is a broad-spectrum imidazole with a fungi static effect, especially in low
(plague) end anaerobes as well as having some action against S t r e p t o c o c c u s pneu- doses, affecting permeability, as well as a fungiCidal effect. It can be administeled
moniae, staphylococci and most gram-negative bacilli (except P s e u d o m o n a s ) . Due to topically to skin for the treatment of dermatophytosis. It is effective in the treatment of
its high lipid solubility it penetrates the comea, blood-aqueous barrier and blood-brain
comeal fungal infections when administered topicaily, subconjunctivally or systemi-
easily. It is therefore an effective topical antibiotic, and the drug of choice for eNS cally. It is active both orally and parentally. It is often used in combination with ampho-
infections (including those due to Bacteroides f r a g i/ is ) . tericin B for severe systemic fungal infections.
Chloramphenicol is highly effective against most S a lm o n e lla infections, including
Ketoconazole is a n antifungal imidazole effective against chronic candidiasis and
typhoid fever. It may be used for the treatment of pneumonia due to H a e m o p h ilu s
dermatophytosis when applied topicaily and when administered orally, in the treatment
but due to its toxic side-effects it is not the drug of choice.
I n f lu e n z a e ,
of deep systemic mycoses due to aspergillosis, cryptococcosis, histoplasmosis, can-
Chloramphenicol has a dose-related side-effect of reversible bone marrow depres-
didiasis and blastomycosis. Side-effects include reversible liver damage that has been
fatal in at least one case, and more commonly nausea and pruritus. Ketoconazole is not
120 P h a rm a c o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h a rm a c o lo g y Answers
121
28 A = True B = True C = True D = False E = False F = True
sion causing anaemia, reduced erythrocyte iron uptake end raised serum iron levels.
Tetracycline inhibits protein synthesis in human and bacterial cells by ribosomal bind- Patients taking systemic or topical chloramphenicol carry a very small risk of the mora
ing. It is not taken up actively in human cells. serious idiosyncratic side-effect of aplastic anaemia. This occurs months after c0m-
Tetracyclines have a broad spectrum of action against gram-positive, gram-negative pletion and results in irreversible pancytopenia. It is worth noting that the topical dose
and both aerobic and anaerobic bacteria. They are useful in the treatment ofRQPONMLKJIHGFEDCBA
M yco- of chloramphenicol is a fraction of the oral dose.
p la s m a p n e u m o n ia e infection, rickettsial infections (typhus and a fever) and chlamydial

infections ( C . t r a c h o m a t is ) .
Tetracycline has an effective roie in the treatment of sterile non-infected corneal
3 1 A = False B = True C = True D = False E = True F = False
ulcers ('corneal melting1 in which stromal necrosis is thought to be due to collagenase
activity. Tetracycline is thought to have anticollagenase properties.
Doxycycline is the only tetracycline excreted mainly by the gastrointestinal tract. Metronidazole is a nitroimidazole with a bactericidal action against anaerobic bacteria
The majority of tetracyclines are excreted renally and are contraindicated in renal such as B a c t e r o id e s . It is also the drug of choice in the treatment of amoebiasis,
T r ic h o m o n a s v a g in a lis and giardiasis. It acts by inhibiting microbial DNA synthesis.
impairment.
Tetracyclines may be used topically in the treatment of chlamydial ophthalmia neo- Although metronidazole has not been proven to be teratogenic in humans, animal
natorum but systemic erythromycin is the drug of choice. In children below the age of 8 experiments have shown nitroimidazoles to be carcinogenic, and so the use is contra-
years tetracycline slows bone growth and causes changes in dentition including dis- indicated in pregnancy. It is recommended that alcohol be avoided whilst taking
coloration and dysgenesis due to the formation of tetracycline-calcium phosphate metronidazole due to the interaction with ethanol producing an unpleasant acetalde-
hyde intoxication and histamine release.
complexes.
Metronidazole has excellent penetration of the blood-brain barrier.

29 A = False B = True C = False D = True E = True

32 A = False B = True C = True 0 = true E = False
Erythromycin is a bactericidal antibiotic. It is effective in the treatment of atypical
pneumonias such as that caused by M y c o p la s m a p n e u m o n ia e , C o x ie lla b u m e t li, Nystatin ~ew york STATe) is useful in the treatment of oral, enteric and vaginal
L e g io n e lla p n e u m o p h ila , or as an altemative to penicillin in streptococcal infections. candidiasis. Hypersensitivity, mucous membrane irritation, blood interactions or ser-
Erythromycin crosses the blood-brain and blood-ocular barriers poorly. Cholestatic ious systemic side-effects have not been reported.
jaundice is a rare but recognized complication of erythromycin therapy. Fluconazole is an imidazole antifungal agent active against aerobic organisms. It
penetrates the blood-brain barrier well and is useful in the treatment of infections due
to Cryptococcus n e o f o n n a n s .
30 A = True B = False C = True 0 = True E = True r = True Flucytosine is a fluorinated pyrimidine derivative that is converted to fluorouracil in
fungal cells end not in host cells. Useful in infections by C r y p t o c o c c u s neoformans and
Chloramphenicol is a bacteriostatic antibiotic containing the key toxic element nitro- C a n d id a (including endophthalmitis), it is used in combination with amphotericin B due
benzene. It acts by competing with mRNA for binding on to bacterial ribosomes and to the high incidence of resistance. It has good blood-brain barrier penetration but can
inhibiting protein synthesis. It has a broad spectrum of gram-positive and gram-nega- be hepatotoxic as well as causing bone marrow suppression.
tive activity and is effective against H a e m o p h ilu s in f lu e n z a e , N a ls s e r ia , Y e r s ln ia p e s t is Miconazole is a broad-spectrum imidazole with a fungi static effect, especially in low
(plague) end anaerobes as well as having some action against S t r e p t o c o c c u s pneu- doses, affecting permeability, as well as a fungiCidal effect. It can be administeled
moniae, staphylococci and most gram-negative bacilli (except P s e u d o m o n a s ) . Due to topically to skin for the treatment of dermatophytosis. It is effective in the treatment of
its high lipid solubility it penetrates the comea, blood-aqueous barrier and blood-brain
comeal fungal infections when administered topicaily, subconjunctivally or systemi-
easily. It is therefore an effective topical antibiotic, and the drug of choice for eNS cally. It is active both orally and parentally. It is often used in combination with ampho-
infections (including those due to Bacteroides f r a g i/ is ) . tericin B for severe systemic fungal infections.
Chloramphenicol is highly effective against most S a lm o n e lla infections, including
Ketoconazole is a n antifungal imidazole effective against chronic candidiasis and
typhoid fever. It may be used for the treatment of pneumonia due to H a e m o p h ilu s
dermatophytosis when applied topicaily and when administered orally, in the treatment
but due to its toxic side-effects it is not the drug of choice.
I n f lu e n z a e ,
of deep systemic mycoses due to aspergillosis, cryptococcosis, histoplasmosis, can-
Chloramphenicol has a dose-related side-effect of reversible bone marrow depres-
didiasis and blastomycosis. Side-effects include reversible liver damage that has been
fatal in at least one case, and more commonly nausea and pruritus. Ketoconazole is not
 Pharmacology AnswersUTSRQPONMLKJIHGFEDCBA
Pharmacology Answers 123
122

toxic to the eye when administered orally. It can cause irritation when ~Iied topically topical acyclovir on its own is not so effective in penetrating and treating stromal
In the treatment of comeal fungal infection. keratitis. Combined steroid therapy is indicated.
Acyclovir 800 mg five times a day for 7 days is an effective treatment for herpes
zoster ophthalmicus, especially in conjunction with topical ointment.
33 A = True B = False C = False 0 = True E = True Side-effects of acyciovir include mild buming, stinging or itching when applied
topically, nausea, diarrhoea, headache and arthralgia when taken orally, and phlebitis
Amphotericin 8 is a potent polyene antifungal agent that can be used intravenously in and renal impairment with Intravenous administration.
severe deep systemic fungal infections as well as in a dilute form for topical aomims-
tration in fungal corneal ulcerS. It acts by binding to sterols in the fungal cell membrane
and altering the selective permeability of the membrane to facilitate the leaking out of
36 A = True B = False C = False 0 = True E = False F = False G = False
intracellular solutes.
Amphotericin is ineffective against bacteria due to the absence of sterols 10 their cell
Rifampicin has a bactericidal action by binding to DNA-dependent RNA polymerase
membrane. Unfortunately, due to the presence of sterols in renal tubular cells and red
and inhibiting initiation of transcription.
blood cells, Amphotericin binding causes nephrotoxicity and reversible anaemia. Hypo-
kalaemia and hypomagnasaemia may also be seen. Amphotericin is a very unpleasant Chloramphenicol has a bacteriostatic action inhibiting translation.
drug when administered intravenousiy, causing discomfort, nausea, pyrexia, rigors and Tetracycline has a bacteriostatic action inhibiting translation.
Ciprofloxac/n is quinolone that has' a bactericidal action inhibiting the enzyme
headaches.
Treatment of systemic infections is usefully continued for 6 -1 0 weeks but can be for responsible for bacterial DNA coiling.
Trimethoprim has a bacteriostatic action by Inhibiting bacterial dihydrofolate reduc-
as long as four months.
tase and preventing new nucleic acid synthesis.
Sulphonamides have a bacteriostatic action by acting as analogues of para-
4 A = True B = False C = False 0 = False E = True aminobenzoic acid and inhibiting folic acid synthesis.
Co-trimoxazole is a combination of trimethoprim and the sulphonamide sulpha-
Idoxuridine is a thymidine analogue and is active against herpes simplex virus. It methoxazole. It incorporates the bacteriostatic actions of both trimethoprim and the
creates fraudulent DNA both in the host cells and the virus. It is useful in topical
sulphonamide.
treatment of dendritic ulcers of the comeal epithelium. Seventy-five per cent of patients
are cured within two weeks. Treatment should not be continued for more than three
weeks due to toxicity. Idoxuridine does not reduce the risk of recurrence.
Due to water insolubility, ldoxuridine shows poor penetration of the corneal stroma. It
IS ineffective in the treatment of herpes stromal keratitis. Due to its high toxicity to host
cells, systemic use is extremely limited. It is available as 0 .1 ~ topical eye solution, and
a 5% solution with dimethyl sulphoxide (DMSO) for topical skin application, but these
have generally been superseded by more recent preparatioos and are thought to be of

little use.

35 A = False B = False C = True 0 = True E = True

Acyclovir is a guanosine analogue. This is activated only through phosphorylation by

herpes thymidine kinase. The activated phosphate inhibits the DNA polymerase of
herpes-infected cells. Thymidine kinase is induced in virally infected cells and remains
stable in non-infected host cells. Acyclovir therefore remains inactive in the presence of

non-infected cells.
Acyclovir is effective against herpes simplex virus and herpes zoster virus.
Although highly successful in the treatment of narpetic comeal dendritic ulcers.
 Pharmacology AnswersUTSRQPONMLKJIHGFEDCBA
Pharmacology Answers 123
122

toxic to the eye when administered orally. It can cause irritation when ~Iied topically topical acyclovir on its own is not so effective in penetrating and treating stromal
In the treatment of comeal fungal infection. keratitis. Combined steroid therapy is indicated.
Acyclovir 800 mg five times a day for 7 days is an effective treatment for herpes
zoster ophthalmicus, especially in conjunction with topical ointment.
33 A = True B = False C = False 0 = True E = True Side-effects of acyciovir include mild buming, stinging or itching when applied
topically, nausea, diarrhoea, headache and arthralgia when taken orally, and phlebitis
Amphotericin 8 is a potent polyene antifungal agent that can be used intravenously in and renal impairment with Intravenous administration.
severe deep systemic fungal infections as well as in a dilute form for topical aomims-
tration in fungal corneal ulcerS. It acts by binding to sterols in the fungal cell membrane
and altering the selective permeability of the membrane to facilitate the leaking out of
36 A = True B = False C = False 0 = True E = False F = False G = False
intracellular solutes.
Amphotericin is ineffective against bacteria due to the absence of sterols 10 their cell
Rifampicin has a bactericidal action by binding to DNA-dependent RNA polymerase
membrane. Unfortunately, due to the presence of sterols in renal tubular cells and red
and inhibiting initiation of transcription.
blood cells, Amphotericin binding causes nephrotoxicity and reversible anaemia. Hypo-
kalaemia and hypomagnasaemia may also be seen. Amphotericin is a very unpleasant Chloramphenicol has a bacteriostatic action inhibiting translation.
drug when administered intravenousiy, causing discomfort, nausea, pyrexia, rigors and Tetracycline has a bacteriostatic action inhibiting translation.
Ciprofloxac/n is quinolone that has' a bactericidal action inhibiting the enzyme
headaches.
Treatment of systemic infections is usefully continued for 6 -1 0 weeks but can be for responsible for bacterial DNA coiling.
Trimethoprim has a bacteriostatic action by Inhibiting bacterial dihydrofolate reduc-
as long as four months.
tase and preventing new nucleic acid synthesis.
Sulphonamides have a bacteriostatic action by acting as analogues of para-
4 A = True B = False C = False 0 = False E = True aminobenzoic acid and inhibiting folic acid synthesis.
Co-trimoxazole is a combination of trimethoprim and the sulphonamide sulpha-
Idoxuridine is a thymidine analogue and is active against herpes simplex virus. It methoxazole. It incorporates the bacteriostatic actions of both trimethoprim and the
creates fraudulent DNA both in the host cells and the virus. It is useful in topical
sulphonamide.
treatment of dendritic ulcers of the comeal epithelium. Seventy-five per cent of patients
are cured within two weeks. Treatment should not be continued for more than three
weeks due to toxicity. Idoxuridine does not reduce the risk of recurrence.
Due to water insolubility, ldoxuridine shows poor penetration of the corneal stroma. It
IS ineffective in the treatment of herpes stromal keratitis. Due to its high toxicity to host
cells, systemic use is extremely limited. It is available as 0 .1 ~ topical eye solution, and
a 5% solution with dimethyl sulphoxide (DMSO) for topical skin application, but these
have generally been superseded by more recent preparatioos and are thought to be of

little use.

35 A = False B = False C = True 0 = True E = True

Acyclovir is a guanosine analogue. This is activated only through phosphorylation by

herpes thymidine kinase. The activated phosphate inhibits the DNA polymerase of
herpes-infected cells. Thymidine kinase is induced in virally infected cells and remains
stable in non-infected host cells. Acyclovir therefore remains inactive in the presence of

non-infected cells.
Acyclovir is effective against herpes simplex virus and herpes zoster virus.
Although highly successful in the treatment of narpetic comeal dendritic ulcers.
 Pathology Questions 125

PATHOLOGY 5 Chemical mediators that cause Increased vascular permeability include

QuestionsvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
A platelet-activating factor
B kinins
C lysosomal cationic proteins
1 Acute increase in cell volume may be due to o histamine
E complement C3a and C5a
A reduced phospholipids F leukotriene B .
B intracellular hypoxia
C inhibition of protein synthesisUTSRQPONMLKJIHGFEDCBA 6 Chemical mediators directly causing vasodilation include
o lack of ATP
E failure of cell surface ion pumps A prostaglandin 12
B kinins
C interleukin 1
2 Which of the following statements about cell injury are true? o bacterial endotoxin
E histamine
A The commonest cell changes in non-lethal cell injury are increased cell volume F Nitric oxide
and intracellular fat accumulation.
B There is loss of calcium ions from the cell in cell death.
7 Effects of interleukin 1 include
C There is loss of phospholipid by the cell in ischaemic injury.
o Apoptosis describes degeneration of a cell in which metabolic activity is reduced A osteoclast stimulation
but not abolished. B stimulation of fibroblast proliferation and collagen synthesis
E Aseptic necrosis describes the death of bone due to ischaemia. C B and T ceU activation
o increased neutrophil production of interleukin 1
E fever
3 With regard to cell injury, which of the following are true? F increased synthesis of acute-phase proteins by hepatocytes
G reduced albumin synthesis by hepatocytes
A Nitrosamines cause cell injury by methylation of DNA and RNA.
B Cyanide causes cell injury by combining with iron of cytochrome oxidase.
8 Phagocytosis is a function of
C Methanol is toxigenic by its conversion to formaldehyde.
o Epidermal cells of xeroderma pigmentosa cannot repair damage due to X-rays.
A macrophages
E A free radical is a molecule with a single unpaired electron in its outer orbit.
B eosinophils
C basophils
o plasma cells
4 Which of the following chemical mediators act as chemotactic factors? E neutrophils
F mast cells
A Leukotriene 94
B Complement CSa
9 In acute inflammation, mast cells release
C Interieukin 1 (IL-I)
o Tumour necrosis factor (fNF)
A histamine
E Interieukin 8 (IL-8)
B heparin
 Pathology Questions 125

PATHOLOGY 5 Chemical mediators that cause Increased vascular permeability include

QuestionsvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
A platelet-activating factor
B kinins
C lysosomal cationic proteins
1 Acute increase in cell volume may be due to o histamine
E complement C3a and C5a
A reduced phospholipids F leukotriene B .
B intracellular hypoxia
C inhibition of protein synthesisUTSRQPONMLKJIHGFEDCBA 6 Chemical mediators directly causing vasodilation include
o lack of ATP
E failure of cell surface ion pumps A prostaglandin 12
B kinins
C interleukin 1
2 Which of the following statements about cell injury are true? o bacterial endotoxin
E histamine
A The commonest cell changes in non-lethal cell injury are increased cell volume F Nitric oxide
and intracellular fat accumulation.
B There is loss of calcium ions from the cell in cell death.
7 Effects of interleukin 1 include
C There is loss of phospholipid by the cell in ischaemic injury.
o Apoptosis describes degeneration of a cell in which metabolic activity is reduced A osteoclast stimulation
but not abolished. B stimulation of fibroblast proliferation and collagen synthesis
E Aseptic necrosis describes the death of bone due to ischaemia. C B and T ceU activation
o increased neutrophil production of interleukin 1
E fever
3 With regard to cell injury, which of the following are true? F increased synthesis of acute-phase proteins by hepatocytes
G reduced albumin synthesis by hepatocytes
A Nitrosamines cause cell injury by methylation of DNA and RNA.
B Cyanide causes cell injury by combining with iron of cytochrome oxidase.
8 Phagocytosis is a function of
C Methanol is toxigenic by its conversion to formaldehyde.
o Epidermal cells of xeroderma pigmentosa cannot repair damage due to X-rays.
A macrophages
E A free radical is a molecule with a single unpaired electron in its outer orbit.
B eosinophils
C basophils
o plasma cells
4 Which of the following chemical mediators act as chemotactic factors? E neutrophils
F mast cells
A Leukotriene 94
B Complement CSa
9 In acute inflammation, mast cells release
C Interieukin 1 (IL-I)
o Tumour necrosis factor (fNF)
A histamine
E Interieukin 8 (IL-8)
B heparin
 P a th o lo g y Questions P a th o lo g y QuestionsvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
126
127

14 Acute-phase proteins include

C platelet-activating factor
o tumour necrosis factor a (TNF-a)
A fibrinogen
E fibrin
B C-reactive protein
C serum amyloid A proteln
10 Which of the following statements about inflammation are true? o factor VIII
E ferritin
A [)enervation of local arterioles marl<edlyreduces the acute inflammatory response.
B 190 and complement C3b are opsonins of neutrophils and macrophages.
C Interleukin 2 Is produced by activated macrophages. 15 In type I hypersensitivity,
o Abscess formation implies progression to chronic inflammation.
E Increased vascular permeability within the first 30 mln of inflammation occurs in
A raised serum IgE levels are associated with atopy
venules only. B late response is due to flare and weal
C IL-4 induces IgE production by 8 Iymphocytes

11 Which of the foliowing statements about chronic Inflammation are true?

o macrophages play no role in triggering IgE production
E systemic anaphylaxis is due to massive activation of IgE-producing plasma cells
A Increased plasma cells are seen In chronic inflammation.
B The lifespan of a tissue macrophage is 72 h.
C Granulomatous inflammation implies increased production of granulation tissue. 16 Type 11 hypersensitivity
o A granuloma implies the presence of three or more macrophage-derived cells.
E Marked tissue destruction is a feature of chronic inflammation. A is seen in Goodpasture's syndrome
F Chronic inflammation is associated with amyloid deposition. B is responsible for acute transplantRQPONMLKJIHGFEDCBA
r e je c t io n

C involves activation of complement

o is associated with a positive Coomb's test
12 Interferon E requires IgM or IgG

A prodUction is most strongly stimulated by single-stranded viral DNA

B y is produced by virally Infected leukocytes 17 Type III hypersensitivity
C inhibits translation of viral mRNA
o is specific for an individual virus A involves platelet aggregation
E induces fever
F increases cell surface expression of both MHC (major histocompatibility com- B is a result of formation of soluble antigen/antibody complexes
C is associated with glomerulonephritis
plex) class I and class 11antigens
G activates macrophages
o is characterized by polymorphonuclear leukocyte infiltration
E results in complement-mediated tissue damage

13 With regard to complement, which of the following are true?

18 Which of the following statements about type IV hypersensitivity are true?
A The alternative pathway describes the formation of C1qrs complex.
B The classical pathway is antibody dependent. A Type IV hypersensitivity may be transferred by serum to non-sensitized subjects.
C C3 is the most abundant component of the complement proteins. B T cells express !ha CD3 recaptor.
o Two or more antibodies bound to a microbe are required to trigger the comple-
C The major histocompatibility complex is a gene locus found on chromosome 8.
ment cascade. o Class 11 human leukocyte antigens are found on macrophages and 8 cells.
E IgG, IgM or IgE are required to directly trigger the complement cascade.
E CD8 cells recognize antigens associated with class I MHC molecules.
 P a th o lo g y Questions P a th o lo g y QuestionsvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
126
127

14 Acute-phase proteins include

C platelet-activating factor
o tumour necrosis factor a (TNF-a)
A fibrinogen
E fibrin
B C-reactive protein
C serum amyloid A proteln
10 Which of the following statements about inflammation are true? o factor VIII
E ferritin
A [)enervation of local arterioles marl<edlyreduces the acute inflammatory response.
B 190 and complement C3b are opsonins of neutrophils and macrophages.
C Interleukin 2 Is produced by activated macrophages. 15 In type I hypersensitivity,
o Abscess formation implies progression to chronic inflammation.
E Increased vascular permeability within the first 30 mln of inflammation occurs in
A raised serum IgE levels are associated with atopy
venules only. B late response is due to flare and weal
C IL-4 induces IgE production by 8 Iymphocytes

11 Which of the foliowing statements about chronic Inflammation are true?

o macrophages play no role in triggering IgE production
E systemic anaphylaxis is due to massive activation of IgE-producing plasma cells
A Increased plasma cells are seen In chronic inflammation.
B The lifespan of a tissue macrophage is 72 h.
C Granulomatous inflammation implies increased production of granulation tissue. 16 Type 11 hypersensitivity
o A granuloma implies the presence of three or more macrophage-derived cells.
E Marked tissue destruction is a feature of chronic inflammation. A is seen in Goodpasture's syndrome
F Chronic inflammation is associated with amyloid deposition. B is responsible for acute transplantRQPONMLKJIHGFEDCBA
r e je c t io n

C involves activation of complement

o is associated with a positive Coomb's test
12 Interferon E requires IgM or IgG

A prodUction is most strongly stimulated by single-stranded viral DNA

B y is produced by virally Infected leukocytes 17 Type III hypersensitivity
C inhibits translation of viral mRNA
o is specific for an individual virus A involves platelet aggregation
E induces fever
F increases cell surface expression of both MHC (major histocompatibility com- B is a result of formation of soluble antigen/antibody complexes
C is associated with glomerulonephritis
plex) class I and class 11antigens
G activates macrophages
o is characterized by polymorphonuclear leukocyte infiltration
E results in complement-mediated tissue damage

13 With regard to complement, which of the following are true?

18 Which of the following statements about type IV hypersensitivity are true?
A The alternative pathway describes the formation of C1qrs complex.
B The classical pathway is antibody dependent. A Type IV hypersensitivity may be transferred by serum to non-sensitized subjects.
C C3 is the most abundant component of the complement proteins. B T cells express !ha CD3 recaptor.
o Two or more antibodies bound to a microbe are required to trigger the comple-
C The major histocompatibility complex is a gene locus found on chromosome 8.
ment cascade. o Class 11 human leukocyte antigens are found on macrophages and 8 cells.
E IgG, IgM or IgE are required to directly trigger the complement cascade.
E CD8 cells recognize antigens associated with class I MHC molecules.
 P a th o lo g y Q u e s tio n s P a th o lo g y Questions 129
128vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
D Filariasis causes oedema of the extemal genitalia and lower limbs.
19 With regard to transplant immunology.
E Hypoalbuminaemia is associated with hyperaldosteronism.
A corneal grafting usually involves transplant of an isograft
B acute rejection is a cell-mediated immune response
C cyclosporin A acts mainly by inhibiting antigen-activated C 0 8 cells 24 With regard to pigmentation.
o acute rejection is mediated by passenger leukocytes acting as class I major
histocompatibility antigens A lipofuscins are found in the heart and liver
E hyperacute rejection occurs mainly in association with xenograft donor tissue B bilirubin is seen binding to scleral proteins in jaundice
C haemosiderin accumulation Is responsible for the dark blue colour of a bruise
D abnormal melanin metabolism is seen In alcaptonuria
20 AtherosclerosiS E lipofuscin is toxic to cells

A describes atheromatous plaque deposition on to the endothelium

B involves smooth muscle cell proliferation in the intima
25 W ith regard to heterotrophic calcification. which of the following are true?
C may be complicated by aneu~ due to thinning of the underlying media
o may be complicated by plaqUe ulceration
E is associated with raised levels of HOL (high-density lipoprotein) A Dystrophic calcification describes both intracellular and extracellular calcium
deposition.
B Psammoma bodies are usually seen in association with metastatic calcification.
C Old cerebral haemorrhages are associated with calcification.
21 ThrombosiS is associated with
D Metastatic calcifICation occurs in normal tissue due to hypercalcaemia.
E Metastatic calcification is seen in atherosclerosis.
A laminar blood flow
F Dystrophic calcification is seen in tuberculosis.
B homocystinuria
C cardiac failure
o sickle cell anaemia
E protein C deficiency 26 Which of the following statements about neoplasia are correct?
F temporal arteritis
G polyarteritis nodosa A Benign neoplasms contain a high number of cells undergoing mitosis.
F stasis B Nuclei in malignant neoplasia are hyperchromatic.
C Pleomorphism is a feature of malignant neoplasms.
o Malignant neoplasms always invade surrounding tissue.
22 Infarction E Benign neoplasms are well differentiated.
F Benign neoplasms may be fatal.
A histologically is usually wedge-shaped
B in the first hour shows a darker coloUr than nonnal
C except in the brain is followed by coagulative necrosis
27 In neoplasia.
o is associated with venous occlusion
F may precede aoscess formation
A dysplasia means irreversible reduction In cell differentiation without invasion
B carcinoma in situ is defined as epithelial dysplasia in all layers with early base-
23 Which of the following statements about oedema are true? ment membrane invasion
C hamartoma is a non-neoplastic congenital malformation
A Transudate contains predominantly fibrinogen with low levels of albUmin. o dysplasia describes tissue metapiasia
B pulmonary oedema Is associated with acute raised Intracranial pressure. E a polyp is defined as a neoplastic pedunculated cell mass arising from an
C Oedema may be seen in shock. epithelial surface
 P a th o lo g y Q u e s tio n s P a th o lo g y Questions 129
128vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
D Filariasis causes oedema of the extemal genitalia and lower limbs.
19 With regard to transplant immunology.
E Hypoalbuminaemia is associated with hyperaldosteronism.
A corneal grafting usually involves transplant of an isograft
B acute rejection is a cell-mediated immune response
C cyclosporin A acts mainly by inhibiting antigen-activated C 0 8 cells 24 With regard to pigmentation.
o acute rejection is mediated by passenger leukocytes acting as class I major
histocompatibility antigens A lipofuscins are found in the heart and liver
E hyperacute rejection occurs mainly in association with xenograft donor tissue B bilirubin is seen binding to scleral proteins in jaundice
C haemosiderin accumulation Is responsible for the dark blue colour of a bruise
D abnormal melanin metabolism is seen In alcaptonuria
20 AtherosclerosiS E lipofuscin is toxic to cells

A describes atheromatous plaque deposition on to the endothelium

B involves smooth muscle cell proliferation in the intima
25 W ith regard to heterotrophic calcification. which of the following are true?
C may be complicated by aneu~ due to thinning of the underlying media
o may be complicated by plaqUe ulceration
E is associated with raised levels of HOL (high-density lipoprotein) A Dystrophic calcification describes both intracellular and extracellular calcium
deposition.
B Psammoma bodies are usually seen in association with metastatic calcification.
C Old cerebral haemorrhages are associated with calcification.
21 ThrombosiS is associated with
D Metastatic calcifICation occurs in normal tissue due to hypercalcaemia.
E Metastatic calcification is seen in atherosclerosis.
A laminar blood flow
F Dystrophic calcification is seen in tuberculosis.
B homocystinuria
C cardiac failure
o sickle cell anaemia
E protein C deficiency 26 Which of the following statements about neoplasia are correct?
F temporal arteritis
G polyarteritis nodosa A Benign neoplasms contain a high number of cells undergoing mitosis.
F stasis B Nuclei in malignant neoplasia are hyperchromatic.
C Pleomorphism is a feature of malignant neoplasms.
o Malignant neoplasms always invade surrounding tissue.
22 Infarction E Benign neoplasms are well differentiated.
F Benign neoplasms may be fatal.
A histologically is usually wedge-shaped
B in the first hour shows a darker coloUr than nonnal
C except in the brain is followed by coagulative necrosis
27 In neoplasia.
o is associated with venous occlusion
F may precede aoscess formation
A dysplasia means irreversible reduction In cell differentiation without invasion
B carcinoma in situ is defined as epithelial dysplasia in all layers with early base-
23 Which of the following statements about oedema are true? ment membrane invasion
C hamartoma is a non-neoplastic congenital malformation
A Transudate contains predominantly fibrinogen with low levels of albUmin. o dysplasia describes tissue metapiasia
B pulmonary oedema Is associated with acute raised Intracranial pressure. E a polyp is defined as a neoplastic pedunculated cell mass arising from an
C Oedema may be seen in shock. epithelial surface
 P a th o lo g y QuestionsvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P a th o lo g y Questions
130 131

28 In non-neoplastic proliferation. E amylase and pancreatic carcinoma

D acid phosphatase and prostatic carcinoma
A the restriction point in the G1 phase of the cell cycle reffll'S to termination of DNA
polymerase synthesis
B the S phase of the ceUcycle has a constant length 33 Amyloid
C hyperplasia is usually under negative feedback control
D hypertrophy refers to increase in size of cells only
A is a carbohydrate arranged in ~-p/eated sheets
E hyperplasia is never pathological
F hypertrophy may be due to cellular swelling or oedema B bound to Congo Red dye shows dichroism in polarized light
C structure is related to the Bence-Jones protein
D precursor is an acute-phase protein
29 Tumour spread involves E causes restrictive cardiomyopathy
F deposition in the brain is seen In all patients over 40RQPONMLKJIHGFEDCBA
y e a r s of age with Down's
A reduced cell surface expression of laminin receptors syndrome
B type IV collagenase activity G deposition is associated with acute inflammation
C fibroblast growth factor (FGF) felease
D loss of anchorage dependence
F increased fibronectin expression on cell surface

30 Which if the following statements about carcinogenesis are true?

A The initiation step in carcinogenesis Is irreversible.

B Human papillomavirus types 6 and 11 predispose to carcinoma of the cervix.
C Polycyclic aromatic hydrocarbons predispose to skin cancer.
D Saccharine predisposes to bladder cancer.
E UV-A Is the most potent ultraviolet carcinogen.
F Ionizing radiation exposure predispoSeS to thyroid carcinoma.

31 With regard to oncogenes.

A proto-oncogenes are normal genes signalling DNA sequences

B the eroB oncogene codes for a transmembrane growth factor recaptor
C the ras oncogene codes for the cell-signalling G protein
D they may be activated by translocation of a proto-oncogeoe
E they may be carried by viruses

32 With regard to tumour markers. which of the following associations are correct?

A CA125 and ovarian tumours

B AFP (a-fetoprotein) and hepatocellular carcinoma
C CRP (C-reactive protein) and breast cancer
o CEA (carcinoembryonic antigen) and colonic carcinoma
 P a th o lo g y QuestionsvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P a th o lo g y Questions
130 131

28 In non-neoplastic proliferation. E amylase and pancreatic carcinoma

D acid phosphatase and prostatic carcinoma
A the restriction point in the G1 phase of the cell cycle reffll'S to termination of DNA
polymerase synthesis
B the S phase of the ceUcycle has a constant length 33 Amyloid
C hyperplasia is usually under negative feedback control
D hypertrophy refers to increase in size of cells only
A is a carbohydrate arranged in ~-p/eated sheets
E hyperplasia is never pathological
F hypertrophy may be due to cellular swelling or oedema B bound to Congo Red dye shows dichroism in polarized light
C structure is related to the Bence-Jones protein
D precursor is an acute-phase protein
29 Tumour spread involves E causes restrictive cardiomyopathy
F deposition in the brain is seen In all patients over 40RQPONMLKJIHGFEDCBA
y e a r s of age with Down's
A reduced cell surface expression of laminin receptors syndrome
B type IV collagenase activity G deposition is associated with acute inflammation
C fibroblast growth factor (FGF) felease
D loss of anchorage dependence
F increased fibronectin expression on cell surface

30 Which if the following statements about carcinogenesis are true?

A The initiation step in carcinogenesis Is irreversible.

B Human papillomavirus types 6 and 11 predispose to carcinoma of the cervix.
C Polycyclic aromatic hydrocarbons predispose to skin cancer.
D Saccharine predisposes to bladder cancer.
E UV-A Is the most potent ultraviolet carcinogen.
F Ionizing radiation exposure predispoSeS to thyroid carcinoma.

31 With regard to oncogenes.

A proto-oncogenes are normal genes signalling DNA sequences

B the eroB oncogene codes for a transmembrane growth factor recaptor
C the ras oncogene codes for the cell-signalling G protein
D they may be activated by translocation of a proto-oncogeoe
E they may be carried by viruses

32 With regard to tumour markers. which of the following associations are correct?

A CA125 and ovarian tumours

B AFP (a-fetoprotein) and hepatocellular carcinoma
C CRP (C-reactive protein) and breast cancer
o CEA (carcinoembryonic antigen) and colonic carcinoma
 P a th o lo g y Answers 133

PATHOLOGY 3 A = True B = True C = True 0 = False E = True

Answers Cell injury can be described anatomically in terms of pathology In the nucleus, cell
membrane, enzymes or Iysosomes. Acquired causes include harmful agents acting
directly or being produced by metabolism, or indirect action such as enzyme inter-
ference (binding, denaturing or competitive inhibition). Direct action lilcludes nitrogen
1 AUTSRQPONMLKJIHGFEDCBA
= False B = True C = False 0 = True E = True mustards that combine with DNA and RNA and nitrosamines that alkylate by methylat-
ing DNA and RNA.
See notes on Pathology Question 2. Examples of toxicity after metabolism includes methanol that is converted to for-
maldehyde by ethanol-metabolizing enzymes in the liver. Indirect action by interference
With enzymes describes how cyanide binds with iron in cytochrome oxidase, thus
2 A = True B = False C = True 0 = False E = True Inhibiting metabolism.
Injury to the nucleus includes injury to DNA either by mutation, breaks or transforma-
The commonest cell changes seen in non- or sublethal cell injury include increase in tions or by defective repair such as xeroderma pigmentosa where epithelial cells of skin
cell volume and accumulation of intracellular fat. The increase in volume is partly due to lack UV specific endonucleases. These help to break abnormal dimer formation by UV-
light, and so assist other enzymes to excise and repair damage to DNA
interference in the Na+K" ATPase pUmp. Causes of fat accumulation include excess
As X-ray damage results In chain breakage of DNA, cells in xeroderma pigmentosa
formation or entry or reduced dispersal. Excess formation may be seen In hypoxia,
are able to repair damage due to X-rey exposure but are not able to repair UV damage.
where free fatty acids are not oxidized to carbon dioxide, or starvation and diabetes,
Free radicals are molecules with a single unpaired electron in the outer orbit. They
where there are increased free fatty acid levels in blood. It may even be due to cell
can be produced due to radiation energy, hypoxia and toxic agents such as carbon
poisons. Reduced fat dispersal may be due to lack of phospholipids leading to accu-
tetrachloride. They cause damage to cell membranes.
mulation of globular fat, or lack of protein stabilized fat (fatty livers seen in kwashiorkor)
or even excessive levels of cholesterol that antagonize the normal emulsifying functions

of phospholipids. 4 A = True B = True C = True D = True E = True

Pyknosis is an old term that describes cell death and degeneration in which the
nucleus shrinks, condenses and stains more deeply baSOPhilic. The shrunken nucleus Leukotriene B•• complement C5a. 11-1, TNF and IL-8, as well as the leukotrienes HPETE
may progress on to breakage and fragmentation, which is known as karyorrhexis. and HETE and platelet-activating factor are chemotactic agents for granulocytes.
Heterolysis describes lysis of cells by enzymes derived from other cell types. Auto- Complement C3a is an anaphylotoxin that mainly causes increased vascular perme-
ability but also has weak chemotactic properties. C5a is a chemotactic factor for
lysis describes self-lysis of a cen by enzymes released by its lysosome.
Apoptosis describes programmed cell death, during which in two stages the cell is neutrophils.

seen to separate from neighbouring cells and then fragment into membrane-bound
components that either dissipate or are phagocytosed. The cell is seen to shrink.
5 A = True B = True C = True D = True E = True F = False
followed by condensation and aggregation of chromatin. CytoplasmiC blebs and
'apoptotic bodies' of membrane-bound fragments are then seen. These are usually Chemical mediators that cause increased vascular permeability include platelet-acti-
phagocytosed. vating factor. kinins, lysosomal cationic proteins, histamine, complement C3a and cSa
Necrosis describes death of an area of an organ or tissue in which nearby tissue is and leukotrienes C•• D. and E•.
preserved. The dead tissue may be classified either due to the cause of death or its

pearance.
Aseptic necrosis describes death of part of a bone as a result of Ischaemia; for 6 A = True B = True C = False D = False E = True F = True
example, aseptic necrosis of the head of femur as a result of femoral neck fracture.
Coagulative, caseous and colliquative necrosis describe the appearances of the dead Chemical mediators directly causing vasodilation include nitric oxide (also known
endothelial-derived relaxation factor) producing vasodilation locally by activating gua-
tissue.
In contrast to necrosis, apoptosis does not cause surrounding inflammation and nylyl cyclase after release from vascular endothelium and macrophages, prostaglan-
dins ~. E and E2 , kinins and histamine.
occurs in tissue before any histological evidence is present.
 P a th o lo g y Answers 133

PATHOLOGY 3 A = True B = True C = True 0 = False E = True

Answers Cell injury can be described anatomically in terms of pathology In the nucleus, cell
membrane, enzymes or Iysosomes. Acquired causes include harmful agents acting
directly or being produced by metabolism, or indirect action such as enzyme inter-
ference (binding, denaturing or competitive inhibition). Direct action lilcludes nitrogen
1 AUTSRQPONMLKJIHGFEDCBA
= False B = True C = False 0 = True E = True mustards that combine with DNA and RNA and nitrosamines that alkylate by methylat-
ing DNA and RNA.
See notes on Pathology Question 2. Examples of toxicity after metabolism includes methanol that is converted to for-
maldehyde by ethanol-metabolizing enzymes in the liver. Indirect action by interference
With enzymes describes how cyanide binds with iron in cytochrome oxidase, thus
2 A = True B = False C = True 0 = False E = True Inhibiting metabolism.
Injury to the nucleus includes injury to DNA either by mutation, breaks or transforma-
The commonest cell changes seen in non- or sublethal cell injury include increase in tions or by defective repair such as xeroderma pigmentosa where epithelial cells of skin
cell volume and accumulation of intracellular fat. The increase in volume is partly due to lack UV specific endonucleases. These help to break abnormal dimer formation by UV-
light, and so assist other enzymes to excise and repair damage to DNA
interference in the Na+K" ATPase pUmp. Causes of fat accumulation include excess
As X-ray damage results In chain breakage of DNA, cells in xeroderma pigmentosa
formation or entry or reduced dispersal. Excess formation may be seen In hypoxia,
are able to repair damage due to X-rey exposure but are not able to repair UV damage.
where free fatty acids are not oxidized to carbon dioxide, or starvation and diabetes,
Free radicals are molecules with a single unpaired electron in the outer orbit. They
where there are increased free fatty acid levels in blood. It may even be due to cell
can be produced due to radiation energy, hypoxia and toxic agents such as carbon
poisons. Reduced fat dispersal may be due to lack of phospholipids leading to accu-
tetrachloride. They cause damage to cell membranes.
mulation of globular fat, or lack of protein stabilized fat (fatty livers seen in kwashiorkor)
or even excessive levels of cholesterol that antagonize the normal emulsifying functions

of phospholipids. 4 A = True B = True C = True D = True E = True

Pyknosis is an old term that describes cell death and degeneration in which the
nucleus shrinks, condenses and stains more deeply baSOPhilic. The shrunken nucleus Leukotriene B•• complement C5a. 11-1, TNF and IL-8, as well as the leukotrienes HPETE
may progress on to breakage and fragmentation, which is known as karyorrhexis. and HETE and platelet-activating factor are chemotactic agents for granulocytes.
Heterolysis describes lysis of cells by enzymes derived from other cell types. Auto- Complement C3a is an anaphylotoxin that mainly causes increased vascular perme-
ability but also has weak chemotactic properties. C5a is a chemotactic factor for
lysis describes self-lysis of a cen by enzymes released by its lysosome.
Apoptosis describes programmed cell death, during which in two stages the cell is neutrophils.

seen to separate from neighbouring cells and then fragment into membrane-bound
components that either dissipate or are phagocytosed. The cell is seen to shrink.
5 A = True B = True C = True D = True E = True F = False
followed by condensation and aggregation of chromatin. CytoplasmiC blebs and
'apoptotic bodies' of membrane-bound fragments are then seen. These are usually Chemical mediators that cause increased vascular permeability include platelet-acti-
phagocytosed. vating factor. kinins, lysosomal cationic proteins, histamine, complement C3a and cSa
Necrosis describes death of an area of an organ or tissue in which nearby tissue is and leukotrienes C•• D. and E•.
preserved. The dead tissue may be classified either due to the cause of death or its

pearance.
Aseptic necrosis describes death of part of a bone as a result of Ischaemia; for 6 A = True B = True C = False D = False E = True F = True
example, aseptic necrosis of the head of femur as a result of femoral neck fracture.
Coagulative, caseous and colliquative necrosis describe the appearances of the dead Chemical mediators directly causing vasodilation include nitric oxide (also known
endothelial-derived relaxation factor) producing vasodilation locally by activating gua-
tissue.
In contrast to necrosis, apoptosis does not cause surrounding inflammation and nylyl cyclase after release from vascular endothelium and macrophages, prostaglan-
dins ~. E and E2 , kinins and histamine.
occurs in tissue before any histological evidence is present.
 P a th o lo g y Answers 135
134UTSRQPONMLKJIHGFEDCBA P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
9 A = True B = True C = True 0 = True E = False
Interleukin-1 and bacterial endotoxin release may result in vasodilation by activa-
tion of neutrophils and mast cells causing release of vasoactive substances such as
Mast cell degranulation leads to release of primary mediators (prefOlTTled)and second-
histamine. ary mediators (synthesied and then released). Primary mediators include histamine,
adenosine, eosinophil and neutrophil chemotactic factors, hydrolytic enzymes that
facilitate kinin and complement production and heparin. Secondary mediators include
7 A = True B = True C = True 0 = False E = True F = True G = True products of arachidonic acid via the Iypoxygenase pathway (leukotrienes, especially
8., C., D., E.) and via the cyclooxygenase pathway (prostaglandins, especially ~,
Interleukin 1 Is a cytokine. In common with other cytokines it is a low molecular weight platelet-activating factor and cytokines including TNF-a, Il-1, Il-3, Il-4, Il-S and Il-6.
protein involved in immunity and inflammation, whereby it plays a key role in influencing
amplitude and duration of response. It is produced briefly around the site of inflamma-
tion and acts at very low concentrations by intel'acting with specific cell surface 10 A = False B '" True C = False 0 = False E = True
recaptors. Il-1 is mainly produced by macrophages and acts in a positive-feedback
manner on macrophages to increase Il-1 production. Acute inflammation is defined as the immediate response to tissue insult resulting in
Il-1 affects the immune system by stimulating B and T iymphocyte activation as well the 'cardinal' signs of 'rubor' (redness), 'calor' (heat), 'tumour' (swelling), 'doIor' (pain)
as natural killer cell activation and iymphoklne production. Effects on granulocytes and and 'functio laesa' Ooss of function).·1t is characterized by vascular and cellular
mast cells include chemotaxis, degranulation, thromboxane production and histamine events. One of the early vascular events is relaxation of artel'ioles due to local release
release. Effects on endothelium include increased leukocyte adhesion, platelet-activa- of chemical mediators, and it has been shown that denervation still allows this
tion factor production, prostaglandin 1 2 (PGI~ and PGE2 and coagulation cascade response to take place in the presence of local injury and inflammation. Opsonins
activity. Effects on bone include increased reabsorption by osteoclast activity. Collage- such IgG and C3b coat bacteria or foreign particles in order that they are recognized
nase activity in the synovium as well as proteinase secretion in cartilage is also as foreign. This process is known as opsonization and prepares neutrophils and
increased. macrophages better for phagocytosis.
Metabolic effects of Il-1 include increased acute-phase protein production and Interleukin 1 is produced by activated macrophages. Interteukin 2 is produced
decreased albumin synthesis by hepatocytes. A fall in cytochrome p450 activity is activated T Iymphocytes and acts to stimulate T cell activation as well as differentiation
also seen. In proliferation. Increased vascular permeability in the fll"St 30 min of inflammation
Effects on the central nervous system include alteration in prostaglandin synthesis occurs due to endothelial cell contraction leaving gaps. This only affects 2().-6() !JrTI
affecting the hypothalamus, resulting in fevel'. For this reason Il-1 is known as an venules and not capillaries or arterioles. It is usually due to the effect of histamine
endogenous pyrogen. It also causes a rise in ACTH levels. release.RQPONMLKJIHGFEDCBA
In general, the effects of Il-1 include a fall in systemic vascular resistance, mean I n v it r o , it has been shown that between 4 and 6 h there is endothelial retraction,

blood pressure and centrel venous pressure. Heart rate and cardiac output are seen to resulting in gaps. This is due to cytoskeletal reorganization separating endothelial cells.
increase. It IS cytokine mediated and is due to release of Il-1, TNF and IFN a.
Direct endothelial injury resulting in cell death and separation causes an immediate
sustained response involving venules, capillaries and arterioles. leakage is seen to
8 A = True B = True C = False 0 = False E = True F = False in immediately and lasts for hours. The delayed response is characterized by a 2-
12 h delay which lasts 5 h to days and this involves capilleries as well. It is seen to be
Phagocytosis is essentially a function of neutrophils and macrophages. Eosinophils are used by thermal injury, X-ray or UV radiation (sunbum). The mechanism is unclear.
granulocytes with acid-staining (eosinophilic) granules that also play a phagocytic role. The immediate transient response is due to mild injury.
They attack parasites that are too large to be successfully destroyed by phagocytosis
and release chemical mediators including leukotrlene C. and platelet-activating factor
that increase vascular permeability and are chemotactic. Circulating eosinophil levels 11 A = True B = False C = False 0 = True E = True F = True
are often raised in allergic conditions.
Basophils have basophilic granules and are similar in many ways to mast cells. They Chronic inflammation describes an outcome of acute inflammation progressing for
contain and release histamine and heparin as well as other chemical mediators when eeks or months. Three main processes of active inflammation, marked tissue destruc-
tion and healing are seen. Due to the chronicity, chronic inflammation has histological
activated. Basophils and mast cells play an Important role in type I hypersensitivity.
differences to acute inflammation. Neutrophils do not play a large role. In contrast,
 P a th o lo g y Answers 135
134UTSRQPONMLKJIHGFEDCBA P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
9 A = True B = True C = True 0 = True E = False
Interleukin-1 and bacterial endotoxin release may result in vasodilation by activa-
tion of neutrophils and mast cells causing release of vasoactive substances such as
Mast cell degranulation leads to release of primary mediators (prefOlTTled)and second-
histamine. ary mediators (synthesied and then released). Primary mediators include histamine,
adenosine, eosinophil and neutrophil chemotactic factors, hydrolytic enzymes that
facilitate kinin and complement production and heparin. Secondary mediators include
7 A = True B = True C = True 0 = False E = True F = True G = True products of arachidonic acid via the Iypoxygenase pathway (leukotrienes, especially
8., C., D., E.) and via the cyclooxygenase pathway (prostaglandins, especially ~,
Interleukin 1 Is a cytokine. In common with other cytokines it is a low molecular weight platelet-activating factor and cytokines including TNF-a, Il-1, Il-3, Il-4, Il-S and Il-6.
protein involved in immunity and inflammation, whereby it plays a key role in influencing
amplitude and duration of response. It is produced briefly around the site of inflamma-
tion and acts at very low concentrations by intel'acting with specific cell surface 10 A = False B '" True C = False 0 = False E = True
recaptors. Il-1 is mainly produced by macrophages and acts in a positive-feedback
manner on macrophages to increase Il-1 production. Acute inflammation is defined as the immediate response to tissue insult resulting in
Il-1 affects the immune system by stimulating B and T iymphocyte activation as well the 'cardinal' signs of 'rubor' (redness), 'calor' (heat), 'tumour' (swelling), 'doIor' (pain)
as natural killer cell activation and iymphoklne production. Effects on granulocytes and and 'functio laesa' Ooss of function).·1t is characterized by vascular and cellular
mast cells include chemotaxis, degranulation, thromboxane production and histamine events. One of the early vascular events is relaxation of artel'ioles due to local release
release. Effects on endothelium include increased leukocyte adhesion, platelet-activa- of chemical mediators, and it has been shown that denervation still allows this
tion factor production, prostaglandin 1 2 (PGI~ and PGE2 and coagulation cascade response to take place in the presence of local injury and inflammation. Opsonins
activity. Effects on bone include increased reabsorption by osteoclast activity. Collage- such IgG and C3b coat bacteria or foreign particles in order that they are recognized
nase activity in the synovium as well as proteinase secretion in cartilage is also as foreign. This process is known as opsonization and prepares neutrophils and
increased. macrophages better for phagocytosis.
Metabolic effects of Il-1 include increased acute-phase protein production and Interleukin 1 is produced by activated macrophages. Interteukin 2 is produced
decreased albumin synthesis by hepatocytes. A fall in cytochrome p450 activity is activated T Iymphocytes and acts to stimulate T cell activation as well as differentiation
also seen. In proliferation. Increased vascular permeability in the fll"St 30 min of inflammation
Effects on the central nervous system include alteration in prostaglandin synthesis occurs due to endothelial cell contraction leaving gaps. This only affects 2().-6() !JrTI
affecting the hypothalamus, resulting in fevel'. For this reason Il-1 is known as an venules and not capillaries or arterioles. It is usually due to the effect of histamine
endogenous pyrogen. It also causes a rise in ACTH levels. release.RQPONMLKJIHGFEDCBA
In general, the effects of Il-1 include a fall in systemic vascular resistance, mean I n v it r o , it has been shown that between 4 and 6 h there is endothelial retraction,

blood pressure and centrel venous pressure. Heart rate and cardiac output are seen to resulting in gaps. This is due to cytoskeletal reorganization separating endothelial cells.
increase. It IS cytokine mediated and is due to release of Il-1, TNF and IFN a.
Direct endothelial injury resulting in cell death and separation causes an immediate
sustained response involving venules, capillaries and arterioles. leakage is seen to
8 A = True B = True C = False 0 = False E = True F = False in immediately and lasts for hours. The delayed response is characterized by a 2-
12 h delay which lasts 5 h to days and this involves capilleries as well. It is seen to be
Phagocytosis is essentially a function of neutrophils and macrophages. Eosinophils are used by thermal injury, X-ray or UV radiation (sunbum). The mechanism is unclear.
granulocytes with acid-staining (eosinophilic) granules that also play a phagocytic role. The immediate transient response is due to mild injury.
They attack parasites that are too large to be successfully destroyed by phagocytosis
and release chemical mediators including leukotrlene C. and platelet-activating factor
that increase vascular permeability and are chemotactic. Circulating eosinophil levels 11 A = True B = False C = False 0 = True E = True F = True
are often raised in allergic conditions.
Basophils have basophilic granules and are similar in many ways to mast cells. They Chronic inflammation describes an outcome of acute inflammation progressing for
contain and release histamine and heparin as well as other chemical mediators when eeks or months. Three main processes of active inflammation, marked tissue destruc-
tion and healing are seen. Due to the chronicity, chronic inflammation has histological
activated. Basophils and mast cells play an Important role in type I hypersensitivity.
differences to acute inflammation. Neutrophils do not play a large role. In contrast,
 P a th o lo g y A n s w e rs 137
P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
136 dependent classical pathway requires two or more IgG or IgM antibodies bound to a
microbe to trigger the cascade via formation of a C1qrs complex. The alternative
mononuclear cells such as macrophages, plasma cells and Iymphocytes are seen.
pathway describes how the most abundant circulatory complement protein, C3, is split
Products of these cells result in collagen and tissue destruction.
after contact with microbial polysaccharides, directly leading to production of its
Repair Is seen by the presence of fibroblasts producing collagen (and possibly
cleavage products.
fibrosis) and new proliferating blood vessels sprouting from existing vessels into the
C3b binds to the microbe acting as an opsonin and C3a is released. These events
Immature collagen. The appearance of buds of new vessels amidst the fibroblasts and
lead to the common pathway of the production of the C5b-9 membrane attack
collagen gives the appearance of pink, soft granular tissue. This is thus referred to as
complex as well as chemotactic agents, mediators increasing vascular permeability
'granulation tissue' . and opsonins.
The presence of the plasma cell is a reliable sign of chronicity. It produces antibodies
that act locally against the foreign antigen.
The half-life of a monocyte is approximately 22-24 h. Tissue macrophages, hoWever,
14 A = True B = True C = True D = True E = True
last for months.
Granulomatous inflammation is a specialized form of chronic inflammation Indicated
Acute-phase proteins are proteins that increase in concentration during the acute-
by the presence of a granuloma, which is defined by the presence of three or more
phase response (Infection, inflammation or tissue damage). Their role is important
macrophage-derived cells. Macrophages are derived from blood monocytes and
locally and systemically. Activation of ttie coagulation and fibrinolytic pathways sees
although relatively inactive, they retain the ability for division. Macrophages activate
a rise in fibrinogen, prothrombin, factor VIII and plasminogen levels.
and transform to epithelioid cells (with an epithelial-like appearance) or may fuse In the
Heat-labile complement proteins produced by the liver and whose serum levels rise
centre of granulomas forming multinucleated giant cells (langhans' giant cells). The T
during the acute-phase response include C1s, C2, C3, C4, CS and C9. Raised levels of
cell-mediated immune reaction is also a feature of granulomatous Inflammation as this
( l 1 - antitrypsin and other proteinase inhibitors are seen, as are raised levels of transport
is required in the activation of macrophages.
proteins, including caeruloplasmin and ferritin. Among a group of proteins with a non-
specific or local role, C-reactive protein, serum amyloid A protein and fibronectin levels

12 A = False B = False C = True D = False E = True F = True G = True are seen to rise.

Interferons are cytokines that may be classified into three groups: 0 ., I} and y. Interferon-
a is produced mainly by infected leukocytes; interferon-13 is produced by fibroblasts, 15 A = True B = False C = True D = False E = False
and interferon-y is produced by activated T Iymphocytes.
Although production may be stimulated by bacterial cell walllypopolysaccharide, the Hypersensitivity is described as an exaggerated immune response causing tissue
strongest stimulus for synthesis is double-stranded RNA virus (often produced as an damage. Type I hypersensitivity is an Immediate hypersensitivity, also known as allergy.
intermediate step in viral replication). Functions of interferon include Inhibition of viral It has an early and late phase in response to an allergen.
replication. Although there is no single method, the main mechanism is by 'inducing' The earlyRQPONMLKJIHGFEDCBA
p h a s e known as a 'flare and weal' reaction, occurs within 20 min, primarily

certain protein kinases whose synthesis would then be switched on by contact with due to mast cell mediators. This phase may be inhibited by drugs such as sodium
double-stranded viral RNA. Protein kinases phosphorylate translator proteins and so chromoglycate, which can bind to different mast cell receptors, stabilizing them and
translation of mRNA is seen to be inhibited. Protein synthesis is also inhibited by making the mast cell resistant to activation.
A la t e phase seen after 5 h and lasting for up to 24 h is often seen following a large
activation of other proteins.
Interferon is specific for a particular species, and is not virus specific. immediate response. This is characterized by dense cellular infiltrates and more
Other functions of interferon include induction of fever and interteron-y is particularly oedema than before. It is thought to be due to neutrophil chemotactic factor released
effective in activating macrophages and increasing expression of cell surface antigens by the mast cells. Corticosteroids are found to be useful in blocking this late phase.
The underlying cellular mechanism of type I hypersensitivity begins by contact of
associated with either class I or class 11MHC molecules.
antigen with antigen-presenting cells (APCs) such as tissue macrophages. Antigen-
presenting cells induce T helper cell stimulation which results in production of inter-
leukins such as IL-5 (eosinophil activation) and IL-4, which induces specifiC B cell 'class
13 A = False B = True C = True D = True E = False
switching' to produce IgE antibodies locally.
The complement system describes an innate non-specifIC form of immunity created by IgE binding to mast cells and cross-linking of mast cell IgE receptors results in mast
an enzyme cascade used to destroy microbes or to attract and activate phagocytes cell degranulation and release of chemical mediators, both stored and synthesized de
against antigens. It consists of a classical and a1temative pathway. The antibody-
 P a th o lo g y A n s w e rs 137
P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
136 dependent classical pathway requires two or more IgG or IgM antibodies bound to a
microbe to trigger the cascade via formation of a C1qrs complex. The alternative
mononuclear cells such as macrophages, plasma cells and Iymphocytes are seen.
pathway describes how the most abundant circulatory complement protein, C3, is split
Products of these cells result in collagen and tissue destruction.
after contact with microbial polysaccharides, directly leading to production of its
Repair Is seen by the presence of fibroblasts producing collagen (and possibly
cleavage products.
fibrosis) and new proliferating blood vessels sprouting from existing vessels into the
C3b binds to the microbe acting as an opsonin and C3a is released. These events
Immature collagen. The appearance of buds of new vessels amidst the fibroblasts and
lead to the common pathway of the production of the C5b-9 membrane attack
collagen gives the appearance of pink, soft granular tissue. This is thus referred to as
complex as well as chemotactic agents, mediators increasing vascular permeability
'granulation tissue' . and opsonins.
The presence of the plasma cell is a reliable sign of chronicity. It produces antibodies
that act locally against the foreign antigen.
The half-life of a monocyte is approximately 22-24 h. Tissue macrophages, hoWever,
14 A = True B = True C = True D = True E = True
last for months.
Granulomatous inflammation is a specialized form of chronic inflammation Indicated
Acute-phase proteins are proteins that increase in concentration during the acute-
by the presence of a granuloma, which is defined by the presence of three or more
phase response (Infection, inflammation or tissue damage). Their role is important
macrophage-derived cells. Macrophages are derived from blood monocytes and
locally and systemically. Activation of ttie coagulation and fibrinolytic pathways sees
although relatively inactive, they retain the ability for division. Macrophages activate
a rise in fibrinogen, prothrombin, factor VIII and plasminogen levels.
and transform to epithelioid cells (with an epithelial-like appearance) or may fuse In the
Heat-labile complement proteins produced by the liver and whose serum levels rise
centre of granulomas forming multinucleated giant cells (langhans' giant cells). The T
during the acute-phase response include C1s, C2, C3, C4, CS and C9. Raised levels of
cell-mediated immune reaction is also a feature of granulomatous Inflammation as this
( l 1 - antitrypsin and other proteinase inhibitors are seen, as are raised levels of transport
is required in the activation of macrophages.
proteins, including caeruloplasmin and ferritin. Among a group of proteins with a non-
specific or local role, C-reactive protein, serum amyloid A protein and fibronectin levels

12 A = False B = False C = True D = False E = True F = True G = True are seen to rise.

Interferons are cytokines that may be classified into three groups: 0 ., I} and y. Interferon-
a is produced mainly by infected leukocytes; interferon-13 is produced by fibroblasts, 15 A = True B = False C = True D = False E = False
and interferon-y is produced by activated T Iymphocytes.
Although production may be stimulated by bacterial cell walllypopolysaccharide, the Hypersensitivity is described as an exaggerated immune response causing tissue
strongest stimulus for synthesis is double-stranded RNA virus (often produced as an damage. Type I hypersensitivity is an Immediate hypersensitivity, also known as allergy.
intermediate step in viral replication). Functions of interferon include Inhibition of viral It has an early and late phase in response to an allergen.
replication. Although there is no single method, the main mechanism is by 'inducing' The earlyRQPONMLKJIHGFEDCBA
p h a s e known as a 'flare and weal' reaction, occurs within 20 min, primarily

certain protein kinases whose synthesis would then be switched on by contact with due to mast cell mediators. This phase may be inhibited by drugs such as sodium
double-stranded viral RNA. Protein kinases phosphorylate translator proteins and so chromoglycate, which can bind to different mast cell receptors, stabilizing them and
translation of mRNA is seen to be inhibited. Protein synthesis is also inhibited by making the mast cell resistant to activation.
A la t e phase seen after 5 h and lasting for up to 24 h is often seen following a large
activation of other proteins.
Interferon is specific for a particular species, and is not virus specific. immediate response. This is characterized by dense cellular infiltrates and more
Other functions of interferon include induction of fever and interteron-y is particularly oedema than before. It is thought to be due to neutrophil chemotactic factor released
effective in activating macrophages and increasing expression of cell surface antigens by the mast cells. Corticosteroids are found to be useful in blocking this late phase.
The underlying cellular mechanism of type I hypersensitivity begins by contact of
associated with either class I or class 11MHC molecules.
antigen with antigen-presenting cells (APCs) such as tissue macrophages. Antigen-
presenting cells induce T helper cell stimulation which results in production of inter-
leukins such as IL-5 (eosinophil activation) and IL-4, which induces specifiC B cell 'class
13 A = False B = True C = True D = True E = False
switching' to produce IgE antibodies locally.
The complement system describes an innate non-specifIC form of immunity created by IgE binding to mast cells and cross-linking of mast cell IgE receptors results in mast
an enzyme cascade used to destroy microbes or to attract and activate phagocytes cell degranulation and release of chemical mediators, both stored and synthesized de
against antigens. It consists of a classical and a1temative pathway. The antibody-
138
P a th o lo g y AnswersRQPONMLKJIHGFEDCBA
P a th o lo g y Answers 139

n o v o . vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
IgE is a large molecule a n d almost all is tissue bound. VfKY little is found in the granules containing antigen, immunoglobulin and complement C3), serum sickness
circulation. Raised serum IgE levels at rest are associated with atopy. Systemic ana- [rnjection of large doses of foreign serum resulting in a reaction up to 8 days latet?
phylaxis is a result of massive IgE release into the circulation binding on to tissue mast and Mhus reaction [mjection of antigen intradermally in an immunized subject; can be
cells located around small blood vessels throughout the body and circulating baso- blocked by depleting complement or polymorphs).
phils. Histamine released into the circulation causes peripheral vasodilation and
increased capillary permeability.
18 A = False B = True C = False D = True E = True

16 A = True B = False C = True 0 = True E = True TYPerv hypersensitivity describes delayed-type hypersensitivity via a T cell-dependent
cell-mediated immune response. T cells express the T cell receptor complex made up of
Type 11hypersensitivity is also known as 'antigen-antibody-dependent cytotoxlcity'. It a heterodimeric T cell receptOf' (TCR) and the COO complex (exclusive to T cells). As a
describes antigen binding of IgM Of' IgG to activate complement via the classical further differentiation, these cells either express C04 or C08 receptors. classifying
pathway or facilitate phagocytosis via the Fc rsceptor on neutrophlls, macrophages them as C04 ( T 4 ) or CD8 ( T 8 ) cells. The CO (cluster of differentiation) molecule
and eosinophils. This mechanism is referred to as hypersensitivity when the Immune describes a family of cell surface marxers Identified by monocJonal antibodies.
response is inappropriate Of'exaggerated and results in tissue damage. The C04 ( T 4 ) cell is associated with the term 'T helper cell' and by the production of
It may be classified as either isoimrnune or autoimmune depending on whether the cytokines. It influences T a n d B cell response a n d in particular can induce the cytotoxic
antigen belongs to a member of the same species or belongs to the subject them- function of the CD8 ( T 8 ) cell. It recognizes antigens restricted to class It of the major
selves. Examples of isoimmune hypersensitivity include incompatible blood transfusion histocompatibility complex.
reactions (antibodies to ABO or rhesus antigens on transfused red cells), rhesus The COO ( T a ) cell is associated with the term 'T cytotoxic cell' and is destructive by
incompatibility and haemolytic disease of the newborn as well as hyperacute organ direct cytotoxicity. It recognizes antigens restricted to class I of the majOf'histocompat-
transplant rejection (preformed circulating antibodies to the donor 0 f '9 8 0 ) . Note that ibility complex.
acute transplant rejection is a cell-mediated type rv hypersensitivity reaction that The major histocompatibility complex is a gene locus located on the short arm of
occurs between 7 and 90 days after transplant. chromosome 6. There are two classes located here: class I which expresses human
Examples of autoimmune type 11hypersensitivity include auto immune haemolytic leukocyte antigens (A-, B- and C-) on all nucleated cells and class 11(HLA-Op, -DO and
anaemia, autoimmune thrombocytopenia, myasthenia gravis (antibodies against the -OR) which expresses antigens on antigen-presenting cells (APCs) and is thus found on
muscle motor end-plate acetylcholine recaptor) and Goodpasture's syndrome ~gG macrophages, dendritic cells (and Langerhans' cells) and B cells. Class I antigens are
antibodies against basement membrane, especially those of kidney and lungs). essential to activate T cytotoxic cells and class It antigens must be present to activate T
The Coomb's test is a means of detecting red cells coated with antibodies by making helper cells.
them agglutinate through the addition of albumin or serum containing immunoglobulins The sequence of events begins with a foreign antigen entering either a n APC Of'(in
against the coating antibodies. It is positive in detecting rhesus antibodies as well as the case of a virus) any nucleated cell. Part of the fOf'eign antigen is expressed as a
red cell antibodies found in autoimmune haemolytic anaemia. hapten on either the class I Of'class 11human leukocyte surface antigen. This activates
either T cytotoxic cells or T helper cells. T helper cells differentiate and, in the process,
release cytokines Ontel1eukins and interferons) that influence B cell proliferation and
17 A = True B = False C = True D = True E = True differentiation and specifIC antibody production. as well as activating natural killer cells,
macrophages and grenulocytes.
Type III hypersensitivity Involves persistent immune antigen/antibody complex fOf'ma- Activation of T cytotoxic cells results in direct cytotoxicity by cell binding a n d enzyme
tion with deposition of insoluble complexes at particular sites, resulting in an acute release, including 'pertorin' to destroy cell membranes. Its most important role is in the
inHammatOf'Yreaction. Three basic events are complement activation, influx of poIy- elimination of virally infected nucleated cells (class I antigenlc). T cytotoxic cells may
morphs a n d platelet aggregation. Complement activation results along with compte- also activate rnacrophages.
ment-mediated tissue damage, anaphylotoxin release, a n d release of mast cell Type IV hypersensitivity is an exaggerated cell-mediated immune response causing
mediators. This results in a n influx of polymorphs that attempt to phagocytose the tissue damage. It takes longer than 12 h (usually 46-72 h) to develop and involves
Immune complexes and during this process release their contents causing further 'eviously sensitized T helper cell activation. It is characterized by erythema and
tissue damage. Platelet aggregation is aiso seen and this provides further vasoactive ioOOration and a heavy mononuclear a n d lymphocytic infiltration. This may progress
amine release as well as causing local ischaemia as a result of the fOf'm3tion of to granuioma formation where epithelioid cells and other macrophage-derived cells are
microthrombi. Examples include immune complex glomerulonephritis (build-up of large seen.
138
P a th o lo g y AnswersRQPONMLKJIHGFEDCBA
P a th o lo g y Answers 139

n o v o . vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
IgE is a large molecule a n d almost all is tissue bound. VfKY little is found in the granules containing antigen, immunoglobulin and complement C3), serum sickness
circulation. Raised serum IgE levels at rest are associated with atopy. Systemic ana- [rnjection of large doses of foreign serum resulting in a reaction up to 8 days latet?
phylaxis is a result of massive IgE release into the circulation binding on to tissue mast and Mhus reaction [mjection of antigen intradermally in an immunized subject; can be
cells located around small blood vessels throughout the body and circulating baso- blocked by depleting complement or polymorphs).
phils. Histamine released into the circulation causes peripheral vasodilation and
increased capillary permeability.
18 A = False B = True C = False D = True E = True

16 A = True B = False C = True 0 = True E = True TYPerv hypersensitivity describes delayed-type hypersensitivity via a T cell-dependent
cell-mediated immune response. T cells express the T cell receptor complex made up of
Type 11hypersensitivity is also known as 'antigen-antibody-dependent cytotoxlcity'. It a heterodimeric T cell receptOf' (TCR) and the COO complex (exclusive to T cells). As a
describes antigen binding of IgM Of' IgG to activate complement via the classical further differentiation, these cells either express C04 or C08 receptors. classifying
pathway or facilitate phagocytosis via the Fc rsceptor on neutrophlls, macrophages them as C04 ( T 4 ) or CD8 ( T 8 ) cells. The CO (cluster of differentiation) molecule
and eosinophils. This mechanism is referred to as hypersensitivity when the Immune describes a family of cell surface marxers Identified by monocJonal antibodies.
response is inappropriate Of'exaggerated and results in tissue damage. The C04 ( T 4 ) cell is associated with the term 'T helper cell' and by the production of
It may be classified as either isoimrnune or autoimmune depending on whether the cytokines. It influences T a n d B cell response a n d in particular can induce the cytotoxic
antigen belongs to a member of the same species or belongs to the subject them- function of the CD8 ( T 8 ) cell. It recognizes antigens restricted to class It of the major
selves. Examples of isoimmune hypersensitivity include incompatible blood transfusion histocompatibility complex.
reactions (antibodies to ABO or rhesus antigens on transfused red cells), rhesus The COO ( T a ) cell is associated with the term 'T cytotoxic cell' and is destructive by
incompatibility and haemolytic disease of the newborn as well as hyperacute organ direct cytotoxicity. It recognizes antigens restricted to class I of the majOf'histocompat-
transplant rejection (preformed circulating antibodies to the donor 0 f '9 8 0 ) . Note that ibility complex.
acute transplant rejection is a cell-mediated type rv hypersensitivity reaction that The major histocompatibility complex is a gene locus located on the short arm of
occurs between 7 and 90 days after transplant. chromosome 6. There are two classes located here: class I which expresses human
Examples of autoimmune type 11hypersensitivity include auto immune haemolytic leukocyte antigens (A-, B- and C-) on all nucleated cells and class 11(HLA-Op, -DO and
anaemia, autoimmune thrombocytopenia, myasthenia gravis (antibodies against the -OR) which expresses antigens on antigen-presenting cells (APCs) and is thus found on
muscle motor end-plate acetylcholine recaptor) and Goodpasture's syndrome ~gG macrophages, dendritic cells (and Langerhans' cells) and B cells. Class I antigens are
antibodies against basement membrane, especially those of kidney and lungs). essential to activate T cytotoxic cells and class It antigens must be present to activate T
The Coomb's test is a means of detecting red cells coated with antibodies by making helper cells.
them agglutinate through the addition of albumin or serum containing immunoglobulins The sequence of events begins with a foreign antigen entering either a n APC Of'(in
against the coating antibodies. It is positive in detecting rhesus antibodies as well as the case of a virus) any nucleated cell. Part of the fOf'eign antigen is expressed as a
red cell antibodies found in autoimmune haemolytic anaemia. hapten on either the class I Of'class 11human leukocyte surface antigen. This activates
either T cytotoxic cells or T helper cells. T helper cells differentiate and, in the process,
release cytokines Ontel1eukins and interferons) that influence B cell proliferation and
17 A = True B = False C = True D = True E = True differentiation and specifIC antibody production. as well as activating natural killer cells,
macrophages and grenulocytes.
Type III hypersensitivity Involves persistent immune antigen/antibody complex fOf'ma- Activation of T cytotoxic cells results in direct cytotoxicity by cell binding a n d enzyme
tion with deposition of insoluble complexes at particular sites, resulting in an acute release, including 'pertorin' to destroy cell membranes. Its most important role is in the
inHammatOf'Yreaction. Three basic events are complement activation, influx of poIy- elimination of virally infected nucleated cells (class I antigenlc). T cytotoxic cells may
morphs a n d platelet aggregation. Complement activation results along with compte- also activate rnacrophages.
ment-mediated tissue damage, anaphylotoxin release, a n d release of mast cell Type IV hypersensitivity is an exaggerated cell-mediated immune response causing
mediators. This results in a n influx of polymorphs that attempt to phagocytose the tissue damage. It takes longer than 12 h (usually 46-72 h) to develop and involves
Immune complexes and during this process release their contents causing further 'eviously sensitized T helper cell activation. It is characterized by erythema and
tissue damage. Platelet aggregation is aiso seen and this provides further vasoactive ioOOration and a heavy mononuclear a n d lymphocytic infiltration. This may progress
amine release as well as causing local ischaemia as a result of the fOf'm3tion of to granuioma formation where epithelioid cells and other macrophage-derived cells are
microthrombi. Examples include immune complex glomerulonephritis (build-up of large seen.
 Pathology Answers Pathology Answers
140vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 141

Cytokines released include IL-2,IFN r and macrophage and lymphoCYtiCchemotac- phages. The result Is an interstitial mononuclear/macrophage cellular infiltrate and lysis
tic and activation factors by T cells. Macrophages release cytokines including IL-1, IL-6 of allogenic cells. Lymphokines such as IFN-jl and TNF-jl activate macrophages. IL-4,
and IL-8 as well as TNF.RQPONMLKJIHGFEDCBA
A s T cells only reoognize haptens expressed by their own class IL-S and IL-B are required for B cell activation to produce antigraft antibodies.
I andUTSRQPONMLKJIHGFEDCBA
11 human leukocyte antigens, type IV hypersensitivity cannot be transferred by Cyclosporin A is a T cell-specific fungal peptide that revolutionized transplant surgery
serum to non-sensitized subjects. in the 1980s by its ability to cause specific immunosuppression. It selectively pene-
Examples of type IV hypersensitivity include the Mantoux and Heaf (tuberculin) skin trates C04 (T helpe" cells and interferes with division, maturation and Production of
test for tuberculosis, the lepromin test for leprosy and contact dermatitis. these cells. It also reduces Production of IL-2 as well as sensitivity to IL-2 (by reduction
of IL-2 recaptor expression). Its main side-effects are nephrotoxicity and hepatotoxicity
as well as the increased risk of lymphomas associated with Epstein-Barr virus.
19 A = False B = True C = False 0 = False E = True

The cornea is in a privileged site for transplantation due to its lack of vascularization.
20 A = False 8 = True C = True 0 = True E = False
For this reason, preoperative HLA matching is not essential. Corneal grafting usually
involves transplantation of an allograft (from a different member of the same species).
An isograft refers to donor tissue from a genetically identical individual (twins, HLA- Atherosclerosis is a disease of large and medium-sized muscular arteries (coronary,
identical siblings). Transplant of a 'xenograft describes living donor tissue between cerebral and popliteaO and elastic vessels (aorta, carotid, iliac). The lesion consists of lI.
raised intimal plaque with a lipid core and a fibrous cap. It may be associated with
species.
Types of immune rejection may be classified as hyperacute, humoral, acute and smooth muscle cells and macrophages (often fat filled) as well as a cell-mediated
immune reaction surrounding it.
chronic.
Hyperacute r e je c t io n may occur within minutes or hours of transplant and is a The current theory is of a response to endothelial injury resulting in intimal thickening.
humoral-mediated rejection due to preformed antibodies involving complement and Exposure of Subendothelial collagen attracts platelet deposition and initiates a repair
occurs usually in association with xenograft transplants. It is not usually a problem with process evidenced by the release of platelet growth factors, the most important beln
allograft transplantation and requires serological cross-matching in order to minimize platelet-derived growth factor (pDGF) (trophic to smooth muscle cells in the intima and
its risk. chemotactic for fibroblasts, smooth muscle cells, macrophages and neutrophils), along
Acute rejection is usually seen after a week and may not occur until 3-4 months after
with endothelial growth factors such as TNF, transforming growth factor ~ (TGF-jl) and
transplant. It is a cell-mediated immune response in a host not previously sensitized. It interferons y .
is mainly associated with aliogfaft transplantation and involves C04 (T helper) and C08
(T cytotoxic) cellS mediating a mononuclear-macrophage response. lA small humorel Intimal smooth muscle cell proliferation is seen and fatty streaks develop. The
resultant intimal thickening due to proliferation is associated with lipid deposition,
component may also been seen in the form of vasculitis.)
C h r o n ic rejection is a vascular rejection with a peony understood mechanism occur- extracellular matrix (proteoglycan), elastic tissue and fibrous tissue (collagen).
ring usually after three months (even as late as 10 years) in association with allografts. Plaques may be classified as type I (smooth or stable) and type 11 (cracked or
Inflammatory atheroma-like occlusion of the vascular intima is seen with dense intimal unstable). The type 11 plaque is seen to be the preceding event to sudden thrombosis
fibrosis resulting In secondary ischaemia of the graft. and plaque occlusion. It has a partly unknown pathogenesis but is characteriZed by
Major attention has been directed towards acute rejection. In the past, the phenom- inflammation, foamy (fat-filled) macrophages and smooth muscle cells. The 'cracking'
enon of tolerance was explained by the fact that T cells were only activated if they and exposure of exquisitely thrombogenic connective tissue results in platelet aggre-
recogniZed foreign antigens in combination with one's own MHC molecules. It has been gation and is followed by triggering of the clotting cascade, resuiting in thrombosis and
shown, however, that donor allograft dendritic cells ('passenger leucocytes') react to occlusion.
cells expressed by foreign MHC molecules and facilitate a host-cell-mediated immune
Complication of plaque formation thus includes ulceration, thrombosis, intraplaque
response. Passenger leucocytes recogniZe class 11 MHC molecules of the graft and haemorrhage, calcification and aneurysm formation.
present to host T cells. These class 11 molecules are found on donor cells and more
Aneurysm formation is due to the thickened intimal layer resulting in thinning and loss
importantly, vascular endothelium, and are usually expressed following the trauma of
of smooth mllscle cells in the underlying media layer. This layer dilates locally as a
surgery. Following recognition, the passenger leucocytes act as antigen-presenting
result of the overlying plaque atheroma
cells themselves and trigger CD4 (T helper) cells to activate a cell-mediated immune
response. Cytoklnes released (e.g. IL-2) stimulate C08 (T cytotoxic) cell proliferation The main factors associated with atherosclerosis are hyperlipidaemia, in particular,
and maturation, and macrophage-activating factors facilitate activation of macro- hypercholesterolaemia (raiSed LDL, reduced HOL), hypertension, smoking and diabetes.
 Pathology Answers Pathology Answers
140vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 141

Cytokines released include IL-2,IFN r and macrophage and lymphoCYtiCchemotac- phages. The result Is an interstitial mononuclear/macrophage cellular infiltrate and lysis
tic and activation factors by T cells. Macrophages release cytokines including IL-1, IL-6 of allogenic cells. Lymphokines such as IFN-jl and TNF-jl activate macrophages. IL-4,
and IL-8 as well as TNF.RQPONMLKJIHGFEDCBA
A s T cells only reoognize haptens expressed by their own class IL-S and IL-B are required for B cell activation to produce antigraft antibodies.
I andUTSRQPONMLKJIHGFEDCBA
11 human leukocyte antigens, type IV hypersensitivity cannot be transferred by Cyclosporin A is a T cell-specific fungal peptide that revolutionized transplant surgery
serum to non-sensitized subjects. in the 1980s by its ability to cause specific immunosuppression. It selectively pene-
Examples of type IV hypersensitivity include the Mantoux and Heaf (tuberculin) skin trates C04 (T helpe" cells and interferes with division, maturation and Production of
test for tuberculosis, the lepromin test for leprosy and contact dermatitis. these cells. It also reduces Production of IL-2 as well as sensitivity to IL-2 (by reduction
of IL-2 recaptor expression). Its main side-effects are nephrotoxicity and hepatotoxicity
as well as the increased risk of lymphomas associated with Epstein-Barr virus.
19 A = False B = True C = False 0 = False E = True

The cornea is in a privileged site for transplantation due to its lack of vascularization.
20 A = False 8 = True C = True 0 = True E = False
For this reason, preoperative HLA matching is not essential. Corneal grafting usually
involves transplantation of an allograft (from a different member of the same species).
An isograft refers to donor tissue from a genetically identical individual (twins, HLA- Atherosclerosis is a disease of large and medium-sized muscular arteries (coronary,
identical siblings). Transplant of a 'xenograft describes living donor tissue between cerebral and popliteaO and elastic vessels (aorta, carotid, iliac). The lesion consists of lI.
raised intimal plaque with a lipid core and a fibrous cap. It may be associated with
species.
Types of immune rejection may be classified as hyperacute, humoral, acute and smooth muscle cells and macrophages (often fat filled) as well as a cell-mediated
immune reaction surrounding it.
chronic.
Hyperacute r e je c t io n may occur within minutes or hours of transplant and is a The current theory is of a response to endothelial injury resulting in intimal thickening.
humoral-mediated rejection due to preformed antibodies involving complement and Exposure of Subendothelial collagen attracts platelet deposition and initiates a repair
occurs usually in association with xenograft transplants. It is not usually a problem with process evidenced by the release of platelet growth factors, the most important beln
allograft transplantation and requires serological cross-matching in order to minimize platelet-derived growth factor (pDGF) (trophic to smooth muscle cells in the intima and
its risk. chemotactic for fibroblasts, smooth muscle cells, macrophages and neutrophils), along
Acute rejection is usually seen after a week and may not occur until 3-4 months after
with endothelial growth factors such as TNF, transforming growth factor ~ (TGF-jl) and
transplant. It is a cell-mediated immune response in a host not previously sensitized. It interferons y .
is mainly associated with aliogfaft transplantation and involves C04 (T helper) and C08
(T cytotoxic) cellS mediating a mononuclear-macrophage response. lA small humorel Intimal smooth muscle cell proliferation is seen and fatty streaks develop. The
resultant intimal thickening due to proliferation is associated with lipid deposition,
component may also been seen in the form of vasculitis.)
C h r o n ic rejection is a vascular rejection with a peony understood mechanism occur- extracellular matrix (proteoglycan), elastic tissue and fibrous tissue (collagen).
ring usually after three months (even as late as 10 years) in association with allografts. Plaques may be classified as type I (smooth or stable) and type 11 (cracked or
Inflammatory atheroma-like occlusion of the vascular intima is seen with dense intimal unstable). The type 11 plaque is seen to be the preceding event to sudden thrombosis
fibrosis resulting In secondary ischaemia of the graft. and plaque occlusion. It has a partly unknown pathogenesis but is characteriZed by
Major attention has been directed towards acute rejection. In the past, the phenom- inflammation, foamy (fat-filled) macrophages and smooth muscle cells. The 'cracking'
enon of tolerance was explained by the fact that T cells were only activated if they and exposure of exquisitely thrombogenic connective tissue results in platelet aggre-
recogniZed foreign antigens in combination with one's own MHC molecules. It has been gation and is followed by triggering of the clotting cascade, resuiting in thrombosis and
shown, however, that donor allograft dendritic cells ('passenger leucocytes') react to occlusion.
cells expressed by foreign MHC molecules and facilitate a host-cell-mediated immune
Complication of plaque formation thus includes ulceration, thrombosis, intraplaque
response. Passenger leucocytes recogniZe class 11 MHC molecules of the graft and haemorrhage, calcification and aneurysm formation.
present to host T cells. These class 11 molecules are found on donor cells and more
Aneurysm formation is due to the thickened intimal layer resulting in thinning and loss
importantly, vascular endothelium, and are usually expressed following the trauma of
of smooth mllscle cells in the underlying media layer. This layer dilates locally as a
surgery. Following recognition, the passenger leucocytes act as antigen-presenting
result of the overlying plaque atheroma
cells themselves and trigger CD4 (T helper) cells to activate a cell-mediated immune
response. Cytoklnes released (e.g. IL-2) stimulate C08 (T cytotoxic) cell proliferation The main factors associated with atherosclerosis are hyperlipidaemia, in particular,
and maturation, and macrophage-activating factors facilitate activation of macro- hypercholesterolaemia (raiSed LDL, reduced HOL), hypertension, smoking and diabetes.
 P a th o lo g y Answers 143
Pathology Answers
1 4 2 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
circulation, anastomosis, single or dual venous drainage), rate of onset of occlusion
21 A = False B = True C = True 0 = True E = True F = True G = True H = True and the type of tissue and its vulnerability to ischaemia.

A thrombus is a solid mass formed in the heart, arteries, veins or capillaries from
circulating components of blood. According to Virchow's triad, the risk factors for
23 A = False B = True C = True 0 = True E = True
thrombus may be classified as changes in the intimal surface of vessels, changes in
blood flow and changes in the constituents of blood.
Oedema refers to excess fluid in the extracellular space. It may be in exudate Oncluding
Changes in theRQPONMLKJIHGFEDCBA
in t im a l surface of v e s s e ls include atherosclerosis, injury, inflammation
purulent exudate) or transudate. Exudate Is cellular containing high levels of protein,
(temporal arteritis, polyarteritis nodosa) and tumour invasion.
especially plasma proteins Oncluding fibrinogen) and has a raised specific gravity
C h a n g e s in b lo o d f lo w include the speed (stasis and venous thrombosis) and type of
( 1 . 0 2 0 ) . T r a n s u d a t e may contaln a few cells and low levels of protein (1 g/100 mO
flow (turbulent flow causing cardiac and arterial thrombij. malnly albumin. Specific gravity is less than 1.012.
C h a n g e s in the constituents of b lo o d leading to a hypercoagulant state may be
Pulmonary oedema may be haemodynamic In origin (with increased hydrostatic
classified as congenital or acquired. Congenital causes include antithrombin III defi-
pressure, reduced oncotic pressure or lymphatic obstruction) or microvascular in origin.
ciency. protein C deficiency. protein S deficiency and mutation in coagulation factor V
This may be due to infectious agents, inhalation of gases, aspiration, drugs. shock.
(factor V Leiden) or activated protein C resistance.
trauma or seosls, radiation or in severe acute pancreatitis. It is also seen in association
Acquired causes may be divided into high and low risk. High-risk factors Include
with acutely raised intracranial pressure (neurogenic origin) and is occasionally seen at
prolonged bedrest and immobilization, myocardial infarction, tissue trauma Oncluding
high altitudes.
surgery, burns, fractures), cardiac failure (stasis), acute leukaemia, cancer (release of
Filariasis is a disease caused by a nematode worm ( W u c h e r e r ia bancroftl) found in
factor X or extrinsic pathway-activating products), myeloproliferative disorders, DIC
groin Iymphatics. On dying, the nematode can elicit a local inflammatory reaction
(disseminated intravascular coagulation) and homocystinuria (toxic to endothelium).
resulting in lymphatic obstruction and oedema of the external genitalia and lower limbs.
Low-risk factors include the oral contraceptive pill and increased levels of plasma
Hypoalbuminaemia results in fluid shift from the intravascular to interstitiaispace.
fibrinogen, prothrombin and factors VII. VIII and X, atrial fibrillation, hyperlipidaemia,
Due to a resulting fall in plasma volume, there is a fall in renal per1usion that stimulates
sickle cell anaemia (occlusion causing secondary stasis), smoking and thrombocytosis.
renin-angiotensin release and so results in a secondary hyperaldosteronism. Due to a
basic protein defICiency. however, any salt and water retained will inevitably leave the
intravascular space to enter the interstitial space as oedema.

22 A = True B = False C = True 0 = True E = True

24 A = True B = False C = False 0 = True E = False
Infarction is a large localized area of ischaemic necrosis within a tissue or organ either
due to arterial insufficiency or venous occlusion. The majority are due to thromboem-
Pigmentation may be exogenous (carbon, tattoos) or endogenous Oipofuscin, bilirubin,
bolic arterial occlusion. melanin. haemosiderin). Lipofuscin is an insoluble 'wear and tear' pigment made of lipid
It may be pale in the case of arterial occlusion, especially in solid tissue. or haem or-
polymers and proteins. They are formed as a result of lipid peroxldation of membranes
rhagic in venous occlusion or tissue previously congested. 'Infarct' implies 'stuffed'
and indicate free radical activity. In themselves they are not toxic. They are yellowy
with blood from surrounding tissue. Histologically, most infarcts tend to be wedge-
brown in colour. they are found in the heart and liver and are also seen beneath the
shaped with the apex pointing to the origin of vascular occlusion.
retinal pigment epithelium as a result of pigment epithelium breakdown and photore-
Initial events include no cellular change until the first few hours, after which the area
ceptor renewal.
becomes poorly defined and darker in colour. Over 24 h, definition improves and the
Haemosiderin is formed by iron accumulation either from ferritin or haemoglobin and
colour becomes darker. Between 24 and 36 h, the blood extrudes, leaving the tissue
may be local or systemic. The best example of local haemosicJerosis is a bruise. By the
area paler. A narrow red margin reveals an inflammatory response with neutrophils
action of macrophage and lysosomal enzymes the dark redlblue colour of haemoglobin
followed by macrophages. cellular infiltrate and a fibroblastic repair process preserving
transforms to dark greenlblue (biliverdin) and then bilirubin. The later golden yellow
the outer margins. colour of haemosiderin is due to iron deposition remaining. Raised levels of bilirubin in
In the brain, dead tissue undergoes liquefactive necrosis, cavity formation and is
the conjunctival vessels during jaundice give rise to the yellow appearance of the
replaced by glial tissue synthesized by astrocytes. Elsewhere in the body the dead
sclera. This is not due to scleral protein binding.
tissue undergoes coagulative necrosis. In the presence of a bacterial infection around
One of the key steps in melanin metabolism involves conversion of tyrosine to DOPA.
the area of necrosis, abscess formation is seen. Factors determining the risk of infarc-
Tyrosine is also broken down along with phenylalanine by the enzyme homogentisic
tion include the nature of the arterial supply and venous drainage (end-artery or dual
 P a th o lo g y Answers 143
Pathology Answers
1 4 2 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
circulation, anastomosis, single or dual venous drainage), rate of onset of occlusion
21 A = False B = True C = True 0 = True E = True F = True G = True H = True and the type of tissue and its vulnerability to ischaemia.

A thrombus is a solid mass formed in the heart, arteries, veins or capillaries from
circulating components of blood. According to Virchow's triad, the risk factors for
23 A = False B = True C = True 0 = True E = True
thrombus may be classified as changes in the intimal surface of vessels, changes in
blood flow and changes in the constituents of blood.
Oedema refers to excess fluid in the extracellular space. It may be in exudate Oncluding
Changes in theRQPONMLKJIHGFEDCBA
in t im a l surface of v e s s e ls include atherosclerosis, injury, inflammation
purulent exudate) or transudate. Exudate Is cellular containing high levels of protein,
(temporal arteritis, polyarteritis nodosa) and tumour invasion.
especially plasma proteins Oncluding fibrinogen) and has a raised specific gravity
C h a n g e s in b lo o d f lo w include the speed (stasis and venous thrombosis) and type of
( 1 . 0 2 0 ) . T r a n s u d a t e may contaln a few cells and low levels of protein (1 g/100 mO
flow (turbulent flow causing cardiac and arterial thrombij. malnly albumin. Specific gravity is less than 1.012.
C h a n g e s in the constituents of b lo o d leading to a hypercoagulant state may be
Pulmonary oedema may be haemodynamic In origin (with increased hydrostatic
classified as congenital or acquired. Congenital causes include antithrombin III defi-
pressure, reduced oncotic pressure or lymphatic obstruction) or microvascular in origin.
ciency. protein C deficiency. protein S deficiency and mutation in coagulation factor V
This may be due to infectious agents, inhalation of gases, aspiration, drugs. shock.
(factor V Leiden) or activated protein C resistance.
trauma or seosls, radiation or in severe acute pancreatitis. It is also seen in association
Acquired causes may be divided into high and low risk. High-risk factors Include
with acutely raised intracranial pressure (neurogenic origin) and is occasionally seen at
prolonged bedrest and immobilization, myocardial infarction, tissue trauma Oncluding
high altitudes.
surgery, burns, fractures), cardiac failure (stasis), acute leukaemia, cancer (release of
Filariasis is a disease caused by a nematode worm ( W u c h e r e r ia bancroftl) found in
factor X or extrinsic pathway-activating products), myeloproliferative disorders, DIC
groin Iymphatics. On dying, the nematode can elicit a local inflammatory reaction
(disseminated intravascular coagulation) and homocystinuria (toxic to endothelium).
resulting in lymphatic obstruction and oedema of the external genitalia and lower limbs.
Low-risk factors include the oral contraceptive pill and increased levels of plasma
Hypoalbuminaemia results in fluid shift from the intravascular to interstitiaispace.
fibrinogen, prothrombin and factors VII. VIII and X, atrial fibrillation, hyperlipidaemia,
Due to a resulting fall in plasma volume, there is a fall in renal per1usion that stimulates
sickle cell anaemia (occlusion causing secondary stasis), smoking and thrombocytosis.
renin-angiotensin release and so results in a secondary hyperaldosteronism. Due to a
basic protein defICiency. however, any salt and water retained will inevitably leave the
intravascular space to enter the interstitial space as oedema.

22 A = True B = False C = True 0 = True E = True

24 A = True B = False C = False 0 = True E = False
Infarction is a large localized area of ischaemic necrosis within a tissue or organ either
due to arterial insufficiency or venous occlusion. The majority are due to thromboem-
Pigmentation may be exogenous (carbon, tattoos) or endogenous Oipofuscin, bilirubin,
bolic arterial occlusion. melanin. haemosiderin). Lipofuscin is an insoluble 'wear and tear' pigment made of lipid
It may be pale in the case of arterial occlusion, especially in solid tissue. or haem or-
polymers and proteins. They are formed as a result of lipid peroxldation of membranes
rhagic in venous occlusion or tissue previously congested. 'Infarct' implies 'stuffed'
and indicate free radical activity. In themselves they are not toxic. They are yellowy
with blood from surrounding tissue. Histologically, most infarcts tend to be wedge-
brown in colour. they are found in the heart and liver and are also seen beneath the
shaped with the apex pointing to the origin of vascular occlusion.
retinal pigment epithelium as a result of pigment epithelium breakdown and photore-
Initial events include no cellular change until the first few hours, after which the area
ceptor renewal.
becomes poorly defined and darker in colour. Over 24 h, definition improves and the
Haemosiderin is formed by iron accumulation either from ferritin or haemoglobin and
colour becomes darker. Between 24 and 36 h, the blood extrudes, leaving the tissue
may be local or systemic. The best example of local haemosicJerosis is a bruise. By the
area paler. A narrow red margin reveals an inflammatory response with neutrophils
action of macrophage and lysosomal enzymes the dark redlblue colour of haemoglobin
followed by macrophages. cellular infiltrate and a fibroblastic repair process preserving
transforms to dark greenlblue (biliverdin) and then bilirubin. The later golden yellow
the outer margins. colour of haemosiderin is due to iron deposition remaining. Raised levels of bilirubin in
In the brain, dead tissue undergoes liquefactive necrosis, cavity formation and is
the conjunctival vessels during jaundice give rise to the yellow appearance of the
replaced by glial tissue synthesized by astrocytes. Elsewhere in the body the dead
sclera. This is not due to scleral protein binding.
tissue undergoes coagulative necrosis. In the presence of a bacterial infection around
One of the key steps in melanin metabolism involves conversion of tyrosine to DOPA.
the area of necrosis, abscess formation is seen. Factors determining the risk of infarc-
Tyrosine is also broken down along with phenylalanine by the enzyme homogentisic
tion include the nature of the arterial supply and venous drainage (end-artery or dual
 P a th o lo g y Answers
144 P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 145

acid oxidase. Deficiency of this enzyme and build-up of homogentisic acid causes dark 27 A = False B = False C = True D = False E = False
brown pigmentation of the skin and eyes (ochronosis) and is known as alcaptonuria.
Dysplasia refers to the loss or reduction in the degree of differentiation of cell types,
especially epithelial cells, without invasion of surrounding tissues. Dysplastic cells
show pleomorphism, hyperchromatic nuclei and evidence of mitosis appearing not
25 A = True B = False C = False 0 = True E = False F = True
only in the basal layers. Although it Is commonly seen before malignant neoplaSia,
dysplaSia does not always progress and is reversible in the presence of moderate
Heterotrophic calcification describes deposition of calcium outside bone and enamel. It
change not involving the full epithelial thiCkness. Dysplasia of all epithelial layers but
may be dystrophic or metastatic.RQPONMLKJIHGFEDCBA
not invading the basement membrane is referred to as carcinoma in s itu .
D y s tr o p h ic c a lc ific a tio n is found in the presence of normal serum calcium levels in
A hamartoma is a non-neoplastic congenital malformation that forms a neoplastic-
areas of necrosis, atherosclerosis, tuberculosis or haematoma (not old cerebral hae-
like mass, but grows at a normal rate (unlike neoplasms) to its surrounding tissue
matoma which undergoes reabsorption). It may be seen on aortic stenotic valves.
without a capsule and often regresses with age. Examples include port-wine stains
Calcium deposition may be intracellular in the mitochondria of dead cells, or extra- and Peutz-Jeghers polyps.
cellular. Psammoma bodies are lamellae of dystrophic calcification around necrotic Metaplasia describes the change from one fully differentiated form of tissue to
cells. These are often seen in intracranial tumours. another fully differentiated form. Examples inClude Sarrett's oesophagus, where the
M e ta s ta tic c a lc ific a tio n occurs in normal tissue in the presence of hypercalcaemia. normal squamous epithelium lining the oeSophagus is replaced by columnar epithelium
Hypercalcaemia may be due to bone reabsorption, increased gut absorption or as a due to persistent damage as a result of reflux oesophagitis, and tobacco-induced
result of raised serum phosphate levels due to renal osteodystrophy. Causes therefore metaplasia of the bronchus where normal pseudostratified ciliated columnar epithelium
include hyperparathyroidism, inCreased levels of vitamin D, sarcoidosis, hyperthyroid- of the bronchus is replaced by squamous epithelium.
ism and bone malignancy (metastatic disease, myeloma). Calcium deposition Is seen in A polyp is a pedunculated mass arising from an epithelial surface as a result of
kidney tubules, lungs (alveolar walls), gastric mucosa, coronary arteries and the cornea. neoplasia, hamartoma (non-neoplastic), inflammation or metaplasia.

26 A = False B"= True C = True 0 = True E = True F = True 28 A = False B = True C = True 0 = True E = False F = False

To quote Sir Rupert Willis: 'A neoplasm is an abnormal mass of tissue, the growth of The normal cell cycle is made up of a G " S, G :! and M phase. The G , phase has a
which exceeds and Is unco-ordinated with that of the normal tissues and persist in the variable length of days to years, the other phases are reasonably constant.
same excessive manner after cessation of the stimuli which evoked the change.' This When in the G , phase (also known as the 'gap' phase) the cell may enter a resting Go
implies an abnormal autonomous proliferation, differentiation and relationship with phase, or opt out and terminally differentiate to eventually die. It leaves the G , phase
surrounding tissue. A 'tumour' is a swelling that mayor may not be neoplastic, although after passing the restriction point late in G ,. where it is thought that synthesis of DNA
today, the term tumour is usually taken to be synonymous with neoplasm. polymerase begins. The cell then enters the S phase (up to 12 h) of DNA synthesis and
Benign neoplasms are well differentiated and grow slowly in an expansile non- following a short G2 phase (up to 6 h) enters the M (mitosis) phase (up to 2 h).
invasive manner with very few cells undergoing mitosis. They do not metastasize. Hyperplasia refers to a stimulus-led increase in the number of cells of an organ. It
Malignant neoplasms are less differentiated with a high rate of cell turnover. They may be physiological or pathological. Hyperplasia is seen in hormonal stimulation of
display both cellular and nuclear pleomorphism with variations in both cellular and endocrine glands such as the adrenal and thyroid glands. Negative feedback regulation
of the hormonal signal controls the degree of hyperplasia.
nuclear size and shape. The nuclei are also hyperchromatic with a large amount of DNA
Pathological hyperplasia with the example of endometrial proliferation is associated
and dark staining. Rather than the normal 1:4 to 1:6 nuclear: cytoplasmic ratio, there is
with an increased risk of developing endometrial carcinoma, particularly if there is
an increased nuclear. cytoplasmic ratio of up to 1:1. There is also loss of normal ploidy. associated dysplasia.
Malignant neoplasms may spread locally in an invasive manner or by Iymphatics.
Hypertrophy is a demand-led increase in cell size of an organ with no increase in the
blood or across a cavity such as the peritoneum. Although mortality is associated with
number. The increase in size is due to an increase in synthesis of structural compo-
malignancy, benign neoplasms can result in fatal local mechanical effects as in the case
nents. Increase in cell size due to cellular swelling or oedema is not described as
of benign neoplasms of the brain, resulting in hydrocephalus and raised intracranial hypertrophy.
pressure.
 P a th o lo g y Answers
144 P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 145

acid oxidase. Deficiency of this enzyme and build-up of homogentisic acid causes dark 27 A = False B = False C = True D = False E = False
brown pigmentation of the skin and eyes (ochronosis) and is known as alcaptonuria.
Dysplasia refers to the loss or reduction in the degree of differentiation of cell types,
especially epithelial cells, without invasion of surrounding tissues. Dysplastic cells
show pleomorphism, hyperchromatic nuclei and evidence of mitosis appearing not
25 A = True B = False C = False 0 = True E = False F = True
only in the basal layers. Although it Is commonly seen before malignant neoplaSia,
dysplaSia does not always progress and is reversible in the presence of moderate
Heterotrophic calcification describes deposition of calcium outside bone and enamel. It
change not involving the full epithelial thiCkness. Dysplasia of all epithelial layers but
may be dystrophic or metastatic.RQPONMLKJIHGFEDCBA
not invading the basement membrane is referred to as carcinoma in s itu .
D y s tr o p h ic c a lc ific a tio n is found in the presence of normal serum calcium levels in
A hamartoma is a non-neoplastic congenital malformation that forms a neoplastic-
areas of necrosis, atherosclerosis, tuberculosis or haematoma (not old cerebral hae-
like mass, but grows at a normal rate (unlike neoplasms) to its surrounding tissue
matoma which undergoes reabsorption). It may be seen on aortic stenotic valves.
without a capsule and often regresses with age. Examples include port-wine stains
Calcium deposition may be intracellular in the mitochondria of dead cells, or extra- and Peutz-Jeghers polyps.
cellular. Psammoma bodies are lamellae of dystrophic calcification around necrotic Metaplasia describes the change from one fully differentiated form of tissue to
cells. These are often seen in intracranial tumours. another fully differentiated form. Examples inClude Sarrett's oesophagus, where the
M e ta s ta tic c a lc ific a tio n occurs in normal tissue in the presence of hypercalcaemia. normal squamous epithelium lining the oeSophagus is replaced by columnar epithelium
Hypercalcaemia may be due to bone reabsorption, increased gut absorption or as a due to persistent damage as a result of reflux oesophagitis, and tobacco-induced
result of raised serum phosphate levels due to renal osteodystrophy. Causes therefore metaplasia of the bronchus where normal pseudostratified ciliated columnar epithelium
include hyperparathyroidism, inCreased levels of vitamin D, sarcoidosis, hyperthyroid- of the bronchus is replaced by squamous epithelium.
ism and bone malignancy (metastatic disease, myeloma). Calcium deposition Is seen in A polyp is a pedunculated mass arising from an epithelial surface as a result of
kidney tubules, lungs (alveolar walls), gastric mucosa, coronary arteries and the cornea. neoplasia, hamartoma (non-neoplastic), inflammation or metaplasia.

26 A = False B"= True C = True 0 = True E = True F = True 28 A = False B = True C = True 0 = True E = False F = False

To quote Sir Rupert Willis: 'A neoplasm is an abnormal mass of tissue, the growth of The normal cell cycle is made up of a G " S, G :! and M phase. The G , phase has a
which exceeds and Is unco-ordinated with that of the normal tissues and persist in the variable length of days to years, the other phases are reasonably constant.
same excessive manner after cessation of the stimuli which evoked the change.' This When in the G , phase (also known as the 'gap' phase) the cell may enter a resting Go
implies an abnormal autonomous proliferation, differentiation and relationship with phase, or opt out and terminally differentiate to eventually die. It leaves the G , phase
surrounding tissue. A 'tumour' is a swelling that mayor may not be neoplastic, although after passing the restriction point late in G ,. where it is thought that synthesis of DNA
today, the term tumour is usually taken to be synonymous with neoplasm. polymerase begins. The cell then enters the S phase (up to 12 h) of DNA synthesis and
Benign neoplasms are well differentiated and grow slowly in an expansile non- following a short G2 phase (up to 6 h) enters the M (mitosis) phase (up to 2 h).
invasive manner with very few cells undergoing mitosis. They do not metastasize. Hyperplasia refers to a stimulus-led increase in the number of cells of an organ. It
Malignant neoplasms are less differentiated with a high rate of cell turnover. They may be physiological or pathological. Hyperplasia is seen in hormonal stimulation of
display both cellular and nuclear pleomorphism with variations in both cellular and endocrine glands such as the adrenal and thyroid glands. Negative feedback regulation
of the hormonal signal controls the degree of hyperplasia.
nuclear size and shape. The nuclei are also hyperchromatic with a large amount of DNA
Pathological hyperplasia with the example of endometrial proliferation is associated
and dark staining. Rather than the normal 1:4 to 1:6 nuclear: cytoplasmic ratio, there is
with an increased risk of developing endometrial carcinoma, particularly if there is
an increased nuclear. cytoplasmic ratio of up to 1:1. There is also loss of normal ploidy. associated dysplasia.
Malignant neoplasms may spread locally in an invasive manner or by Iymphatics.
Hypertrophy is a demand-led increase in cell size of an organ with no increase in the
blood or across a cavity such as the peritoneum. Although mortality is associated with
number. The increase in size is due to an increase in synthesis of structural compo-
malignancy, benign neoplasms can result in fatal local mechanical effects as in the case
nents. Increase in cell size due to cellular swelling or oedema is not described as
of benign neoplasms of the brain, resulting in hydrocephalus and raised intracranial hypertrophy.
pressure.
 P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P a th o lo g y Answers 147
146UTSRQPONMLKJIHGFEDCBA
31 A = True B = True C = True 0 = True E = True
29 A = False B = True C = True D = True E = False
Normal cell signalling is transient and in response to a stimulus. It usually consists of a
Tumour spread may be direct, lymphatic, bloodbome or metastatic. Direct spread growth factor binding to a membrane receptor which signalS an intracellular secondary
involves detachment. This requires loss of cell-to-cell adhesiveness. A reduction in messenger transducer protein to interact with a nuclear receptor and this increases
cell surface fibronectin is seen to reduce cell-to-cell binding. A loss of anchorage production or expression of DNA.
dependence is seen. Progressive infiltration, invasion and destruction of surrounding A proto-oncogene is a normal cell-signalling DNA sequence that codes for anything
tissue is seen. Invasion of basement membrane and extracellular matrix requires from the growth factor to enzymes produced by upregulation of DNA. An oncogene is a
attachment to and degradation of the matrix. Increased cell surface expression of mutated-cell signalling gene that encodes a step in the cell-signalling pathway. Onco-
genes are either overexpressed or remain active regardless of stimulus cessation.
the laminin recaptor is needed in order to bind basement membrane laminin. Tumour
TheRQPONMLKJIHGFEDCBA
e r b B oncogene codes for tile EGF cell membrane receptor, the ras oncogene
cells either secrete or induce secretion of proteolytic enzymes. The three classes
codes for the secondary messenger G protein; the m y c and f o s oncogenes code for
involved are serine proteinases, cysteine proteinases and metalloproteinases.
nuclear regulating proteins. The s is oncogene codes for production of paracrine growth
Type IV collagenase is a metalloproteinase that is very important during invasion in
factors such as PDGF.Oncogenes may be carried by the virus genome. DNA oncogenic
cleaving basement membrane. viruses include the papillomavirus, herpes viruses (EBV, Burkitt's lymphoma and naso-
Tumour angiogenesis is crucial for tumour growth and spread. The most powerful pharyngeal carcinoma), and hepatitis B viruS (hepatoma). Oncogenes may be activated
and important tumour-derived angiogenic factors include the fibroblast growth factors by proto-oncogene overexpression such as gene amplifICation or excess promotion in
(FGFs), which are chemotactic andrnltoqenlc for endothelial cells and stimulate pro- the case of translocation of 8 - m y c proto-oncogene to chromosome 1 4 (the immuno-
teolytic enzymes to facilitate stromal infiltration of new vessels, TGFa and ~, EGF and globulin chromosome), resulting in promotion of immunoglobulin production and Bur-
kitt's lymphoma. Oncogenes may also be activated by alteration in their structure (POint
PDGF.
mutations etc.) or even by deletion or mutation of a suppressed gene.

30 A = True B = False C = True D = True E = False F = True

32 A = True B = True C = False 0 = True E = False F = True
A carcinogen is an environmental agent, either physical, chemical or viral, responsible
Tumour markers are substances present in the body in concentrations that may be
for either the initiation or promotion of malignant transformation. Initiation is a result of
related to the presence of a tumour. They may be either expressed or secreted and
exposure to a carcinogen whose active form binds on to DNA and irreversibly initiates a
should be able to suggest tumour size and/or aggressiveness.
change. Promotion occurs following possibly repeated exposures to non-mutagenic
I3-Human chromic gonadotrophin (J3HCG)is raised in trophoblastic tumours as well
irritants that result in progression of carcinogenesis. Chemical carcinogens include
as germ cell tumours. CEA (carcino-embryonic antigen) may be used to confirm the
direct-acting alkylating agents, polycyclic aromatic hydrocarbons (skin cancer), aro- presence of colonic carcinomas. CA125 is raised in 90% of women with stage 3 or 4
matic amines and azo dyes (bladder cancer, by liver detoxification and further break- ovarian cancer. PSA (prostate-specific antigen) is more sensitive than the previously
down by the enzyme glucuronidase in the bladder), saccharine (bladder cancer in rats) used acid phosphatase in marking the presence and progress of prostatic carcinoma.
and asbestos (carcinoma of the bronchus, mesothelioma and cancer of the gastro- Serum AFP (a-fetoprotein) is raised in over 50% of patients with hepatocellular carci-
noma. CA15-3 is a mucin marker found in raised levels in the presence of breast
intestinal tract).
Physical carcinogens include ionizing radiation which predisposes to leukaemia carcinoma.
(except chronic lymphocytic leukaemia) and thyroid carcinoma On the young) and
ultraviolet radiation. UV-B is most implicated in skin cancer. UV-C is perhaps more
carcinogenic but is absorbed by the ozone layer and UV-A has a photosensitizing 33 A = False B = True C = True 0 = True E = True F = True G = False
effect, but has been shown to cause cancer in animals.
Included in the viral carcinogens is the human papillomavirus, especially types 16 Amyloid is associated with a spectrum of diseases caused by the deposition of extra-
and 18 (however, types 31, 33 and 35 may also be factors) which have been implicated cellular protein made up of J}-pleated sheets. Amyloid is not a carbohydrate (as its
name 'starch-like' would suggest) but is a protein which stains a rich brown colour with
in carcinoma of the cervix. HPV-6 and 11 are associated with genital warts and are
Lugol's iodine and shows yellow/green birefringence (dichroism) when bound with
considered a 'Iow risk' for malignancy.
 P a th o lo g y AnswersvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P a th o lo g y Answers 147
146UTSRQPONMLKJIHGFEDCBA
31 A = True B = True C = True 0 = True E = True
29 A = False B = True C = True D = True E = False
Normal cell signalling is transient and in response to a stimulus. It usually consists of a
Tumour spread may be direct, lymphatic, bloodbome or metastatic. Direct spread growth factor binding to a membrane receptor which signalS an intracellular secondary
involves detachment. This requires loss of cell-to-cell adhesiveness. A reduction in messenger transducer protein to interact with a nuclear receptor and this increases
cell surface fibronectin is seen to reduce cell-to-cell binding. A loss of anchorage production or expression of DNA.
dependence is seen. Progressive infiltration, invasion and destruction of surrounding A proto-oncogene is a normal cell-signalling DNA sequence that codes for anything
tissue is seen. Invasion of basement membrane and extracellular matrix requires from the growth factor to enzymes produced by upregulation of DNA. An oncogene is a
attachment to and degradation of the matrix. Increased cell surface expression of mutated-cell signalling gene that encodes a step in the cell-signalling pathway. Onco-
genes are either overexpressed or remain active regardless of stimulus cessation.
the laminin recaptor is needed in order to bind basement membrane laminin. Tumour
TheRQPONMLKJIHGFEDCBA
e r b B oncogene codes for tile EGF cell membrane receptor, the ras oncogene
cells either secrete or induce secretion of proteolytic enzymes. The three classes
codes for the secondary messenger G protein; the m y c and f o s oncogenes code for
involved are serine proteinases, cysteine proteinases and metalloproteinases.
nuclear regulating proteins. The s is oncogene codes for production of paracrine growth
Type IV collagenase is a metalloproteinase that is very important during invasion in
factors such as PDGF.Oncogenes may be carried by the virus genome. DNA oncogenic
cleaving basement membrane. viruses include the papillomavirus, herpes viruses (EBV, Burkitt's lymphoma and naso-
Tumour angiogenesis is crucial for tumour growth and spread. The most powerful pharyngeal carcinoma), and hepatitis B viruS (hepatoma). Oncogenes may be activated
and important tumour-derived angiogenic factors include the fibroblast growth factors by proto-oncogene overexpression such as gene amplifICation or excess promotion in
(FGFs), which are chemotactic andrnltoqenlc for endothelial cells and stimulate pro- the case of translocation of 8 - m y c proto-oncogene to chromosome 1 4 (the immuno-
teolytic enzymes to facilitate stromal infiltration of new vessels, TGFa and ~, EGF and globulin chromosome), resulting in promotion of immunoglobulin production and Bur-
kitt's lymphoma. Oncogenes may also be activated by alteration in their structure (POint
PDGF.
mutations etc.) or even by deletion or mutation of a suppressed gene.

30 A = True B = False C = True D = True E = False F = True

32 A = True B = True C = False 0 = True E = False F = True
A carcinogen is an environmental agent, either physical, chemical or viral, responsible
Tumour markers are substances present in the body in concentrations that may be
for either the initiation or promotion of malignant transformation. Initiation is a result of
related to the presence of a tumour. They may be either expressed or secreted and
exposure to a carcinogen whose active form binds on to DNA and irreversibly initiates a
should be able to suggest tumour size and/or aggressiveness.
change. Promotion occurs following possibly repeated exposures to non-mutagenic
I3-Human chromic gonadotrophin (J3HCG)is raised in trophoblastic tumours as well
irritants that result in progression of carcinogenesis. Chemical carcinogens include
as germ cell tumours. CEA (carcino-embryonic antigen) may be used to confirm the
direct-acting alkylating agents, polycyclic aromatic hydrocarbons (skin cancer), aro- presence of colonic carcinomas. CA125 is raised in 90% of women with stage 3 or 4
matic amines and azo dyes (bladder cancer, by liver detoxification and further break- ovarian cancer. PSA (prostate-specific antigen) is more sensitive than the previously
down by the enzyme glucuronidase in the bladder), saccharine (bladder cancer in rats) used acid phosphatase in marking the presence and progress of prostatic carcinoma.
and asbestos (carcinoma of the bronchus, mesothelioma and cancer of the gastro- Serum AFP (a-fetoprotein) is raised in over 50% of patients with hepatocellular carci-
noma. CA15-3 is a mucin marker found in raised levels in the presence of breast
intestinal tract).
Physical carcinogens include ionizing radiation which predisposes to leukaemia carcinoma.
(except chronic lymphocytic leukaemia) and thyroid carcinoma On the young) and
ultraviolet radiation. UV-B is most implicated in skin cancer. UV-C is perhaps more
carcinogenic but is absorbed by the ozone layer and UV-A has a photosensitizing 33 A = False B = True C = True 0 = True E = True F = True G = False
effect, but has been shown to cause cancer in animals.
Included in the viral carcinogens is the human papillomavirus, especially types 16 Amyloid is associated with a spectrum of diseases caused by the deposition of extra-
and 18 (however, types 31, 33 and 35 may also be factors) which have been implicated cellular protein made up of J}-pleated sheets. Amyloid is not a carbohydrate (as its
name 'starch-like' would suggest) but is a protein which stains a rich brown colour with
in carcinoma of the cervix. HPV-6 and 11 are associated with genital warts and are
Lugol's iodine and shows yellow/green birefringence (dichroism) when bound with
considered a 'Iow risk' for malignancy.
 Pathology Answers
1 4 8 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Congo Red dye and viewed in polarized light. The main feature is of ~-pleated fibril
MICROBIOLOGY
sheets.
Amyloidosis may be classified into either: (1) amyloidosis of immune origin (ALlight
Questions
chain type), or (2) reactive systemic amyloidosis.
The immune origin type is an acquired disorder characterized by monoclonal pro-
liferation of B Iymphocytes or plasma cells. This proliferation may be neoplastic as in 1 The normal flora of the eyelids and conjunctiva includes •
the case of myeloma. The amyloid in this type is related to a light chain (especially y
type) or a terminal fragment produced that is then somehow converted from the nonnal ARQPONMLKJIHGFEDCBA
S ta p h y lo c o c c u s e p id e r m id is
a-helical structure to the characteristic ~pleated sheet structure. Antibodies raised B Diphtheroids
against this protein have been found to aiso react with a similar light chain, the Bence- e S ta p h y lo c o c c u s a u re u s
Jones protein. The immune origin amyloid is known to systemically deposit in organs o S tr e p to c o c c u s p n e u m o n ia e
and cause neuropathy, restrictive cardiomyopathy, skin nodules, poIyarthropathy, car- E C a n d id a a lb ic a n s
pal tunnel syndrome and macroglossia.
Reactive systemic amyloidosis is related to a liver-produced acute-phase protein
known as the serum amyloid A (SAA) protein. This is a precursor to the amyloid which is
2 S ta p h y lo c o c c u s
derived by cleavage of 28 amino acid residues at the carboxy-tenninal. Due to raised
levels of SM protein in inflammation, amyloid is seen to be deposited systemically in
the presence of chronic inflammation, either due to infection or hypersensitivity. It is A species are catalase positive
also seen in neoplasia Deposition occurs in the spleen, liver and kidney (common B s a p r o p h y fic u s is coagulase negative
cause of death due to chronic renal failure). In rare cases amyloid may be inherited in an e e p id e n n id isis novobiocin sensitive
autosomal dominant pattern with varying origins of the amyloid protein, one of which is o a u re u s is coagulase positive
the ~ protein. The p protein (also known as A4 protein) is deposited in the brain in E a u re u s is an aeropic or facultative anaerobic organism
Down's syndrorn& (and inherited Alzheimer's disease). The gene for this protein is found
on the long arm of chromosome 21.
3 Which of the follOwing statements about S ta p h y lo c o c c u s are true?

A Cross-infection is increased with penicillin resistance.

B Cross-infection is due to colonies on curtains and linen.
e S ta p h . a u te u s causes osteomyelitis.
o S ta p h . aumus is a nasal and skin commensal.
E Human carriers are more usually male than female.

4 S ta p h y lo c o c c u s a u te u s

A produces protein S
B produces enterotoxins and haemolysins
e is associated with endocarditis
D grows on simple media
E strains can be characterized by bacteriophage typing
 Pathology Answers
1 4 8 vutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Congo Red dye and viewed in polarized light. The main feature is of ~-pleated fibril
MICROBIOLOGY
sheets.
Amyloidosis may be classified into either: (1) amyloidosis of immune origin (ALlight
Questions
chain type), or (2) reactive systemic amyloidosis.
The immune origin type is an acquired disorder characterized by monoclonal pro-
liferation of B Iymphocytes or plasma cells. This proliferation may be neoplastic as in 1 The normal flora of the eyelids and conjunctiva includes •
the case of myeloma. The amyloid in this type is related to a light chain (especially y
type) or a terminal fragment produced that is then somehow converted from the nonnal ARQPONMLKJIHGFEDCBA
S ta p h y lo c o c c u s e p id e r m id is
a-helical structure to the characteristic ~pleated sheet structure. Antibodies raised B Diphtheroids
against this protein have been found to aiso react with a similar light chain, the Bence- e S ta p h y lo c o c c u s a u re u s
Jones protein. The immune origin amyloid is known to systemically deposit in organs o S tr e p to c o c c u s p n e u m o n ia e
and cause neuropathy, restrictive cardiomyopathy, skin nodules, poIyarthropathy, car- E C a n d id a a lb ic a n s
pal tunnel syndrome and macroglossia.
Reactive systemic amyloidosis is related to a liver-produced acute-phase protein
known as the serum amyloid A (SAA) protein. This is a precursor to the amyloid which is
2 S ta p h y lo c o c c u s
derived by cleavage of 28 amino acid residues at the carboxy-tenninal. Due to raised
levels of SM protein in inflammation, amyloid is seen to be deposited systemically in
the presence of chronic inflammation, either due to infection or hypersensitivity. It is A species are catalase positive
also seen in neoplasia Deposition occurs in the spleen, liver and kidney (common B s a p r o p h y fic u s is coagulase negative
cause of death due to chronic renal failure). In rare cases amyloid may be inherited in an e e p id e n n id isis novobiocin sensitive
autosomal dominant pattern with varying origins of the amyloid protein, one of which is o a u re u s is coagulase positive
the ~ protein. The p protein (also known as A4 protein) is deposited in the brain in E a u re u s is an aeropic or facultative anaerobic organism
Down's syndrorn& (and inherited Alzheimer's disease). The gene for this protein is found
on the long arm of chromosome 21.
3 Which of the follOwing statements about S ta p h y lo c o c c u s are true?

A Cross-infection is increased with penicillin resistance.

B Cross-infection is due to colonies on curtains and linen.
e S ta p h . a u te u s causes osteomyelitis.
o S ta p h . aumus is a nasal and skin commensal.
E Human carriers are more usually male than female.

4 S ta p h y lo c o c c u s a u te u s

A produces protein S
B produces enterotoxins and haemolysins
e is associated with endocarditis
D grows on simple media
E strains can be characterized by bacteriophage typing
 M ic ro b io lo g y Questions 151
150 M ic ro b io lo g y QuestionsnmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
10 Ocular infections due to streptococci include
5 Staphylococcal infections related to the eye include

A purulent conjunctivitis
A blepharitis
B dacryocystitis
B conjunctivitis
C endophthalmitis
C ulcerative keratitis (corneal ulcer)
o hordeolum
o endophthalmitls
E ulcerative keratitis
E hordeolum and chalazion

11 The gram-negative cocci N e is s e r ia

6 Which of the following statements about streptococci are true?

A species are aerobic or facultative anaerobic organisms

A Streptococci are catalase positive.
B gonorrfloeae ferments glucose only
B Streptococci are mostly facultative anaerobes.
C species grow best in cooled blood agar
C Streptococci are classified using the Lancefield classification based on the pre-
o species are oxidase positive
sence of surface antigen M proteins.
E species produce exotoxins
o Streptococci are never commensal.
E Ninety per cent of streptococcal infections in humans are due to a !I-haemolytic
Lancefield group A organism.PONMLKJIHGFEDCBA
12 Neisseria m e n in g it id is

A is prevented from causing meningococcal disease in most adults by the pre-

7 S tre p to c o c c u s pyogenes
sence of protective serum antibodies
B is found in the nasopharynx of asymptomatic carriers
A is a commensal of the nose in up to 25% of the population
C type C is associated with major epidemics
B is a commensal of the throat in up to 4% of the population
o is found in pairs in Iymphocytes
C is sensitive to bacitracin
E is capsulated
o can be subtyped by Griffiths typing
E produces oxygen-stable streptolysin 0

13 Mycobacteria

8 S tre p to c o c c u s p n e u m o n ia e (pneumococcus)
A are non-motile. non-capsulated. non-sporing obligate aerobes
B induce a type IV hypersensitivity reaction
A is a ~-haemolytic gram-positive ovoid diplococcus 11/

C known 'as acid and alcohol fast bacilli due to their inability to take up Gram
a re
B is resistant to optochln
stain
C Is an upper respiratory tract commensal
o cause orbital cellulitis
o is lysed by bile
E cause ulcerative keratitis
E possesses 84 different types of antigenic capsules
F a re easily destroyed by drying

9 S tre p to c o c c u s v ir id a n s is responsible for

14 Which of the following features are essential for histological diagnosis of tubercu-
losis caused by M, t u b e r c u lo s is ?
A green colonies on blood agar
B acute glomerulonephritis
A Caseation
C subacute bacterial endocarditis
B Epithelioid cells
o lobar pneumonia
C Acid-fast bacilli
E rheumatic fever
 M ic ro b io lo g y Questions 151
150 M ic ro b io lo g y QuestionsnmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
10 Ocular infections due to streptococci include
5 Staphylococcal infections related to the eye include

A purulent conjunctivitis
A blepharitis
B dacryocystitis
B conjunctivitis
C endophthalmitis
C ulcerative keratitis (corneal ulcer)
o hordeolum
o endophthalmitls
E ulcerative keratitis
E hordeolum and chalazion

11 The gram-negative cocci N e is s e r ia

6 Which of the following statements about streptococci are true?

A species are aerobic or facultative anaerobic organisms

A Streptococci are catalase positive.
B gonorrfloeae ferments glucose only
B Streptococci are mostly facultative anaerobes.
C species grow best in cooled blood agar
C Streptococci are classified using the Lancefield classification based on the pre-
o species are oxidase positive
sence of surface antigen M proteins.
E species produce exotoxins
o Streptococci are never commensal.
E Ninety per cent of streptococcal infections in humans are due to a !I-haemolytic
Lancefield group A organism.PONMLKJIHGFEDCBA
12 Neisseria m e n in g it id is

A is prevented from causing meningococcal disease in most adults by the pre-

7 S tre p to c o c c u s pyogenes
sence of protective serum antibodies
B is found in the nasopharynx of asymptomatic carriers
A is a commensal of the nose in up to 25% of the population
C type C is associated with major epidemics
B is a commensal of the throat in up to 4% of the population
o is found in pairs in Iymphocytes
C is sensitive to bacitracin
E is capsulated
o can be subtyped by Griffiths typing
E produces oxygen-stable streptolysin 0

13 Mycobacteria

8 S tre p to c o c c u s p n e u m o n ia e (pneumococcus)
A are non-motile. non-capsulated. non-sporing obligate aerobes
B induce a type IV hypersensitivity reaction
A is a ~-haemolytic gram-positive ovoid diplococcus 11/

C known 'as acid and alcohol fast bacilli due to their inability to take up Gram
a re
B is resistant to optochln
stain
C Is an upper respiratory tract commensal
o cause orbital cellulitis
o is lysed by bile
E cause ulcerative keratitis
E possesses 84 different types of antigenic capsules
F a re easily destroyed by drying

9 S tre p to c o c c u s v ir id a n s is responsible for

14 Which of the following features are essential for histological diagnosis of tubercu-
losis caused by M, t u b e r c u lo s is ?
A green colonies on blood agar
B acute glomerulonephritis
A Caseation
C subacute bacterial endocarditis
B Epithelioid cells
o lobar pneumonia
C Acid-fast bacilli
E rheumatic fever
152 M ic ro b io lo g y Q u e s tio n s nmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M i c r o b i o l o g y Questions 153

D Langhan's giant cells

o C lo s tr id iu m p e r fr in g e n s is sensitive to penicillin.
E Lymphocytes
E C lo s tr id iu m te ta n i can be isolated from cerebrospinal fluid in tetanus.

PONMLKJIHGFEDCBA
Hypersensitivity in tuberculosis
1 5 M . t u b e r c u lo s is :
19 Regarding B a c illu s spp., which of the following are true?

A crosses the placental barrier

A B a c illu s a n th r a c is is a motile aerobic spore-forming rod.
B results in spread
C is associated with erythema nodosum
B B a c illu s c e r e u s is associated with panophthalmitis.
D results in enhanced caseating necrosis e Polymyxin is an antibiotic produced by an aerobic spore-forming bacillus.
E is enhanced by neonatal thymectomy o B a c illu s s u b tilis is gram negative.
E Some spore-forming bacilli produce endotoxins.

16 Which of the following statements about M y c o b a c t e r iu m t u b e r c u lo s is are true?

20 With regard to corynebacteria and actinomycete group organisms,
A M. t u b e r c u lo s is is never a commensa/ in humans.
B Past infection results in a positive Mantoux test within 48 h. A C o r y n e b a c te r iu m d ip h th e r ia e is a capsulated, motile, gram-positive aerobe
C BCG vaccine protects 80% of those vaccinated for life. B actinomyces are obligate anaerobes or microaerophilic bacteria that are corn-
D M. t u b e r c u lo s is is associated with Assman foci.
mensais of the throat and mouth
E Miliary T B is associated with a negative Mantoux test.
e A c tin o m y c e s i!r a e /i produces sulphur granules in tissues
F Mantoux test is mediated by antibodies.
o A c tin o m y c e s is r a e li is implicated as a common cause of canaliculitis
G Primary sites. of T B infection are lung, skin, tonsils and small intestine.
E N o c a r d ia a s te r o id e s is an aerobic, motile, acid-fast bacillus found in soil

17 Which of the following are intracellular organisms?

21 Which of the following bacteria produce hyaluronidase?

A M y c o b a c t e r ia
e L is t e r ia A P r o te u s

C B r u c e lla B C lo s tr id iu m p e r lr in g e n s I
o T o x o p la s m a e E s c h e r ic h ia c o li
E S a lm o n e lla o S tr e p to c o c c u s
11

F C h la m y d ia E Neisseria lil
G L e is h m a n ia F S ta p h . aureus
H R ic k e t t s ia
I N e is s e r ia
J N o c a r d ia a s t e r o id e s
22 How many of the following statements about Enterobacteriaceae are true?
K L e g io n e J / a p n e u m o p h ila

A Enterobacteriaceae are bile-soluble, gram-negative, oxidase-negative bacilli.

B E. c o li is usually a motile, lactose-fermenting, gram-negative bacillus with no
18 Which of the following statements about gram-positive bacilli are true?
urease activity.

A C lo s t r id iu m p e r lr in g e n s is a non-motile, anaerobic, spore-forming rod.

e S a lm o n e lla ty p h i is found in the liver of typhoid carriers.

e Spores do not contain mRNA. o Diagnosis of typhoid in the second week of illness is by faeces.
C C lo s t r id iu m is a comrnensal of the intestine.
p e r lr in g e n s E Salmonella species are identified by agglutination tests.
152 M ic ro b io lo g y Q u e s tio n s nmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M i c r o b i o l o g y Questions 153

D Langhan's giant cells

o C lo s tr id iu m p e r fr in g e n s is sensitive to penicillin.
E Lymphocytes
E C lo s tr id iu m te ta n i can be isolated from cerebrospinal fluid in tetanus.

PONMLKJIHGFEDCBA
Hypersensitivity in tuberculosis
1 5 M . t u b e r c u lo s is :
19 Regarding B a c illu s spp., which of the following are true?

A crosses the placental barrier

A B a c illu s a n th r a c is is a motile aerobic spore-forming rod.
B results in spread
C is associated with erythema nodosum
B B a c illu s c e r e u s is associated with panophthalmitis.
D results in enhanced caseating necrosis e Polymyxin is an antibiotic produced by an aerobic spore-forming bacillus.
E is enhanced by neonatal thymectomy o B a c illu s s u b tilis is gram negative.
E Some spore-forming bacilli produce endotoxins.

16 Which of the following statements about M y c o b a c t e r iu m t u b e r c u lo s is are true?

20 With regard to corynebacteria and actinomycete group organisms,
A M. t u b e r c u lo s is is never a commensa/ in humans.
B Past infection results in a positive Mantoux test within 48 h. A C o r y n e b a c te r iu m d ip h th e r ia e is a capsulated, motile, gram-positive aerobe
C BCG vaccine protects 80% of those vaccinated for life. B actinomyces are obligate anaerobes or microaerophilic bacteria that are corn-
D M. t u b e r c u lo s is is associated with Assman foci.
mensais of the throat and mouth
E Miliary T B is associated with a negative Mantoux test.
e A c tin o m y c e s i!r a e /i produces sulphur granules in tissues
F Mantoux test is mediated by antibodies.
o A c tin o m y c e s is r a e li is implicated as a common cause of canaliculitis
G Primary sites. of T B infection are lung, skin, tonsils and small intestine.
E N o c a r d ia a s te r o id e s is an aerobic, motile, acid-fast bacillus found in soil

17 Which of the following are intracellular organisms?

21 Which of the following bacteria produce hyaluronidase?

A M y c o b a c t e r ia
e L is t e r ia A P r o te u s

C B r u c e lla B C lo s tr id iu m p e r lr in g e n s I
o T o x o p la s m a e E s c h e r ic h ia c o li
E S a lm o n e lla o S tr e p to c o c c u s
11

F C h la m y d ia E Neisseria lil
G L e is h m a n ia F S ta p h . aureus
H R ic k e t t s ia
I N e is s e r ia
J N o c a r d ia a s t e r o id e s
22 How many of the following statements about Enterobacteriaceae are true?
K L e g io n e J / a p n e u m o p h ila

A Enterobacteriaceae are bile-soluble, gram-negative, oxidase-negative bacilli.

B E. c o li is usually a motile, lactose-fermenting, gram-negative bacillus with no
18 Which of the following statements about gram-positive bacilli are true?
urease activity.

A C lo s t r id iu m p e r lr in g e n s is a non-motile, anaerobic, spore-forming rod.

e S a lm o n e lla ty p h i is found in the liver of typhoid carriers.

e Spores do not contain mRNA. o Diagnosis of typhoid in the second week of illness is by faeces.
C C lo s t r id iu m is a comrnensal of the intestine.
p e r lr in g e n s E Salmonella species are identified by agglutination tests.
154 M ic ro b io lo g y Q u e s tio n s M ic ro b io lo g y Questions 155 nmlkjihgfedcbaZYXWVU
23 Which of the following statements about other gram-negative bacilli are true? 27 Which of the following statements about herpes simplex virus are true?

APONMLKJIHGFEDCBA
P s e u d o m o n a s a e r u g ln o s a is a motile, oxidase-positive, gram-negative bacillus. A Herpes simplex type I and 11can be differentiated by complement fixation anti-
B Pseudomonas aeruginosa produces a green pigment and antibacterial substance. body tests.
C P s e u d o m o n a s produces potent endotoxins rasponsible for its pathogenicity. B Type I infection is subclinical in 10% of those infected.
o H a e m o p h ilu s is a gram-negative bacillus that shows 'satellitism' around strep- C Giemsa stain is effective in showing eosinophilic intranuclear inclusion bodies.
tococci in mixed culture o n blood agar. o Herpes simplex virus is a double-stranded DNA virus with a helical capsid of
E H a e m o p h i/u s in flu e n z a e is a nonnal commensal of the mouth and pharynx. 100 nm in diameter.
E Type 11infection is associated with meningitis.

24 Uve attenuated vaccines are used in the prophylaxis of

28 Varicella zoster virus
A poliomyelitis
B rubella A is spread by direct contact and faeco-orally
C hepatitis A B is associated with UpschOtz bodies
o measles C can affect both motor and sensorY nerves
E smallpox o shingles may be acquired as a primary infection through vesicle contact or air-
F influenza borne transmission
G tuberculosis E complement fixation testing shows rising antibody titres in the eariy stages of
H yellow f&ver shingles
I shigella

29 Which of the following statements about cytomegalovirus are true?

2 5 C h la m y d ia
A Cytomegalovirus is associated with 'owl's eye' inclusion bodies.
A types E-K are associated with trachoma B IgM titres indicate active infection.
B is associated with Reiter's disease C Primary infection in pregnancy Is incompatible with foetal life.
C is an intracellular parasite associated with cytoplasmic inclusion bodies o Uve attenuated vaccine is available for the immunocompromised.
o does not possess a cell wall E Cytomegalovirus is present in the cervix of up to 10% of healthy women.
E type G is associated with lymphogranuloma venereum F Cytomegalovirus is infective for animals.
F possesses both RNA and DNA
G is resistant to lysosomal enzymes
H possesses outer cell walls similar to gram-negative bacteria 30 Measles

A is caused by a paramyxovirus
B live vaccine may be transmitted
26 Exotoxins
C infection is commonly associated with a secondary bacterial pneumonia

A are mostly enzyme lipopolysaccharides

o incubation is 5 -7 days
E active disease results in raised levels of IgM antibody
B are heat stable
F infection is usually subclinical
C form toxoids with ethanol
o do not usually elicit a strong antigenic response
E are produced by A s p e r g illu s fla v u s
154 M ic ro b io lo g y Q u e s tio n s M ic ro b io lo g y Questions 155 nmlkjihgfedcbaZYXWVU
23 Which of the following statements about other gram-negative bacilli are true? 27 Which of the following statements about herpes simplex virus are true?

APONMLKJIHGFEDCBA
P s e u d o m o n a s a e r u g ln o s a is a motile, oxidase-positive, gram-negative bacillus. A Herpes simplex type I and 11can be differentiated by complement fixation anti-
B Pseudomonas aeruginosa produces a green pigment and antibacterial substance. body tests.
C P s e u d o m o n a s produces potent endotoxins rasponsible for its pathogenicity. B Type I infection is subclinical in 10% of those infected.
o H a e m o p h ilu s is a gram-negative bacillus that shows 'satellitism' around strep- C Giemsa stain is effective in showing eosinophilic intranuclear inclusion bodies.
tococci in mixed culture o n blood agar. o Herpes simplex virus is a double-stranded DNA virus with a helical capsid of
E H a e m o p h i/u s in flu e n z a e is a nonnal commensal of the mouth and pharynx. 100 nm in diameter.
E Type 11infection is associated with meningitis.

24 Uve attenuated vaccines are used in the prophylaxis of

28 Varicella zoster virus
A poliomyelitis
B rubella A is spread by direct contact and faeco-orally
C hepatitis A B is associated with UpschOtz bodies
o measles C can affect both motor and sensorY nerves
E smallpox o shingles may be acquired as a primary infection through vesicle contact or air-
F influenza borne transmission
G tuberculosis E complement fixation testing shows rising antibody titres in the eariy stages of
H yellow f&ver shingles
I shigella

29 Which of the following statements about cytomegalovirus are true?

2 5 C h la m y d ia
A Cytomegalovirus is associated with 'owl's eye' inclusion bodies.
A types E-K are associated with trachoma B IgM titres indicate active infection.
B is associated with Reiter's disease C Primary infection in pregnancy Is incompatible with foetal life.
C is an intracellular parasite associated with cytoplasmic inclusion bodies o Uve attenuated vaccine is available for the immunocompromised.
o does not possess a cell wall E Cytomegalovirus is present in the cervix of up to 10% of healthy women.
E type G is associated with lymphogranuloma venereum F Cytomegalovirus is infective for animals.
F possesses both RNA and DNA
G is resistant to lysosomal enzymes
H possesses outer cell walls similar to gram-negative bacteria 30 Measles

A is caused by a paramyxovirus
B live vaccine may be transmitted
26 Exotoxins
C infection is commonly associated with a secondary bacterial pneumonia

A are mostly enzyme lipopolysaccharides

o incubation is 5 -7 days
E active disease results in raised levels of IgM antibody
B are heat stable
F infection is usually subclinical
C form toxoids with ethanol
o do not usually elicit a strong antigenic response
E are produced by A s p e r g illu s fla v u s
156 M ic ro b io lo g y QuestionsnmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M ic ro b io lo g y Questions 157

31 Epstein-Barr virus
F is associated with a T cell-mediated immune response
A is associated with nasophalyngeal carcinoma and Burkitt's lymphoma G causes a subclinical infection with full recovery in 65% of those Infected
B is a double-stranded RNA virus
C specific antibodies in active disease are directed against the capsid
o past infection is indicated by antibodies to nuclear antigens 36 Hepatitis C
E is transmitted by the mosquito
A is a single-stranded RNA virus
B is associated with post-transfusion hepatitis
32 Rubella C is not associated with hepatoma
D causes chronic hepatitis in 50% of those infected
A infection is associated with suboccipital lymphadenopathy E is diagnosed by serology
B primary infection in pregnancy is associated with congenital cataracts F incubation is up to five months
C is a DNA togavirus easily killed by heat and UV light
o incubation period is 7 days
E maximum infectivity is during the time the rash is present
37 Human immunodeficiency virus (HIV)

33 Adenovirus A is a lentivirus
B is a double-stranded RNA retrovirus
C binds to CD4+ cells via the gp41 envelope protein
A is an RNA virus
o contains the enzymes protease and integrase
B has more than 40 different serotypes
E results in apoptosis of T helper cells
C Infection is associated with a neutrophil followed by a mononuclear cell response
F results in increased levels of interleukin 2
o is associated with pharyngitis and latent tonsillar infection
G can be isolated from blood
E is heat resistant
H infection is associated with hypergammaglobulinaemia

34 Hepatitis A
38 Ocular complications of HN include
A infection is often subclinical
B virus can be seen in stool during clinical illness A CMV retinitis
C is a 28 nm DNA virus B increased risk of, intraocular lymphoma
o past infection is indicated by IgG antibody titres C increased risk of herpes zoster ophthalmicus
E infection can result in chronic hepatitis o increased risk of cryptococcus choroiditis
F is associated with carrier status E conjunctival Kaposi's sarcoma
G is associated with an increased risk of developing hepatoma

35 Hepatitis B 39 PONMLKJIHGFEDCBA
A s p e r g illu s

A virus disappears from the blood with the onset of jaundice A is a yeast
B produces heat- and chemical-resistant spores
B vaccine consists of core antigen
C may be found in TB lung cavities
C virus can be cultured from serum
o is associated with a type I hypersensitivity reaction
o 'e' antigen is initially present in all cases of acute hepatitis B
E is found routinely in 15% of persons with chronic lung disease
E is a DNA virus
F is associated with eosinophilia
156 M ic ro b io lo g y QuestionsnmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M ic ro b io lo g y Questions 157

31 Epstein-Barr virus
F is associated with a T cell-mediated immune response
A is associated with nasophalyngeal carcinoma and Burkitt's lymphoma G causes a subclinical infection with full recovery in 65% of those Infected
B is a double-stranded RNA virus
C specific antibodies in active disease are directed against the capsid
o past infection is indicated by antibodies to nuclear antigens 36 Hepatitis C
E is transmitted by the mosquito
A is a single-stranded RNA virus
B is associated with post-transfusion hepatitis
32 Rubella C is not associated with hepatoma
D causes chronic hepatitis in 50% of those infected
A infection is associated with suboccipital lymphadenopathy E is diagnosed by serology
B primary infection in pregnancy is associated with congenital cataracts F incubation is up to five months
C is a DNA togavirus easily killed by heat and UV light
o incubation period is 7 days
E maximum infectivity is during the time the rash is present
37 Human immunodeficiency virus (HIV)

33 Adenovirus A is a lentivirus
B is a double-stranded RNA retrovirus
C binds to CD4+ cells via the gp41 envelope protein
A is an RNA virus
o contains the enzymes protease and integrase
B has more than 40 different serotypes
E results in apoptosis of T helper cells
C Infection is associated with a neutrophil followed by a mononuclear cell response
F results in increased levels of interleukin 2
o is associated with pharyngitis and latent tonsillar infection
G can be isolated from blood
E is heat resistant
H infection is associated with hypergammaglobulinaemia

34 Hepatitis A
38 Ocular complications of HN include
A infection is often subclinical
B virus can be seen in stool during clinical illness A CMV retinitis
C is a 28 nm DNA virus B increased risk of, intraocular lymphoma
o past infection is indicated by IgG antibody titres C increased risk of herpes zoster ophthalmicus
E infection can result in chronic hepatitis o increased risk of cryptococcus choroiditis
F is associated with carrier status E conjunctival Kaposi's sarcoma
G is associated with an increased risk of developing hepatoma

35 Hepatitis B 39 PONMLKJIHGFEDCBA
A s p e r g illu s

A virus disappears from the blood with the onset of jaundice A is a yeast
B produces heat- and chemical-resistant spores
B vaccine consists of core antigen
C may be found in TB lung cavities
C virus can be cultured from serum
o is associated with a type I hypersensitivity reaction
o 'e' antigen is initially present in all cases of acute hepatitis B
E is found routinely in 15% of persons with chronic lung disease
E is a DNA virus
F is associated with eosinophilia
 M ic ro b io lo g y Q u e s tio n s
158nmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
40 candida
MICROBIOLOGY
A is a mucocutaneous yeast
B grows on blood agar
Answers
C infection resulting in vaginal candidosis is associated with the oral contracePtive

pill
o is unicellular and grows by budding 1 A = True 8 = True C = True 0 = True E = True
E is the commonest cause of fungal endophthalmitis
All of the organisms listed have been isolated as 00tma1flora of the skin of the eyelids
and conjunctiva
41 The protozoan:PONMLKJIHGFEDCBA
A c a n th a m o e b a

A is found in mains water supply 2 A = True B = True C = True 0 = True E = True

B forms pH-, chemical- and temperature-resistant cysts
C is sensitive to chlomexidine See notes on Microbiology Question 5:

o causes uveitis
E is a parasitic amoeba
3 A = False B = False e = True 0 = True E = True

42 Surgical gloves can be sterilised by See notes on Microbiology Question 5.

A dry heat at 130"C

4 A = False B = True C = True 0 = True E = True
B gamma radiation
C UV radiation
See notes on Microbiology Question 5.
o chlorhexidine
E steam at 130"C

5 A = True B = True C = True 0 = True E = True

43 Osteomyelitis is caused by Staphylococci are gram-positive aerobic or tacultatively anaerobic bacteria found in
grape-like clusters. They are catalase positive and so cause hydrogen peroxide (H:Pv
A Brucella a b o r tu s to bubble when in contact on a slide. The coagulase test where fibrinogen is coagulated
B B o r d e te l/a p e r tu s s is to fibrin differentiates S ta p h . aureus (coagulase positive) from coagulase-negative
C amyloid staphylococci. including S ta p h . e p id e tm id ls (novobiocin sensitive), S ta p h . s a p r o p h y ti-
o StaphylOCOCCusa u r 8 U S cus (novobiocin resistant). staphylococci do not require special media to be cultured.
E S a lm o n e lla typhi S ta p h . aunsus is a nasal and skin cornmensal and is usually spread directly or
indirectly (by hospital stafI). Spread by air can occur due to some survival against
immediate drying. Strains can be characterized by bacteriophage-typing. S ta p h . a u r -
80S produces many toxins, including:

• protein A (antiphagocytic complement-inhibiting protein that binds the Fc portion of

19G),
• haemolysigs a, 1 3 and t.
• leucocidin. an antipolymorph toxin,
 M ic ro b io lo g y Q u e s tio n s
158nmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
40 candida
MICROBIOLOGY
A is a mucocutaneous yeast
B grows on blood agar
Answers
C infection resulting in vaginal candidosis is associated with the oral contracePtive

pill
o is unicellular and grows by budding 1 A = True 8 = True C = True 0 = True E = True
E is the commonest cause of fungal endophthalmitis
All of the organisms listed have been isolated as 00tma1flora of the skin of the eyelids
and conjunctiva
41 The protozoan:PONMLKJIHGFEDCBA
A c a n th a m o e b a

A is found in mains water supply 2 A = True B = True C = True 0 = True E = True

B forms pH-, chemical- and temperature-resistant cysts
C is sensitive to chlomexidine See notes on Microbiology Question 5:

o causes uveitis
E is a parasitic amoeba
3 A = False B = False e = True 0 = True E = True

42 Surgical gloves can be sterilised by See notes on Microbiology Question 5.

A dry heat at 130"C

4 A = False B = True C = True 0 = True E = True
B gamma radiation
C UV radiation
See notes on Microbiology Question 5.
o chlorhexidine
E steam at 130"C

5 A = True B = True C = True 0 = True E = True

43 Osteomyelitis is caused by Staphylococci are gram-positive aerobic or tacultatively anaerobic bacteria found in
grape-like clusters. They are catalase positive and so cause hydrogen peroxide (H:Pv
A Brucella a b o r tu s to bubble when in contact on a slide. The coagulase test where fibrinogen is coagulated
B B o r d e te l/a p e r tu s s is to fibrin differentiates S ta p h . aureus (coagulase positive) from coagulase-negative
C amyloid staphylococci. including S ta p h . e p id e tm id ls (novobiocin sensitive), S ta p h . s a p r o p h y ti-
o StaphylOCOCCusa u r 8 U S cus (novobiocin resistant). staphylococci do not require special media to be cultured.
E S a lm o n e lla typhi S ta p h . aunsus is a nasal and skin cornmensal and is usually spread directly or
indirectly (by hospital stafI). Spread by air can occur due to some survival against
immediate drying. Strains can be characterized by bacteriophage-typing. S ta p h . a u r -
80S produces many toxins, including:

• protein A (antiphagocytic complement-inhibiting protein that binds the Fc portion of

19G),
• haemolysigs a, 1 3 and t.
• leucocidin. an antipolymorph toxin,
158
M ic r o b io lo g y QuestionsqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
MICROBIOLOGY
40 candida
Answers
A is a mucocutaneous yeast
B grows on blood agar
C infection resulting in vaginal candidosis is associated with the oral contraceptive 1 A = True B = True C = True D = True E = True
pill
o is unicellular and grows by budding All of the organisms listed have been isolated as rbmal flora of the skin of the eyelids
E is the commonest cause of fungal endophthalmitis and conjunctiva.

41 The protozoan:AA c a n th a m o e b a 2 A = True B = True C = True D = True E = True

See notes on Microbiology Question 5:

A is found in mains water supply
B forms pH-, chemical- and temperature-resistant cysts •
C Is sensitive to chloltlexidine
o causes uveitis 3 A = False B = False C = True D = True E = True
E is a parasitic amoeba
See notes on Microbiology Question 5.

4 2 Surgical gloves can be sterilised by

4 A = False B = True C = True 0 = True E = True
A dry heat at 130"C
See notes on Microbiology Question 5.
B gamma radiatlon
C U V radiation
o chlorhexidine
5 A = True B = True C = True D = True E = True
E steam at 1 3 0 · C

Staphylococci are gram-positive aerobic or facultatively anaerobic bacteria found in

grape-like clusters. They are catalase positive and so cause hydrogen peroxide (H20V
43 Osteomyelitis is caused by to bubble when in contact on a slide. The coagulase test whera fibrinogen is coagulated
to fibrin differentiates S ts p h . aureus (coagulase positive) from coagulase-negative
A B ru c e lla abortus staphylococci, including S ta p h . epidermicJs (novobiocin sensitive), S t a p h . s a p r o p h y ti-
B B o rd e te lla pertussis cus (novobiocin resistant). Staphylococci do not require special media to be cultured.
Carnyloid S ta p h . aureus is a nasal and skin cornmensal and is usually spread directly or
o Staphylococcus a u re u s indirectly (by hospital staff). Spread by air can occur due to some survival against
E Salmonella ty p h i immediate drying. Strains can be characterized by bacteriophage-typing. S t a p h . sur-
eus produces many toxins, including:

• protein A (antiphagocytic complement-inhibiting protein that binds the Fc portion of

19G),
• haemolysins a, ~ and y,
• leucocidin, an anti polymorph toxin,
158
M ic r o b io lo g y QuestionsqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
MICROBIOLOGY
40 candida
Answers
A is a mucocutaneous yeast
B grows on blood agar
C infection resulting in vaginal candidosis is associated with the oral contraceptive 1 A = True B = True C = True D = True E = True
pill
o is unicellular and grows by budding All of the organisms listed have been isolated as rbmal flora of the skin of the eyelids
E is the commonest cause of fungal endophthalmitis and conjunctiva.

41 The protozoan:AA c a n th a m o e b a 2 A = True B = True C = True D = True E = True

See notes on Microbiology Question 5:

A is found in mains water supply
B forms pH-, chemical- and temperature-resistant cysts •
C Is sensitive to chloltlexidine
o causes uveitis 3 A = False B = False C = True D = True E = True
E is a parasitic amoeba
See notes on Microbiology Question 5.

4 2 Surgical gloves can be sterilised by

4 A = False B = True C = True 0 = True E = True
A dry heat at 130"C
See notes on Microbiology Question 5.
B gamma radiatlon
C U V radiation
o chlorhexidine
5 A = True B = True C = True D = True E = True
E steam at 1 3 0 · C

Staphylococci are gram-positive aerobic or facultatively anaerobic bacteria found in

grape-like clusters. They are catalase positive and so cause hydrogen peroxide (H20V
43 Osteomyelitis is caused by to bubble when in contact on a slide. The coagulase test whera fibrinogen is coagulated
to fibrin differentiates S ts p h . aureus (coagulase positive) from coagulase-negative
A B ru c e lla abortus staphylococci, including S ta p h . epidermicJs (novobiocin sensitive), S t a p h . s a p r o p h y ti-
B B o rd e te lla pertussis cus (novobiocin resistant). Staphylococci do not require special media to be cultured.
Carnyloid S ta p h . aureus is a nasal and skin cornmensal and is usually spread directly or
o Staphylococcus a u re u s indirectly (by hospital staff). Spread by air can occur due to some survival against
E Salmonella ty p h i immediate drying. Strains can be characterized by bacteriophage-typing. S t a p h . sur-
eus produces many toxins, including:

• protein A (antiphagocytic complement-inhibiting protein that binds the Fc portion of

19G),
• haemolysins a, ~ and y,
• leucocidin, an anti polymorph toxin,
 M ic ro b io lo g y M ic ro b io lo g y Answers
AnswersqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 161
160

other enriched media). Many are commensals as well as pathogens. Classification is

• enterotoxlns, heat-stable and enzyme-stable proteins that resist 30 mln of boiling as
based on their appearance on blood agar.
well as the action of gut enzymes, produced mainly by bacteriophage group III
~-Haemolytic streptococci produce a soluble haemolysin that leaves a clear zone
strains when grown in carbohydrate and protein foods such as rice, act on vomiting
after complete lysis of media blood cells. Further serological subdivision of J3-haemo-
centre of brain to induce vomiting 'staphylococcal food poisoning',
lytic streptococci is by the Lancefield classification (A, B, C, D, etc.) based on the cell
• coagulase, a fibrin-depositing enzyme inhibiting leukocyte migration and causing
wall polysaccharide antigens. p-Haemolytic streptococci can also be subdivided by
localization, their in v itr o sensitivity to bacitracin. S tr e p t. p y o g e n e s (Lancefield group A) is sensitive
• hyaluronidase, an enzyme that breaks down hyaluronic acid and allows it to spread
to bacitracin whereas Lancefield group B (gut and vaginal commensal, causes infection
through connective tissue,
in new-bom including septicaemia and meningitis), groups C and D (wound infections
• epidermolytic toxins A and B epidermis-splitting and blister-forming toxins that
and sore throats) are resistant to bacitracin.
cause 'scalded skin' - Ritter-lyeU's disease, and
fl-Haemolytic streptococci including S tr e p t. pneumoniae (optochin sensitive) and
• TSS Toxin I, which causes 'toxic shock syndrome', a multiorgan disease and state of
S tr e p t. v ir id a n s (optochin resistant) produce a zone of partial haemolysis around
acute shock due to septicaemia. The commonest cause is a retained foreign body
each colony (they do not possess haemolysin) with a green zone around each colony
such as an Infected tampon or IUCD.
due to reduction of h~oglobin.
Infections due to Staphylococcus Aa u r e u s include abscess, impetigo, paronychia, S tr e p t. pyogenes is a fl-haemolytic Lancefield group A streptococcus that can be
wound infection, osteomyelitis, endocarditis (usually right heart especially in intrave- further subtyped by Grifflths typing (M; R, T) based o n the surface antigen M protein
nous drug abusers), septicaemia, pyaemia, pneumonia (usually secondary to Influenza), indicating virulence, It is a commensal of the throat in up to 25% of the population and
food poisoning and specific toxin-related diseases (see above). of the nose in up to 4% of the population. Toxins produced include streptokinase,
streptolysin 0 (oxygen-labile haemolysin) and streptolysin S (oxygen stable), hyaluro-
nidase, erythrogenic toxin (scarlet fever - Dick test - toxin antibodies diagnostic for
immunity), DNAase and leucocidin.
6 A = False B = TNe C = False 0 = False E = TNe
A l l allergic response to Strepf. p y o g e n e s infection can result in rheumatic fever or
glomeNlonephritis.
See notes on Microbiology Question 10.
Strept. v ir id a n s is a j}-haemolytic commensal of the mouth. It produces a green zone
of haemolysis around colonies on blood agar. It is associated with subacute bacterial
endocarditis on damaged heart valves only when introduced into the blood.
7 A = False B = False C = TNe 0 = TNe E = False S tr a p t. p n e u m o n ia e (pneumococcus) is a p-haemolytic gram-positive diplococcus.
Sensitivity to optochin is an important feature as 24 h cultures do not easily differenti-
See notes on Microbiology Question 10.
ate it from other p-haernolytic streptococci. It is lysed by bile and is described as being
bile soluble. It Is encapsulated with up to 84 different antigenic types including C
substance and M antigen. The pneumococcus is found in the upper respiratory tract
8 A = TNe B = False C = True 0 = TNe E = True as a commensal of the pharynx. Infections include bronchopneumonia and lobar
pneumonia, sinusitus, otitis media and meningitis.
See notes on Microbiology Question 10.

11 A = False B = TNe C = False 0 = TNe E = False

9 A = False 8 = False C = TNe D = False E = False
See notes on Microbiology Question 12.
See notes on Microbiology Question 10.

12 A = True B = True C = False 0 = False E = TNe

10 A = TNe B = TNe C = True 0 = False E = TNe

N e is s e r ia m e n in g itid is and N e is s e r ia g o n o r r llo e a e are gram-negative strict aerobic
Streptococci are gram-positive cocci, catalase negative (staphylococci are catalase cocci found in pairs in polymorphs (not Iymphocytes). They are oxidase positive and
positive), mainly facultative anaerobes or aerobes, and prefer to grow on blood agar (or ferment carbohydrates. Neisseria gonorrhoeae ferments glucose only and N e is s e r ia
 M ic ro b io lo g y M ic ro b io lo g y Answers
AnswersqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 161
160

other enriched media). Many are commensals as well as pathogens. Classification is

• enterotoxlns, heat-stable and enzyme-stable proteins that resist 30 mln of boiling as
based on their appearance on blood agar.
well as the action of gut enzymes, produced mainly by bacteriophage group III
~-Haemolytic streptococci produce a soluble haemolysin that leaves a clear zone
strains when grown in carbohydrate and protein foods such as rice, act on vomiting
after complete lysis of media blood cells. Further serological subdivision of J3-haemo-
centre of brain to induce vomiting 'staphylococcal food poisoning',
lytic streptococci is by the Lancefield classification (A, B, C, D, etc.) based on the cell
• coagulase, a fibrin-depositing enzyme inhibiting leukocyte migration and causing
wall polysaccharide antigens. p-Haemolytic streptococci can also be subdivided by
localization, their in v itr o sensitivity to bacitracin. S tr e p t. p y o g e n e s (Lancefield group A) is sensitive
• hyaluronidase, an enzyme that breaks down hyaluronic acid and allows it to spread
to bacitracin whereas Lancefield group B (gut and vaginal commensal, causes infection
through connective tissue,
in new-bom including septicaemia and meningitis), groups C and D (wound infections
• epidermolytic toxins A and B epidermis-splitting and blister-forming toxins that
and sore throats) are resistant to bacitracin.
cause 'scalded skin' - Ritter-lyeU's disease, and
fl-Haemolytic streptococci including S tr e p t. pneumoniae (optochin sensitive) and
• TSS Toxin I, which causes 'toxic shock syndrome', a multiorgan disease and state of
S tr e p t. v ir id a n s (optochin resistant) produce a zone of partial haemolysis around
acute shock due to septicaemia. The commonest cause is a retained foreign body
each colony (they do not possess haemolysin) with a green zone around each colony
such as an Infected tampon or IUCD.
due to reduction of h~oglobin.
Infections due to Staphylococcus Aa u r e u s include abscess, impetigo, paronychia, S tr e p t. pyogenes is a fl-haemolytic Lancefield group A streptococcus that can be
wound infection, osteomyelitis, endocarditis (usually right heart especially in intrave- further subtyped by Grifflths typing (M; R, T) based o n the surface antigen M protein
nous drug abusers), septicaemia, pyaemia, pneumonia (usually secondary to Influenza), indicating virulence, It is a commensal of the throat in up to 25% of the population and
food poisoning and specific toxin-related diseases (see above). of the nose in up to 4% of the population. Toxins produced include streptokinase,
streptolysin 0 (oxygen-labile haemolysin) and streptolysin S (oxygen stable), hyaluro-
nidase, erythrogenic toxin (scarlet fever - Dick test - toxin antibodies diagnostic for
immunity), DNAase and leucocidin.
6 A = False B = TNe C = False 0 = False E = TNe
A l l allergic response to Strepf. p y o g e n e s infection can result in rheumatic fever or
glomeNlonephritis.
See notes on Microbiology Question 10.
Strept. v ir id a n s is a j}-haemolytic commensal of the mouth. It produces a green zone
of haemolysis around colonies on blood agar. It is associated with subacute bacterial
endocarditis on damaged heart valves only when introduced into the blood.
7 A = False B = False C = TNe 0 = TNe E = False S tr a p t. p n e u m o n ia e (pneumococcus) is a p-haemolytic gram-positive diplococcus.
Sensitivity to optochin is an important feature as 24 h cultures do not easily differenti-
See notes on Microbiology Question 10.
ate it from other p-haernolytic streptococci. It is lysed by bile and is described as being
bile soluble. It Is encapsulated with up to 84 different antigenic types including C
substance and M antigen. The pneumococcus is found in the upper respiratory tract
8 A = TNe B = False C = True 0 = TNe E = True as a commensal of the pharynx. Infections include bronchopneumonia and lobar
pneumonia, sinusitus, otitis media and meningitis.
See notes on Microbiology Question 10.

11 A = False B = TNe C = False 0 = TNe E = False

9 A = False 8 = False C = TNe D = False E = False
See notes on Microbiology Question 12.
See notes on Microbiology Question 10.

12 A = True B = True C = False 0 = False E = TNe

10 A = TNe B = TNe C = True 0 = False E = TNe

N e is s e r ia m e n in g itid is and N e is s e r ia g o n o r r llo e a e are gram-negative strict aerobic
Streptococci are gram-positive cocci, catalase negative (staphylococci are catalase cocci found in pairs in polymorphs (not Iymphocytes). They are oxidase positive and
positive), mainly facultative anaerobes or aerobes, and prefer to grow on blood agar (or ferment carbohydrates. Neisseria gonorrhoeae ferments glucose only and N e is s e r ia
162
M ic ro b io lo g y AnswersA M ic ro b io lo g y Answers 163

m e n in g itld is qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ferments both glucose and maltose. Neither of them ferment sucrose. 15 A = False B = False C = True D,. True E = False
They grow best on chocolate agar (heated blood agar) with increased carbon dioxide
levels. Hypersensitivity to TB is a type IV granulomatous reaction. Cell-mediated immunity
Neisseriae are capsulated and do not produce exotoxlns, but have outer pill and does not cross the piacental barrier. The reaction results In an aggressive immune
membrane proteins such as proteases that allow attachment and bfeakdoWl'l of anti- response, inhibiting spread of the organism and resulting in greater caseating necrosis,
bodies such as IgA to allow invasion as well as an endotoxin effect due to lipopoly- perhaps accompanied by constitutional symptoms. Erythema nodosum is a skin man-
saccharide. This endotoxin effect is a major factor of virulence. ifestation of TB hypersensitivity. Neonatal thymectomy reduces the body's ability to
Neisseria meningitidis is a parasite of the nasopharynx in asymptomatic carriers. It mount a strong T cell-mediated immune response.
further invades in susceptible children or young adults Into the blood and possibly the
meninges and CSF. Serum antibodies in most adults 8/'9 protective in preventing
septicaemia and meningitis. Serotyping has shown type A to be associated with major 16 A = True B = False C = False D = True E = True F = False G = False
epidemics and Band C to be sporadic cases.
N e is s e ria gonorrlloeae is responsible for gonorrtloeal ophthalmia neonatorum. Diag- M. tu b e r c u lo s is is never a commensal in humans. It is an intracellular infection. It is
nosis is established by microscopy and cultures. Thayer-Martin medium inhibits over- phagocytosed in macrophages and resists destruction by Intracellular enzymes. It is
growth of unwanted organisms and so is more useful in isolating N e is s e r ia gotIOIThoeae thus protected from Circulating antibodies and is controlled by T cell-mediated immu-
from genitourinary samples rather than ocular culture samples. Topical erythromycin or nity. Infection can be acquired by inhalation, ingestion and inoculation. Primary sites of
silver nitrate is effective as treatment, as 8/'9 systemic antibiotics such as erythromycin, infection include lung, tonsils and skin.
peniclllins or third-generation cephalosporins. Primary infection of pulmonary tuberculosis (childhood type) begins either in the
basal segment of the upper lobe or in the apical segment of the lower lobe as a GOOn's
focus. Once macrophage migration causes hilar lymph node enlargement, the resultant
combination is called a Ghon's complex. These usually heal with dystrophic calcifica-
13 A = True B = True C = False D = True E = True F = True G = False tion, but may spread via bronchi (open TB, haemoptysis) or haematogenously, resulting
in multiple granulomatous foci (miliary tuberculosis). Thl$ is usually found in immune-
Mycobacteria are non-motile, non-sporing, non-capsulated obligate aerobic bacilli. suppressed patients with a reduced hypersensitivity response.
They have a waxy cell wall that does not take up Gram stain. They are known as Pulmonary tuberculosis in adults usually affects the upper lobe subapical segment,
acid-fast bacilli (AFB) or, more accurately, acid- and alcohol-fast bacilli (AAFB) because referred to as an Assmann's focus. This may heal with scarring or cavitate involving
after staining with hot, strong, carbol fuchsin the stain is retained despite attempts to either the bronchus (broncopneumonia, open TB, haemoptysis) or pleura (pleural
remove it with a mixture of mineral acid and alcohol (Ziehl-Neelsen stain, ZN). effusions) .
They have very slow generation times and require enriched media. M. tuberculosis TB spread may reach the Peyer's patches of the small intestine through swallowing
grows on Lowenstein-Jensen medium. Atypical mycobacteria such as M. fo r tu /tu m of coughed material (intestinal obstruction).
grow on blood agar. M. le p r a e as yet cannot be cultured on artificial media. The bacille Calmette-Guerin (BCG) vaccine Is a live attenuated vaccine and protects
They are resistant to drying and can survive for weeks in dust. Mycobacteria induce a 80% of those vaccinated for 10 years.
slowly progressive chronic type r.t granulomatous hypersensitivity reaction. Immunodiagnosis is based on injecting a purified protein derivative intradermaliy in
Ocular manifestations of mycobacteria infection include phlyctenular keratitis (M. order to elicit a cell-mediated hypersensitivity response between 48 and 72 h. (Man-
tuberculosis), interstitial keratitis, ulcerative keratitis, orbital cellulitis and the ocular toux = syringe and needle, Heaf = spring-loaded six-needle gun). A positive Mantoux
features of leprosy (Hansen's disease-M. /eprae) such as conjunctivitis. episcleritis, test indicates past infection either by M. tuberculosis or a live attenuated BCG vaccine.
corneal anaesthesia, keratitis, scleritis and iritis (the commonest cause of blindness Miliary TB is usually seen In the Immunosuppressed and is thus associated with a
due to leprosy). negative Mantoux test.

17 A = True B = True C = True D = True E = True F = True G = True

14 A = False B = False C = True D = False E = False H = True I = True J = True K = True

Although the above five are features of tuberculosis, only the presence of acid-fast The organisms listed are engulfed by macrophages or neutrophils and remain Intracel-
bacilli is essential fer the diagnosis. lular, resisting destruction by intracellular enzymes.
162
M ic ro b io lo g y AnswersA M ic ro b io lo g y Answers 163

m e n in g itld is qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ferments both glucose and maltose. Neither of them ferment sucrose. 15 A = False B = False C = True D,. True E = False
They grow best on chocolate agar (heated blood agar) with increased carbon dioxide
levels. Hypersensitivity to TB is a type IV granulomatous reaction. Cell-mediated immunity
Neisseriae are capsulated and do not produce exotoxlns, but have outer pill and does not cross the piacental barrier. The reaction results In an aggressive immune
membrane proteins such as proteases that allow attachment and bfeakdoWl'l of anti- response, inhibiting spread of the organism and resulting in greater caseating necrosis,
bodies such as IgA to allow invasion as well as an endotoxin effect due to lipopoly- perhaps accompanied by constitutional symptoms. Erythema nodosum is a skin man-
saccharide. This endotoxin effect is a major factor of virulence. ifestation of TB hypersensitivity. Neonatal thymectomy reduces the body's ability to
Neisseria meningitidis is a parasite of the nasopharynx in asymptomatic carriers. It mount a strong T cell-mediated immune response.
further invades in susceptible children or young adults Into the blood and possibly the
meninges and CSF. Serum antibodies in most adults 8/'9 protective in preventing
septicaemia and meningitis. Serotyping has shown type A to be associated with major 16 A = True B = False C = False D = True E = True F = False G = False
epidemics and Band C to be sporadic cases.
N e is s e ria gonorrlloeae is responsible for gonorrtloeal ophthalmia neonatorum. Diag- M. tu b e r c u lo s is is never a commensal in humans. It is an intracellular infection. It is
nosis is established by microscopy and cultures. Thayer-Martin medium inhibits over- phagocytosed in macrophages and resists destruction by Intracellular enzymes. It is
growth of unwanted organisms and so is more useful in isolating N e is s e r ia gotIOIThoeae thus protected from Circulating antibodies and is controlled by T cell-mediated immu-
from genitourinary samples rather than ocular culture samples. Topical erythromycin or nity. Infection can be acquired by inhalation, ingestion and inoculation. Primary sites of
silver nitrate is effective as treatment, as 8/'9 systemic antibiotics such as erythromycin, infection include lung, tonsils and skin.
peniclllins or third-generation cephalosporins. Primary infection of pulmonary tuberculosis (childhood type) begins either in the
basal segment of the upper lobe or in the apical segment of the lower lobe as a GOOn's
focus. Once macrophage migration causes hilar lymph node enlargement, the resultant
combination is called a Ghon's complex. These usually heal with dystrophic calcifica-
13 A = True B = True C = False D = True E = True F = True G = False tion, but may spread via bronchi (open TB, haemoptysis) or haematogenously, resulting
in multiple granulomatous foci (miliary tuberculosis). Thl$ is usually found in immune-
Mycobacteria are non-motile, non-sporing, non-capsulated obligate aerobic bacilli. suppressed patients with a reduced hypersensitivity response.
They have a waxy cell wall that does not take up Gram stain. They are known as Pulmonary tuberculosis in adults usually affects the upper lobe subapical segment,
acid-fast bacilli (AFB) or, more accurately, acid- and alcohol-fast bacilli (AAFB) because referred to as an Assmann's focus. This may heal with scarring or cavitate involving
after staining with hot, strong, carbol fuchsin the stain is retained despite attempts to either the bronchus (broncopneumonia, open TB, haemoptysis) or pleura (pleural
remove it with a mixture of mineral acid and alcohol (Ziehl-Neelsen stain, ZN). effusions) .
They have very slow generation times and require enriched media. M. tuberculosis TB spread may reach the Peyer's patches of the small intestine through swallowing
grows on Lowenstein-Jensen medium. Atypical mycobacteria such as M. fo r tu /tu m of coughed material (intestinal obstruction).
grow on blood agar. M. le p r a e as yet cannot be cultured on artificial media. The bacille Calmette-Guerin (BCG) vaccine Is a live attenuated vaccine and protects
They are resistant to drying and can survive for weeks in dust. Mycobacteria induce a 80% of those vaccinated for 10 years.
slowly progressive chronic type r.t granulomatous hypersensitivity reaction. Immunodiagnosis is based on injecting a purified protein derivative intradermaliy in
Ocular manifestations of mycobacteria infection include phlyctenular keratitis (M. order to elicit a cell-mediated hypersensitivity response between 48 and 72 h. (Man-
tuberculosis), interstitial keratitis, ulcerative keratitis, orbital cellulitis and the ocular toux = syringe and needle, Heaf = spring-loaded six-needle gun). A positive Mantoux
features of leprosy (Hansen's disease-M. /eprae) such as conjunctivitis. episcleritis, test indicates past infection either by M. tuberculosis or a live attenuated BCG vaccine.
corneal anaesthesia, keratitis, scleritis and iritis (the commonest cause of blindness Miliary TB is usually seen In the Immunosuppressed and is thus associated with a
due to leprosy). negative Mantoux test.

17 A = True B = True C = True D = True E = True F = True G = True

14 A = False B = False C = True D = False E = False H = True I = True J = True K = True

Although the above five are features of tuberculosis, only the presence of acid-fast The organisms listed are engulfed by macrophages or neutrophils and remain Intracel-
bacilli is essential fer the diagnosis. lular, resisting destruction by intracellular enzymes.
164 M ic ro b io lo g y AnswersqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M i c r o b i o l o g y Answers
165
18 A = True B = True C = True 0 = True E = False
21 A = False B = True C = True D = True E = False F = True

Clostidia are spore-forming, anaerobic, gram-positive rods. Spores are formed to allow
a donnant existence in suboptimal conditions. Spores consist of a cysteine-rich kera- Not all S tr e p to c o c c u s species produce hyaluronidase.
tin-like cortex, some cytoplasm, double-stranded DNA. ribosomes and tANA but no
mRNA. They are resistant to heat, chemicals and drying and do not reproduce or have
any metabolism. They are produced by A
C lo s tr id iu m and B a c illu s species. Clostridia are 22 A = False B = True C = False D = True E = True
mostly soil saprophytes. C lo s tr id iu m p e r lr in g e n s is a non-motile anaerobic spore-
forming rod and a commensal of the intestine. There are six types (A-F) depending
See notes on Microbiology Question 2 3 .
on exotoxins produced. Type A is associated with gas gangrene and produces I3-toxin
Oecithlnase) as well as collagenase, hyaluronidase, and deoxyribonuclease.
C lo s tr id iu m p e r fr fn g e n s is sensitive to penicillin. Treatment of gas gangrene includes
surgical debridement. hyperbaric oxygen, penicillin and antitoxin against I3-toxin. 23 A = True B = True C = False D = False E = True
C lo s tr iu m tetani is motile. Infection is usually by the spherical terminal 'drumstick'
spores. It is usually present in animal intestines as well as soil and dust. It produces Enterobacteriaceae are bile-tolerant, gram-negative, oxidase-negative bacilli. E . c o li is
exotoxlns that act on the CNS causing tonic spasm of voluntary muscles, eventually
a motile, lactos~fermenting, gram-negative bacillus with no urease activity. It is a
progressing to r e s p ir a to I y failure.
commensal of the gut (except tor the enteropathic enterotoxin-producing strains). It
may cause infantile gastroenteritis, travMers' diarrhoea, haemorrhagic colitis and hae-
molytic uraemic syndrome. It may cause sepsis of the urinary tract, wounds, perito-
19 A = False Er= True C = True 0 = False E = False
neum (peritonitis and septicaemia), bili3/)' tract and is a cause of n60natal meningitis.
Bacillus species are gram-positive, aerobic, spore-forming rods. B a c illu s anthracis Is Salmonella are motile, non-lactose-fermenting, urease-negative, enteric pathogens
non-motile, grows on blood agar, is transmitted from animals a n d Is responsible for causing gastroenteritis and enteric fever. Over 1 0 0 0 species possess different surface
anthrax due to exotoxin effects on the skin, lungs and intestinas. antigens that are serologically identified by agglutination tests. Most species cause
B a c illu s cereus and B a c illu s s u b tilis are associated with penetrating trauma,
gastroenteritis. Four species (5 . ty p h i and S. p a ra ty p h i A, B and C) cause enteric fever.
endophthalmitis and keratitis as well as food poisoning by their production of a poten-
The bacteria is transmitted by water or food and invades the gut lymphoid tissue before
tially lethal exotoxin.
multiplying in macrophages and causing a second bacteraemia. They then reinfect the
Antibiotics such polymyxin and bacitracin are produced by B a c illu s species.
Endotoxins are the lipopolysaccharide constituents of gram-negative bacteria cell gut via the biliary system. Five per cent of patients with typhoid become chronic
walls and are released on bacterial death. Spore-forming bacilli are gram positive. carriers with S. ty p h i colonizing the gall bladder. This may be eradicated by ciproflox-
acin. The incubation period is for 1-2 weeks before headache, .fever, malaise and
constipation start, followed by gastrointestinal upset. Diagnosis in the first week of
20 A = False B = True C = True D = True E = False illness is by blood culture, in the second week by culture of the faeces, and in the third
week by urine or later by serology (Widal's test) which may not be positive for at least
Corynebacterium d ip h th e r ia e is a non-sporing, non-capsulated, non-motile, aerobic,
three weeks.
grarn-pcsitive bacillus. A c tin o m y c e s is r a e /i is a gram-positive bacillus. It is an obligate
P seudom onas a e ru g in o s a (n o t a member of the Enterobacteriaceae) is a strictly
anaerobe that has branched filaments and gives the appearance of sulphur granules. It
is an oral and throat commensal and may cause infection of the lacrimal canaliculi aerobic, flagellated, motile, oxidase-positive, gram-negative bacillus that produces
(canaliculitis) and often the conjunctiva (conjunctivitis) as well as causing lung green pigment. It is an opportunistic organism in the immunosuppressed. It is known
abscesses, ileitis and pelvic inflammatory disease associated with long-term use of to contaminate antibiotic and disinfectant solutions and is thermophilic. It produces
the IUCD. pyocins which are themselves antibacterial as well as being useful in subtyping the
Nocardia asteroides is a motile, aerobic, filamentous, gram-positive bacillus found in organism.
soil. It is an intracellular parasite. Although a few filaments may show acid fast proper-
H a e m o p h ilu s is a gram-negative bacillus that shows satellitism around staphylococci
ties, it is not acid-fast. It is responsible for granulomatous lung and skin infections,
in mixed culture on blood agar. It Is a normal commeosal of the mouth and pharynx.
often with cerebral involvement in the lmrnonosuppressed.
164 M ic ro b io lo g y AnswersqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M i c r o b i o l o g y Answers
165
18 A = True B = True C = True 0 = True E = False
21 A = False B = True C = True D = True E = False F = True

Clostidia are spore-forming, anaerobic, gram-positive rods. Spores are formed to allow
a donnant existence in suboptimal conditions. Spores consist of a cysteine-rich kera- Not all S tr e p to c o c c u s species produce hyaluronidase.
tin-like cortex, some cytoplasm, double-stranded DNA. ribosomes and tANA but no
mRNA. They are resistant to heat, chemicals and drying and do not reproduce or have
any metabolism. They are produced by A
C lo s tr id iu m and B a c illu s species. Clostridia are 22 A = False B = True C = False D = True E = True
mostly soil saprophytes. C lo s tr id iu m p e r lr in g e n s is a non-motile anaerobic spore-
forming rod and a commensal of the intestine. There are six types (A-F) depending
See notes on Microbiology Question 2 3 .
on exotoxins produced. Type A is associated with gas gangrene and produces I3-toxin
Oecithlnase) as well as collagenase, hyaluronidase, and deoxyribonuclease.
C lo s tr id iu m p e r fr fn g e n s is sensitive to penicillin. Treatment of gas gangrene includes
surgical debridement. hyperbaric oxygen, penicillin and antitoxin against I3-toxin. 23 A = True B = True C = False D = False E = True
C lo s tr iu m tetani is motile. Infection is usually by the spherical terminal 'drumstick'
spores. It is usually present in animal intestines as well as soil and dust. It produces Enterobacteriaceae are bile-tolerant, gram-negative, oxidase-negative bacilli. E . c o li is
exotoxlns that act on the CNS causing tonic spasm of voluntary muscles, eventually
a motile, lactos~fermenting, gram-negative bacillus with no urease activity. It is a
progressing to r e s p ir a to I y failure.
commensal of the gut (except tor the enteropathic enterotoxin-producing strains). It
may cause infantile gastroenteritis, travMers' diarrhoea, haemorrhagic colitis and hae-
molytic uraemic syndrome. It may cause sepsis of the urinary tract, wounds, perito-
19 A = False Er= True C = True 0 = False E = False
neum (peritonitis and septicaemia), bili3/)' tract and is a cause of n60natal meningitis.
Bacillus species are gram-positive, aerobic, spore-forming rods. B a c illu s anthracis Is Salmonella are motile, non-lactose-fermenting, urease-negative, enteric pathogens
non-motile, grows on blood agar, is transmitted from animals a n d Is responsible for causing gastroenteritis and enteric fever. Over 1 0 0 0 species possess different surface
anthrax due to exotoxin effects on the skin, lungs and intestinas. antigens that are serologically identified by agglutination tests. Most species cause
B a c illu s cereus and B a c illu s s u b tilis are associated with penetrating trauma,
gastroenteritis. Four species (5 . ty p h i and S. p a ra ty p h i A, B and C) cause enteric fever.
endophthalmitis and keratitis as well as food poisoning by their production of a poten-
The bacteria is transmitted by water or food and invades the gut lymphoid tissue before
tially lethal exotoxin.
multiplying in macrophages and causing a second bacteraemia. They then reinfect the
Antibiotics such polymyxin and bacitracin are produced by B a c illu s species.
Endotoxins are the lipopolysaccharide constituents of gram-negative bacteria cell gut via the biliary system. Five per cent of patients with typhoid become chronic
walls and are released on bacterial death. Spore-forming bacilli are gram positive. carriers with S. ty p h i colonizing the gall bladder. This may be eradicated by ciproflox-
acin. The incubation period is for 1-2 weeks before headache, .fever, malaise and
constipation start, followed by gastrointestinal upset. Diagnosis in the first week of
20 A = False B = True C = True D = True E = False illness is by blood culture, in the second week by culture of the faeces, and in the third
week by urine or later by serology (Widal's test) which may not be positive for at least
Corynebacterium d ip h th e r ia e is a non-sporing, non-capsulated, non-motile, aerobic,
three weeks.
grarn-pcsitive bacillus. A c tin o m y c e s is r a e /i is a gram-positive bacillus. It is an obligate
P seudom onas a e ru g in o s a (n o t a member of the Enterobacteriaceae) is a strictly
anaerobe that has branched filaments and gives the appearance of sulphur granules. It
is an oral and throat commensal and may cause infection of the lacrimal canaliculi aerobic, flagellated, motile, oxidase-positive, gram-negative bacillus that produces
(canaliculitis) and often the conjunctiva (conjunctivitis) as well as causing lung green pigment. It is an opportunistic organism in the immunosuppressed. It is known
abscesses, ileitis and pelvic inflammatory disease associated with long-term use of to contaminate antibiotic and disinfectant solutions and is thermophilic. It produces
the IUCD. pyocins which are themselves antibacterial as well as being useful in subtyping the
Nocardia asteroides is a motile, aerobic, filamentous, gram-positive bacillus found in organism.
soil. It is an intracellular parasite. Although a few filaments may show acid fast proper-
H a e m o p h ilu s is a gram-negative bacillus that shows satellitism around staphylococci
ties, it is not acid-fast. It is responsible for granulomatous lung and skin infections,
in mixed culture on blood agar. It Is a normal commeosal of the mouth and pharynx.
often with cerebral involvement in the lmrnonosuppressed.
 M ic ro b io lo g y A n sw e rs qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
167

166
M ic ro b io lo g y Answers
HSV is associated with UpschOtz bodies. These are epithelial cell eosinophilic intra-
24 A = True 8 = True C = False D = True E = True F = False G = True nuclear inclusion bodies. Papanicolaou staining demonstrates these well (papanico-
H = True I = True laou - nuclear inclusion bodies, Giemsa - cytoplasmic inclusion bodies).
Type 11primary infection is usually sexually transmitted and may be associated with a
Except for hepatitis A, whose prophylactiC vaccination involves a killed preparation, all mild meningitis.
the above require live attenuated strain vaccines for prophylaxis.
BCG (bacille Calmette-Guerin) is the vaccine for tuberculosis.
28 A = False B = True C = True D = False E •• True

25 A = False B = True C = True 0 = False E = False F = True G = True Varicella zoster virus (a herpes virus) is a doubl&-stranded DNA virus associated with
H = True eosinophilic nuclear inclusion bodies (Upschlitz bodies). It produces two diseases.
Varicella, the primary infection, known as Chickenpox, and herpes zoster, known as
Chlamydia are intracellular organisms. They possess a bacterial cell wall similar to shingles. Patients with either are infective and the virus may be spread by direct
gram-negative bacteria as well as DNA, RNA, ribosomes and metabolic enzymes. contact with virus-filled skin vesicles or via the respiratory route through the mucosa
They ara resistant to lysosomal enzymes. In epithelial (not Inflamed) cells, large baso- of the upper respiratory tract. Varicella zoster virus can affect sensory ganglia, causing
philic cytoplasmic inclusion bodies are also seen. (Giemsa - cytoplasmic inclusion shingles, or affect motor nerves such as the facial nerve, causing Bell's palsy. Shingles
bodies, Papanicolaou - nuclear inclusion bodies.) Chlamydia may be serologically is never acquired as a primary infection. Complement fixation is useful in showing rising
subtyped. Types A-C are associated with trachoma, types D-K with sexually trans- antibody titres in the early stages of both varicella and zoster. Levels change very little
mitted inclusion conjunctivitis and type L with lymphogranuloma venereum. Chlamydia A during reactivation of zoster.
tr a c h o m a fis is associated with non-specific urethritis and Reiter's disease (urethritis,
conjunctivitis and arthritis).
29 A = True B = True C = False D = False E = True F = False

26 A = False 8 = False C = False 0 = False E = True Cytomegalovirus (a herpes virus) infection is usually asymptomatic in children. Over
50% of the UK population are thought to be seropositive. Human CMV does not infect
Exotoxins are usually enzymatic proteins produced mainly by gram-positive bacteria as animals. The virus remains latent, possibly in Iymphocytes or macrophages, and may be
well as a few grnm-negative (V.coo/erse, E col~. They are produced whilst the bacteria reactivated. Foetal infection may be due to matemal reactivation, in which case it is
ara living as opposed to endotoxins (from Gram negative organisms) which are released usually asymptomatic, or primary maternal infection. In the latter, infection is associated
on bacterial death. Exotoxins ara potent, strongly antigenic, usually heat-labile proteins with CNS involvement ranging from deafness to motor disorders and microcephaly, as
that form toxoids with formaldehyde and have a specific action. well as jaundice, hepatosplenomegaly, thrombocytopenia and haemolytic anaemia
Aspergillus fla v u s is a fungus that infects groundnuts and produces a toxin known as Primary infection in pregnancy is associated with a 33% risk of foetal infection. Of
aflatoxin. these, 10% are believed to acquire cytomegalic inclusion disease (CMID). CMID has an
incidence of 100 per year in the UK, and is associated with microphthalmia, chorior-
etinitis and strabismus.
27 A = False B = False C = False D = False E = True CMV may be shed from the genitourinary route and is a source of infection to infants
during childbirth. Diagnosis is by serology with IgM Indicating active infection and IgG
Herpes simpleX, varicella zoster, cytomegalo and Epstein-Barr viruses are double- past infection, or isolation in tissue culture identifying the characteristic nuclear 'owl's
stranded DNA viruses with icosahedral capsids of 1 0 0 nm and complete enveloped eye' inclusion bodies. CMV causes severe infection in the immunocompromised and no
particle of 1 5 0 nm in diameter. The particles form in celi nuclei and ara able to remain
vaccine is available.
latent in the body for life.
Type I and 11herpes simplex virus can ba differentiated with monoclonai antibodies by
fluorescent antibody staining of scrapings taken from skin, comea- or conjunctiva.
30 A = True 8 = False C = True D = False E = True F = False
Complement fixation antibody testing is only useful if differentiating primary from
recurrent herpes infection. Serial blood samples show a rise in antibody titra In primary
Measles is a paramyxovirus that is transmitted airborne in respiratory secretions early in
infection and little change during recurrent infection.
infection. It is characterised by a prodrome of fever, nasal discharge, pharyngitis and
Type I is usually subclinical but in 1 0 % may cause gingivostomatitis.
 M ic ro b io lo g y A n sw e rs qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
167

166
M ic ro b io lo g y Answers
HSV is associated with UpschOtz bodies. These are epithelial cell eosinophilic intra-
24 A = True 8 = True C = False D = True E = True F = False G = True nuclear inclusion bodies. Papanicolaou staining demonstrates these well (papanico-
H = True I = True laou - nuclear inclusion bodies, Giemsa - cytoplasmic inclusion bodies).
Type 11primary infection is usually sexually transmitted and may be associated with a
Except for hepatitis A, whose prophylactiC vaccination involves a killed preparation, all mild meningitis.
the above require live attenuated strain vaccines for prophylaxis.
BCG (bacille Calmette-Guerin) is the vaccine for tuberculosis.
28 A = False B = True C = True D = False E •• True

25 A = False B = True C = True 0 = False E = False F = True G = True Varicella zoster virus (a herpes virus) is a doubl&-stranded DNA virus associated with
H = True eosinophilic nuclear inclusion bodies (Upschlitz bodies). It produces two diseases.
Varicella, the primary infection, known as Chickenpox, and herpes zoster, known as
Chlamydia are intracellular organisms. They possess a bacterial cell wall similar to shingles. Patients with either are infective and the virus may be spread by direct
gram-negative bacteria as well as DNA, RNA, ribosomes and metabolic enzymes. contact with virus-filled skin vesicles or via the respiratory route through the mucosa
They ara resistant to lysosomal enzymes. In epithelial (not Inflamed) cells, large baso- of the upper respiratory tract. Varicella zoster virus can affect sensory ganglia, causing
philic cytoplasmic inclusion bodies are also seen. (Giemsa - cytoplasmic inclusion shingles, or affect motor nerves such as the facial nerve, causing Bell's palsy. Shingles
bodies, Papanicolaou - nuclear inclusion bodies.) Chlamydia may be serologically is never acquired as a primary infection. Complement fixation is useful in showing rising
subtyped. Types A-C are associated with trachoma, types D-K with sexually trans- antibody titres in the early stages of both varicella and zoster. Levels change very little
mitted inclusion conjunctivitis and type L with lymphogranuloma venereum. Chlamydia A during reactivation of zoster.
tr a c h o m a fis is associated with non-specific urethritis and Reiter's disease (urethritis,
conjunctivitis and arthritis).
29 A = True B = True C = False D = False E = True F = False

26 A = False 8 = False C = False 0 = False E = True Cytomegalovirus (a herpes virus) infection is usually asymptomatic in children. Over
50% of the UK population are thought to be seropositive. Human CMV does not infect
Exotoxins are usually enzymatic proteins produced mainly by gram-positive bacteria as animals. The virus remains latent, possibly in Iymphocytes or macrophages, and may be
well as a few grnm-negative (V.coo/erse, E col~. They are produced whilst the bacteria reactivated. Foetal infection may be due to matemal reactivation, in which case it is
ara living as opposed to endotoxins (from Gram negative organisms) which are released usually asymptomatic, or primary maternal infection. In the latter, infection is associated
on bacterial death. Exotoxins ara potent, strongly antigenic, usually heat-labile proteins with CNS involvement ranging from deafness to motor disorders and microcephaly, as
that form toxoids with formaldehyde and have a specific action. well as jaundice, hepatosplenomegaly, thrombocytopenia and haemolytic anaemia
Aspergillus fla v u s is a fungus that infects groundnuts and produces a toxin known as Primary infection in pregnancy is associated with a 33% risk of foetal infection. Of
aflatoxin. these, 10% are believed to acquire cytomegalic inclusion disease (CMID). CMID has an
incidence of 100 per year in the UK, and is associated with microphthalmia, chorior-
etinitis and strabismus.
27 A = False B = False C = False D = False E = True CMV may be shed from the genitourinary route and is a source of infection to infants
during childbirth. Diagnosis is by serology with IgM Indicating active infection and IgG
Herpes simpleX, varicella zoster, cytomegalo and Epstein-Barr viruses are double- past infection, or isolation in tissue culture identifying the characteristic nuclear 'owl's
stranded DNA viruses with icosahedral capsids of 1 0 0 nm and complete enveloped eye' inclusion bodies. CMV causes severe infection in the immunocompromised and no
particle of 1 5 0 nm in diameter. The particles form in celi nuclei and ara able to remain
vaccine is available.
latent in the body for life.
Type I and 11herpes simplex virus can ba differentiated with monoclonai antibodies by
fluorescent antibody staining of scrapings taken from skin, comea- or conjunctiva.
30 A = True 8 = False C = True D = False E = True F = False
Complement fixation antibody testing is only useful if differentiating primary from
recurrent herpes infection. Serial blood samples show a rise in antibody titra In primary
Measles is a paramyxovirus that is transmitted airborne in respiratory secretions early in
infection and little change during recurrent infection.
infection. It is characterised by a prodrome of fever, nasal discharge, pharyngitis and
Type I is usually subclinical but in 1 0 % may cause gingivostomatitis.
168 M ic ro b io lo g y AnswersqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M i c r o b i o l o g y Answers 169

conjunctivitis followed by a progressively generalizing rash and Koplik's spots. Symp- response. It Is associated with pharyngitis, cough, pyrexia, latent tonsillar Infection in
toms may be severe with complications such as otitis media and secondary bacterial children and ocular infections including follicular conjunctivitis.
and viral pneumonia. Postinfectious encephalitis has a 50% mortality. Subacute scler-
osing panencephalitis is associated with children, especially boys who acquire measles
before the age of 2 years. The illness begins insidiously 7 years postmeasles with 34 A = True B = False C = False 0 = True E = False F = False G = False
changes in behaviour, personality, intellect and progresses to death.
The incubation period for measles is between 10 and 14 days and Infection is never Hepatitis A is a 28 nm RNA virus spread faeco-orally and causes nausea, vomiting,
subclinical. The virus may be isolated as well as diagnosed by a rise in !gM antibody jaundice (that lasts for weeks), dark urine and pale faeces. Incubation is up to 6 weeks.
titres. A live attenuated vaccine is routinely given and is not transmitted. Although virus isolation Is not routine, it may be seen by electron microcroscopy in
stool-during incubation. The virus disappears with the onset of symptoms. Diagnosis is
by serology. !gM indicates recent infection and IgG past infection. The virus causes
31 A = True B = False C = True 0 = True E = False acute hepatitis and is not associated with chronic hepatitis or carrier state. It is not
associated with an increased risk of primary hepatoma.
EBV is a double-stranded DNA virus belonging to the herpes group of viruses. It usually
causes asymptomatic primary infection in children. However, infection in adolescence
and adulthood causes infectious mononucleosis (glandular fever). 35 A = False B = False C = False 0 = True E = True F = True G = True
Diagnosis of active disease is by detection of circulating heterophile antibodies
(pau!-Bunnell test) or by detection of antibodies against the capsid. IgM and IgG are Hepatitis B is a 42 nm diameter DNA virus made up of an outer protein coat and an
raised in active disease, however only IgG remains later in life In low levels. Past Inner protein core containing circular DNA and DNA polymerase as well as an 'e'
infection may be diagnosed by the presence of nuclear antibodies which appear weeks antigen. This is collectively known as a Dane particle.
after infection and remain present for life. It is associated with nasopharyngeal carci- Transmission is parenteral, vertical, sexual and by close contact. Incubation is up to
noma in parts of China and Burkett's lymphoma. The link between EBV and Burkett's five months before the onset of jaundice. At this stage the virus continues to remain in
lymphoma in Africa is thought to be due to the presence of malaria. Humans appear to the blood for many weeks after. Diagnosis is by serology, however the virus may be
be the only host. isolated from blood and seen under electron microscopy. It cannot be cultured.
Pathogenesis is by a cytotoxic T cell-mediated immune response which is directed
against hepatocytes expressing viral antigen. Two-thirds of those infected have a
32 A = True B = True C = False 0 = False E = True subclinical infection with only 5% becoming carriers and 95% recovering fully. Of the
remaining one-third, three-quarters undergo acute hepatitis with 99% recovery and 1%
Rubella is a fragile RNA togavirus easily killed by heat and UV light. It is spread by developing fulminant hepatitis. The remaining one-quarter (i.e. approximately 10%)
droplets via the respirary tract and has an incubation period of between 14 and 21 develop chronic hepatitis. one-third of whom continue with chronic persistent hepatitis
days, averaging 18 days. Its importance lies in the risk of congenital abnormalities in - and two-thirds progress to chronic active hepatitis with a risk of developing cirrhosis.
children whose mothers were infected early in pregnancy. Infection Is associated with Overall mortality is 1 % , with carriers and those with chronic hepatitiS having an
mild fever. headache, general malaise and cervical, suboccipital and postauricular increased risk of developing primary hepatoma.
lymphadenopathy. A fine maculopapular rash begins over the face, spreading over HBeAg 'e' antigen found in the inner core, if found persistently in the blood is
the arms and trunk lasting 2 days and coincides with maximum infectivity. Primary associated with 'super' highly infectious carrier status, but, is present in all acute cases
infection early in pregnancy is associated with congenital heart disease, mental retar- initially.
dation and deafness. Ocular defects include cataract, microphthalmos and glaucoma. A vaccine exists against hepatitis B and consists of the surface antigen HBsAg of the
virus without the core antigen or protein. It is produced by cloning the surface antigen
gene in yeast.
33 A = False B = True C = True 0 = True E = False

Adenoviruses are heat-sensitive DNA viruses with more than 40 different antlgenic 36 A = True B = True C = False 0 = True E = True F = False
serotypes, some of which are associated with Infections of the eye. As well as serology
they can be identified by isolation and Immunofluorescent microscopy. Response to Hepatitis C is a single-stranded RNA virus between 30 and 60 nm in size. It is trans-
infection is polymorphonuclear initially followed by a mononuclear macrophage mitted parenterally and associated with post-transfusion hepatitis. Screening of
168 M ic ro b io lo g y AnswersqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M i c r o b i o l o g y Answers 169

conjunctivitis followed by a progressively generalizing rash and Koplik's spots. Symp- response. It Is associated with pharyngitis, cough, pyrexia, latent tonsillar Infection in
toms may be severe with complications such as otitis media and secondary bacterial children and ocular infections including follicular conjunctivitis.
and viral pneumonia. Postinfectious encephalitis has a 50% mortality. Subacute scler-
osing panencephalitis is associated with children, especially boys who acquire measles
before the age of 2 years. The illness begins insidiously 7 years postmeasles with 34 A = True B = False C = False 0 = True E = False F = False G = False
changes in behaviour, personality, intellect and progresses to death.
The incubation period for measles is between 10 and 14 days and Infection is never Hepatitis A is a 28 nm RNA virus spread faeco-orally and causes nausea, vomiting,
subclinical. The virus may be isolated as well as diagnosed by a rise in !gM antibody jaundice (that lasts for weeks), dark urine and pale faeces. Incubation is up to 6 weeks.
titres. A live attenuated vaccine is routinely given and is not transmitted. Although virus isolation Is not routine, it may be seen by electron microcroscopy in
stool-during incubation. The virus disappears with the onset of symptoms. Diagnosis is
by serology. !gM indicates recent infection and IgG past infection. The virus causes
31 A = True B = False C = True 0 = True E = False acute hepatitis and is not associated with chronic hepatitis or carrier state. It is not
associated with an increased risk of primary hepatoma.
EBV is a double-stranded DNA virus belonging to the herpes group of viruses. It usually
causes asymptomatic primary infection in children. However, infection in adolescence
and adulthood causes infectious mononucleosis (glandular fever). 35 A = False B = False C = False 0 = True E = True F = True G = True
Diagnosis of active disease is by detection of circulating heterophile antibodies
(pau!-Bunnell test) or by detection of antibodies against the capsid. IgM and IgG are Hepatitis B is a 42 nm diameter DNA virus made up of an outer protein coat and an
raised in active disease, however only IgG remains later in life In low levels. Past Inner protein core containing circular DNA and DNA polymerase as well as an 'e'
infection may be diagnosed by the presence of nuclear antibodies which appear weeks antigen. This is collectively known as a Dane particle.
after infection and remain present for life. It is associated with nasopharyngeal carci- Transmission is parenteral, vertical, sexual and by close contact. Incubation is up to
noma in parts of China and Burkett's lymphoma. The link between EBV and Burkett's five months before the onset of jaundice. At this stage the virus continues to remain in
lymphoma in Africa is thought to be due to the presence of malaria. Humans appear to the blood for many weeks after. Diagnosis is by serology, however the virus may be
be the only host. isolated from blood and seen under electron microscopy. It cannot be cultured.
Pathogenesis is by a cytotoxic T cell-mediated immune response which is directed
against hepatocytes expressing viral antigen. Two-thirds of those infected have a
32 A = True B = True C = False 0 = False E = True subclinical infection with only 5% becoming carriers and 95% recovering fully. Of the
remaining one-third, three-quarters undergo acute hepatitis with 99% recovery and 1%
Rubella is a fragile RNA togavirus easily killed by heat and UV light. It is spread by developing fulminant hepatitis. The remaining one-quarter (i.e. approximately 10%)
droplets via the respirary tract and has an incubation period of between 14 and 21 develop chronic hepatitis. one-third of whom continue with chronic persistent hepatitis
days, averaging 18 days. Its importance lies in the risk of congenital abnormalities in - and two-thirds progress to chronic active hepatitis with a risk of developing cirrhosis.
children whose mothers were infected early in pregnancy. Infection Is associated with Overall mortality is 1 % , with carriers and those with chronic hepatitiS having an
mild fever. headache, general malaise and cervical, suboccipital and postauricular increased risk of developing primary hepatoma.
lymphadenopathy. A fine maculopapular rash begins over the face, spreading over HBeAg 'e' antigen found in the inner core, if found persistently in the blood is
the arms and trunk lasting 2 days and coincides with maximum infectivity. Primary associated with 'super' highly infectious carrier status, but, is present in all acute cases
infection early in pregnancy is associated with congenital heart disease, mental retar- initially.
dation and deafness. Ocular defects include cataract, microphthalmos and glaucoma. A vaccine exists against hepatitis B and consists of the surface antigen HBsAg of the
virus without the core antigen or protein. It is produced by cloning the surface antigen
gene in yeast.
33 A = False B = True C = True 0 = True E = False

Adenoviruses are heat-sensitive DNA viruses with more than 40 different antlgenic 36 A = True B = True C = False 0 = True E = True F = False
serotypes, some of which are associated with Infections of the eye. As well as serology
they can be identified by isolation and Immunofluorescent microscopy. Response to Hepatitis C is a single-stranded RNA virus between 30 and 60 nm in size. It is trans-
infection is polymorphonuclear initially followed by a mononuclear macrophage mitted parenterally and associated with post-transfusion hepatitis. Screening of
 M ic ro b io lo g y A n s w e rs
170 M ic ro b io lo g y A n s w e r s qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 171

donated blood for hepatitis C virus is now routine in the UK. It has an incubation period seen. Kaposi's sarcoma affects 25% of AIDS patients and may be found on the eyelids
of up to ten weeks and from then on may be diagnosed by serology (antl-HCV anti- or the conjunctiva. Lymphomas of the eye have a greater incidence in AIDS.
bodies). Fifty per cent of those infected recover fully. The remaining 50% develop
chronic hepatitis. Of those, 50% continue insidiously with chronic persistent hepatitiS
whereas the remaining 50% (25% of totaQ develop chronic active hepatitis. Of those 39 A = False B = False C = True 0 = True E = True F = True
patients with chronic active hepatitis, two-thirds remain with chronic active hepatitis
only and one-third of patients (over, 0% of totaQ go on to develop cirmosis of the liver. A s p e r g illu s is a saprophytic thermophilic filamentous fungus (or mould). A s p e r g illu s
Chronic disease is associated with an increased risk of primary hepatoma fu m ig a tu s is the commonest infecting species. It produces chemical- and heat-sensi-
tive reproductive spores as well as filamentous projections (hyphae) which combine
and intertwine to be described as a mycelium. Aspergillus grows on decaying leaves
and plants and are found in high concentrations In the air during autumn. It can be
37 A = True B = False C = False 0 = True E = True F = False G = True
grown routinely in 15% of asymptomatic patients with chronic lung disease. It is
H = True
responsible for allergic bronchopulmonary aspergillosis where it grows on bronchial
walls resulting in an allergic asthmatic type I hypersensitivity reaction accompanied by
HIV is a single-stranded RNA retrovirus with a !antivirus-like life cycle. It consists of a
eosinophilia. .
protein core encasing the genome RNA and the enzymes reverse transcriptase, inte-
In a separate disease it may colonize damaged cystiC or TB lung cavities and
grase and protease. It is surrounded by a complex lipid envelope containing the gp120
produce a ball of mycelium known as an aspergllloma that can be relatively asympto-
and gp41 envelope proteins. The core contains the p24 protein. These proteins are
matic or result in haemoptysis. It commonly results in ocular infections, the main ones
coded for by structural genes A
g a g , po! and env in the genome. ModIfled genes Include
being keratitis and endophthalmitis, especially postsurgery or postinjury, when resis-
tat, rev and re( genes that regulate viral activity. The virus binds to C04 + cells via its
tance is reduced either due to corticosteroid therapy or Immunosuppression.
gp120 envelope protein. These cells include T helper cells, monocytes, macrophages,
some B cells and microglial cells in the CNS. Following production of DNA (reverse
transcriptase) the double-stranded DNA is integrated into the host-cell genome (1Ilte-
grase). This is followed by transcription and translation and then post-transcriptional 40 A = True B = True C = True 0 = True E = True
modifications (protease) of virus proteins. The virus assembles and buds off from the
host cell. Cytopathicity is by enhancing cell destruction. This may be done directly by Candida is a unicellular yeast (a eukaryote) that grows by budding and causes muco-
cell-to-cell fusion, autofusion, accumulation of damaging intrecellular components or cutaneous and deep systemic infections. It is a commensal of the skin, mouth, gastro-
apoptosis of T helper cells (terminal differentiation by programmed cell death). Indirect intestinal tract and genitourinary tract.
cell destruction occurs by clearance of gp120-coated cells by T cytotoxic cells and C a n d id a a lb ic a n s is the commonest cause of candidosis. It is also the commonest
killer cells. HIV also decreases the production of interteukin 2 by the destruction of T cause of fungal endophthalmitis and also causes keratitis. It grows well on blood agar
helper cells. This reduces the T cell-stimUlating response. HIV stimulates certain B cells as well as fungal media, producing large 'cottage cheese' like colonies.
to induce polyclonal immunoglobulin production, resulting in hypergammaglobulinae- The use of oral contraceptives, as well as corticosteroids, antibiotics and cytotoxic
mia. HIV may be isolated from blood or body fluids either free or inside monocytes, drugs can predispose to candidosls.
macrophages or Iymphocytes, however, diagnosis is based on the presence of anti-
bodies against the virus.
41 A = True B = True C = True 0 = True E = False

Acanthamoeba is a free-living amoeba found in SOil,air, ponds and mains water. It can
38 A = True B = True C = True 0 = True E = True
adopt two phases, either an active trophozoite, or a cyst which remains dormant and
Ocular complications of HIV are usually seen with the onset of the acquired Immune resistant to temperature, pH and chemical extremes. Due to its presence in mains water
deficiency syndrome (AIDS) and develops in about 75% of AIDS patients. They can be it can contaminate contact lenses via their storage cases. Common species Include A
casteHania and A p o ly p /la g a .
classifled Into retinal microangiopathies, opportunistic Infections, tumours and neuro-
logical lesions affecting the eyes. Ocular infections include epithelial and stromal keratitis, uveitis and optic neuritis.
Cottonwoof spots are a common finding in AIDS. Opportunistic infections such as Treatment is with dipropamlde, polyhexamethylene blguanide, propamidine esothio-
CMV retinitis, herpes zoster ophthalmicus and cryptococcus choroiditis are commonly nate (Brolene) and neomycin, however it is sensitive to chlorhexidine.
 M ic ro b io lo g y A n s w e rs
170 M ic ro b io lo g y A n s w e r s qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 171

donated blood for hepatitis C virus is now routine in the UK. It has an incubation period seen. Kaposi's sarcoma affects 25% of AIDS patients and may be found on the eyelids
of up to ten weeks and from then on may be diagnosed by serology (antl-HCV anti- or the conjunctiva. Lymphomas of the eye have a greater incidence in AIDS.
bodies). Fifty per cent of those infected recover fully. The remaining 50% develop
chronic hepatitis. Of those, 50% continue insidiously with chronic persistent hepatitiS
whereas the remaining 50% (25% of totaQ develop chronic active hepatitis. Of those 39 A = False B = False C = True 0 = True E = True F = True
patients with chronic active hepatitis, two-thirds remain with chronic active hepatitis
only and one-third of patients (over, 0% of totaQ go on to develop cirmosis of the liver. A s p e r g illu s is a saprophytic thermophilic filamentous fungus (or mould). A s p e r g illu s
Chronic disease is associated with an increased risk of primary hepatoma fu m ig a tu s is the commonest infecting species. It produces chemical- and heat-sensi-
tive reproductive spores as well as filamentous projections (hyphae) which combine
and intertwine to be described as a mycelium. Aspergillus grows on decaying leaves
and plants and are found in high concentrations In the air during autumn. It can be
37 A = True B = False C = False 0 = True E = True F = False G = True
grown routinely in 15% of asymptomatic patients with chronic lung disease. It is
H = True
responsible for allergic bronchopulmonary aspergillosis where it grows on bronchial
walls resulting in an allergic asthmatic type I hypersensitivity reaction accompanied by
HIV is a single-stranded RNA retrovirus with a !antivirus-like life cycle. It consists of a
eosinophilia. .
protein core encasing the genome RNA and the enzymes reverse transcriptase, inte-
In a separate disease it may colonize damaged cystiC or TB lung cavities and
grase and protease. It is surrounded by a complex lipid envelope containing the gp120
produce a ball of mycelium known as an aspergllloma that can be relatively asympto-
and gp41 envelope proteins. The core contains the p24 protein. These proteins are
matic or result in haemoptysis. It commonly results in ocular infections, the main ones
coded for by structural genes A
g a g , po! and env in the genome. ModIfled genes Include
being keratitis and endophthalmitis, especially postsurgery or postinjury, when resis-
tat, rev and re( genes that regulate viral activity. The virus binds to C04 + cells via its
tance is reduced either due to corticosteroid therapy or Immunosuppression.
gp120 envelope protein. These cells include T helper cells, monocytes, macrophages,
some B cells and microglial cells in the CNS. Following production of DNA (reverse
transcriptase) the double-stranded DNA is integrated into the host-cell genome (1Ilte-
grase). This is followed by transcription and translation and then post-transcriptional 40 A = True B = True C = True 0 = True E = True
modifications (protease) of virus proteins. The virus assembles and buds off from the
host cell. Cytopathicity is by enhancing cell destruction. This may be done directly by Candida is a unicellular yeast (a eukaryote) that grows by budding and causes muco-
cell-to-cell fusion, autofusion, accumulation of damaging intrecellular components or cutaneous and deep systemic infections. It is a commensal of the skin, mouth, gastro-
apoptosis of T helper cells (terminal differentiation by programmed cell death). Indirect intestinal tract and genitourinary tract.
cell destruction occurs by clearance of gp120-coated cells by T cytotoxic cells and C a n d id a a lb ic a n s is the commonest cause of candidosis. It is also the commonest
killer cells. HIV also decreases the production of interteukin 2 by the destruction of T cause of fungal endophthalmitis and also causes keratitis. It grows well on blood agar
helper cells. This reduces the T cell-stimUlating response. HIV stimulates certain B cells as well as fungal media, producing large 'cottage cheese' like colonies.
to induce polyclonal immunoglobulin production, resulting in hypergammaglobulinae- The use of oral contraceptives, as well as corticosteroids, antibiotics and cytotoxic
mia. HIV may be isolated from blood or body fluids either free or inside monocytes, drugs can predispose to candidosls.
macrophages or Iymphocytes, however, diagnosis is based on the presence of anti-
bodies against the virus.
41 A = True B = True C = True 0 = True E = False

Acanthamoeba is a free-living amoeba found in SOil,air, ponds and mains water. It can
38 A = True B = True C = True 0 = True E = True
adopt two phases, either an active trophozoite, or a cyst which remains dormant and
Ocular complications of HIV are usually seen with the onset of the acquired Immune resistant to temperature, pH and chemical extremes. Due to its presence in mains water
deficiency syndrome (AIDS) and develops in about 75% of AIDS patients. They can be it can contaminate contact lenses via their storage cases. Common species Include A
casteHania and A p o ly p /la g a .
classifled Into retinal microangiopathies, opportunistic Infections, tumours and neuro-
logical lesions affecting the eyes. Ocular infections include epithelial and stromal keratitis, uveitis and optic neuritis.
Cottonwoof spots are a common finding in AIDS. Opportunistic infections such as Treatment is with dipropamlde, polyhexamethylene blguanide, propamidine esothio-
CMV retinitis, herpes zoster ophthalmicus and cryptococcus choroiditis are commonly nate (Brolene) and neomycin, however it is sensitive to chlorhexidine.
 M ic r o b io lo g y A n s w e r s qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
STRUCTURED EsSAY PLANS
172

42 A = False B = True C = False D = False E = True

Surgicalgloves would melt if exposedto dry heat at 130°Cand would only be disIn-
fected on exposureto UV radiationor chlorhexidine. Note: Each essay summary provides a suggested essay structure with key points
ordered according to importance.For further details of the 'traffic light' system
used to prioritise points, pleaserefer to the Preface(p. viQ.
43 A = True B = False C = False D = True E = True
Outlinethe differencesbetweenthe sympatheticand parasympathetic
Secondaryamyloidosisoften occurs secondalyto chronic diseaseincludingtubercu- divisions of the autonomicnervoussystem 174
losis, rheumatoidarthritis,leprOSy,osteomyelitisand multiple myeloma 2 Describethe mechanismsby which blood flow through a tissue
is controlled 178
3 Describethe mechanismof photoplc and scotopic vision 180
4 Desribethe mechanismsunderlyingthe perceptionof colour 186
(Includesa comparisonof parvocellularand magnocellularpathways) 190
5 Describethe supranuclearcontrol of ocular movements 192
6 Discuss the electrophysio\ogicalinvestigationsof the visualpathway 196
7 Describethe pathwayfrom the retina to the visual cortex of an image
in the left superiorvisual field (includingretinotopic organisation) 200
8 Give an account of the origin, course, relationsand functions of the third
cranial nerve 202
9 Give an account of the origin, course, relationsand function of the fourth
cranial nerve 204
10 Give an account of the origin, course, relationsand functions of the sixth
cranial nerve 206
11 Describethe mechanismsof visual adaptation 208
12 Describethe control of pupillaryresponsesand its modificationsby drugs 212
13 Discussthe anatomicaland physiologicalbasis of binocularvision 214
14 Discussthe factors governingpenetrationof drugs into the eye 218
15 Outlinethe blood supply to the visual pathway 220
16 Describethe causesand effects of ulcers 222
17 Discussthe genetic mechanismsinvolved in neoplasia 224
18 Discussthe possible local and systemic effects of neoplasia 226
19 Discusswith appropriateexamplesthe causesand effects of ischaemia 228
20 Describethe causesand effects of occlusive diseaseoccurring
in musculararteriesand arteriolesincludinggross and
microscopic pathology 230
21 Describethe absorptionof ultraviolet,visible and infraredlight by the eye
Discusstheir harmfuleffects 234
 M ic r o b io lo g y A n s w e r s qponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
STRUCTURED EsSAY PLANS
172

42 A = False B = True C = False D = False E = True

Surgicalgloves would melt if exposedto dry heat at 130°Cand would only be disIn-
fected on exposureto UV radiationor chlorhexidine. Note: Each essay summary provides a suggested essay structure with key points
ordered according to importance.For further details of the 'traffic light' system
used to prioritise points, pleaserefer to the Preface(p. viQ.
43 A = True B = False C = False D = True E = True
Outlinethe differencesbetweenthe sympatheticand parasympathetic
Secondaryamyloidosisoften occurs secondalyto chronic diseaseincludingtubercu- divisions of the autonomicnervoussystem 174
losis, rheumatoidarthritis,leprOSy,osteomyelitisand multiple myeloma 2 Describethe mechanismsby which blood flow through a tissue
is controlled 178
3 Describethe mechanismof photoplc and scotopic vision 180
4 Desribethe mechanismsunderlyingthe perceptionof colour 186
(Includesa comparisonof parvocellularand magnocellularpathways) 190
5 Describethe supranuclearcontrol of ocular movements 192
6 Discuss the electrophysio\ogicalinvestigationsof the visualpathway 196
7 Describethe pathwayfrom the retina to the visual cortex of an image
in the left superiorvisual field (includingretinotopic organisation) 200
8 Give an account of the origin, course, relationsand functions of the third
cranial nerve 202
9 Give an account of the origin, course, relationsand function of the fourth
cranial nerve 204
10 Give an account of the origin, course, relationsand functions of the sixth
cranial nerve 206
11 Describethe mechanismsof visual adaptation 208
12 Describethe control of pupillaryresponsesand its modificationsby drugs 212
13 Discussthe anatomicaland physiologicalbasis of binocularvision 214
14 Discussthe factors governingpenetrationof drugs into the eye 218
15 Outlinethe blood supply to the visual pathway 220
16 Describethe causesand effects of ulcers 222
17 Discussthe genetic mechanismsinvolved in neoplasia 224
18 Discussthe possible local and systemic effects of neoplasia 226
19 Discusswith appropriateexamplesthe causesand effects of ischaemia 228
20 Describethe causesand effects of occlusive diseaseoccurring
in musculararteriesand arteriolesincludinggross and
microscopic pathology 230
21 Describethe absorptionof ultraviolet,visible and infraredlight by the eye
Discusstheir harmfuleffects 234
 MicrobiologyPONMLKJIHGFEDCBA
A nsw ers
172zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA STRUCTUREDZYXWVUTSRQPONMLKJIHGFEDCBA
E sS A Y P L A N S

A = False B = True C = False 0 = False E = True

42jihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

S urgical gloves w ould m elt if exposed to dry heat at 130°C and w ould only be disIn-
fected on exposure to U V radiation or chlorhexidine.
N ote: E ach essay sum m ary provides a suggested essay structure w ith key points
ordered according to im portance. For further details of the 'traffic light' system
used to prioritise points, please refer to the P reface (p. viO .
43 A = True B = False C = False 0 = True E = True

1 O utline the differences betw een the sym pathetic and parasym pathetic
S econdary am yloidosis often occurs secondary to chronic disease including tubercu-
divisions of the autonom ic nervous system 1.74
loS is, rheum atoid arthritis, leprosy, osteom yelitis and m ultiple m yelom a.
2 D escribe the m echanism s by w hich blood flow through a tissue
is controlled 178
3 D escribe the m echanism of photopiC ; and scotopic vision 180
4 D esribe the m echanism s underlying the perception of colour 186
(Includes a com parison of parvocellular and m agnocellular pathw ays) 190
5 D escribe the supranuclear control of ocular m ovem ents 192
6 D iscuss the electrophysiological investigations of the visual pathw ay 196
7 D escribe the pathw ay from the retina to the visual cortex of an im age
in the left superior visual field (including retinotopic organisation) 200
8 G ive an account of the origin, course, relations and functions of the third
cranial nerve 202
9 G ive an account of the origin, course, relations and function of the fourth
cranial nerve 204
10 G ive an account of the origin, course, relations and functions of the sixth
cranial nerve 206
11 D escribe the m echanism s of visual adaptation 208
12 D escribe the control of pupillary responses and its m odifications by drugs 212
13 D iscuss the anatom ical and physiological basis of binocular vision 214
14 D iscuss the factors governing penetration of drugs into the eye 218
15 O utline the blood supply to the visual pathw ay 220
16 D escribe the causes and effects of ulcers 222
17 D iscuss the genetic m echanism s involved In neoplasia 224
18 D iscuss the possible local and system ic effects of neoplasia 226
19 D iscuss w ith appropriate exam ples the causes and effects of ischaem ia 228
20 D escribe the causes and effects of occlusive disease occurring
in m uscular arteries and arterioles including gross and
m icroscopic pathology 230
21 D escribe the absorption of ultraviolet, visible and infrared light by the eye
D iscuss their harm ful effects 234
 MicrobiologyPONMLKJIHGFEDCBA
A nsw ers
172zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA STRUCTUREDZYXWVUTSRQPONMLKJIHGFEDCBA
E sS A Y P L A N S

A = False B = True C = False 0 = False E = True

42jihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

S urgical gloves w ould m elt if exposed to dry heat at 130°C and w ould only be disIn-
fected on exposure to U V radiation or chlorhexidine.
N ote: E ach essay sum m ary provides a suggested essay structure w ith key points
ordered according to im portance. For further details of the 'traffic light' system
used to prioritise points, please refer to the P reface (p. viO .
43 A = True B = False C = False 0 = True E = True

1 O utline the differences betw een the sym pathetic and parasym pathetic
S econdary am yloidosis often occurs secondary to chronic disease including tubercu-
divisions of the autonom ic nervous system 1.74
loS is, rheum atoid arthritis, leprosy, osteom yelitis and m ultiple m yelom a.
2 D escribe the m echanism s by w hich blood flow through a tissue
is controlled 178
3 D escribe the m echanism of photopiC ; and scotopic vision 180
4 D esribe the m echanism s underlying the perception of colour 186
(Includes a com parison of parvocellular and m agnocellular pathw ays) 190
5 D escribe the supranuclear control of ocular m ovem ents 192
6 D iscuss the electrophysiological investigations of the visual pathw ay 196
7 D escribe the pathw ay from the retina to the visual cortex of an im age
in the left superior visual field (including retinotopic organisation) 200
8 G ive an account of the origin, course, relations and functions of the third
cranial nerve 202
9 G ive an account of the origin, course, relations and function of the fourth
cranial nerve 204
10 G ive an account of the origin, course, relations and functions of the sixth
cranial nerve 206
11 D escribe the m echanism s of visual adaptation 208
12 D escribe the control of pupillary responses and its m odifications by drugs 212
13 D iscuss the anatom ical and physiological basis of binocular vision 214
14 D iscuss the factors governing penetration of drugs into the eye 218
15 O utline the blood supply to the visual pathw ay 220
16 D escribe the causes and effects of ulcers 222
17 D iscuss the genetic m echanism s involved In neoplasia 224
18 D iscuss the possible local and system ic effects of neoplasia 226
19 D iscuss w ith appropriate exam ples the causes and effects of ischaem ia 228
20 D escribe the causes and effects of occlusive disease occurring
in m uscular arteries and arterioles including gross and
m icroscopic pathology 230
21 D escribe the absorption of ultraviolet, visible and infrared light by the eye
D iscuss their harm ful effects 234
 • Slow/Chronic
• In te r n a l hom eosrasis • Circulatcrv hormones
• lnvcluntarv • O r ig in s
• P,egdnglionic fibres
• Gdnglia
• Postganglionic fibres
• T " T g e t - rransmitters
- recCptoT.\

• V o lu n tA r y • lnvcluntarv
• u r e A i" involuntary r e f l u .e .s .

oI FUNCTIONAL DIFFERENCES!

I SYMPATHETIC ! IPARASYMPATHETIC!
trl
• "Bodily functionsk (Anabolic I '"
~'"
• S y n e r g is d c .t c c io n ..,~
• Effects are receptor dependeur (a/f31 • All effects PONMLKJIHGFEDCBA
d o not occur ar once C
..•C
1'1
• Include. kfight or flight" prorecrive • V iA a c e ty lc h o lin e tmW;Cd.rin1c recepeorl
..,

-
"

Example.IFrom "Head to roe"]:

ISYMPATHETIC !
I PARASYMPATHETIC I
• Br••in It ••le'tnes.1
• t pupil size •• len. convexirv •• secretions
• Lung./ bronchodilation • ~ pupil.ize • t lens convexiry
• H •••,tltHR/SVI · t s e c r e tio n s (te a r s , S A liv a , nas",I, b r o n c h i , gud
· ~ronchocon$triction
• G I tract tre.i.ax smoorh muscle, COntract sphincters)
• Hurtl.HRj
• Bladder (rei..,. mUKI.,. concrace sphinc«rl
• Cl c r a c t Icon tract smooth mu.scle:, relax sphincterl
• 5 ~ in fv u c x o n s tr ic tio n l' 5 w u r :;n g l
• Ureter !bladder •
• L,ver/panc reas lfat/CHO metabolism I
• Cenitats [erecrion]
• Blood vessel. (a/Ill
• Cenieats lej ••cularion]
lNB: E r e c tio n lE ja c u lA tio n - '1 E )o in t'" [ereccion] and " ~ h O O tIJ { e j a c u la .t io n )

RECEPTOR5:
RECEPTOR5:
• a {alphal- usu. EXCITATORY {inhibitory in GI traetl
• NICOTINIC sanglion cells
• Il (bctal- usu. INHIBITORY (""citatory in hurt I • A u to n o m ic
Ill. -cardi .•c , Il.- bronchi/blood vu,cI,) • N-M junction
• Cholinergic - SWUt glands • IAdren .• 1 medulla]
- .1.Tteriola.r s m o o t h m u s c le in
slc.el~tal m u scle • MUSCARINIC· All postganglionic
p d .r .a .s y m p ..t t h e t ic reccpcors
 • Slow/Chronic
• In te r n a l hom eosrasis • Circulatcrv hormones
• lnvcluntarv • O r ig in s
• P,egdnglionic fibres
• Gdnglia
• Postganglionic fibres
• T " T g e t - rransmitters
- recCptoT.\

• V o lu n tA r y • lnvcluntarv
• u r e A i" involuntary r e f l u .e .s .

oI FUNCTIONAL DIFFERENCES!

I SYMPATHETIC ! IPARASYMPATHETIC!
trl
• "Bodily functionsk (Anabolic I '"
~'"
• S y n e r g is d c .t c c io n ..,~
• Effects are receptor dependeur (a/f31 • All effects PONMLKJIHGFEDCBA
d o not occur ar once C
..•C
1'1
• Include. kfight or flight" prorecrive • V iA a c e ty lc h o lin e tmW;Cd.rin1c recepeorl
..,

-
"

Example.IFrom "Head to roe"]:

ISYMPATHETIC !
I PARASYMPATHETIC I
• Br••in It ••le'tnes.1
• t pupil size •• len. convexirv •• secretions
• Lung./ bronchodilation • ~ pupil.ize • t lens convexiry
• H •••,tltHR/SVI · t s e c r e tio n s (te a r s , S A liv a , nas",I, b r o n c h i , gud
· ~ronchocon$triction
• G I tract tre.i.ax smoorh muscle, COntract sphincters)
• Hurtl.HRj
• Bladder (rei..,. mUKI.,. concrace sphinc«rl
• Cl c r a c t Icon tract smooth mu.scle:, relax sphincterl
• 5 ~ in fv u c x o n s tr ic tio n l' 5 w u r :;n g l
• Ureter !bladder •
• L,ver/panc reas lfat/CHO metabolism I
• Cenitats [erecrion]
• Blood vessel. (a/Ill
• Cenieats lej ••cularion]
lNB: E r e c tio n lE ja c u lA tio n - '1 E )o in t'" [ereccion] and " ~ h O O tIJ { e j a c u la .t io n )

RECEPTOR5:
RECEPTOR5:
• a {alphal- usu. EXCITATORY {inhibitory in GI traetl
• NICOTINIC sanglion cells
• Il (bctal- usu. INHIBITORY (""citatory in hurt I • A u to n o m ic
Ill. -cardi .•c , Il.- bronchi/blood vu,cI,) • N-M junction
• Cholinergic - SWUt glands • IAdren .• 1 medulla]
- .1.Tteriola.r s m o o t h m u s c le in
slc.el~tal m u scle • MUSCARINIC· All postganglionic
p d .r .a .s y m p ..t t h e t ic reccpcors
 SPINAL CORD, T, - L';J
!GANGLlON!lparave"ebral!
• Synapse

0-1-jihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
0- -
0- -
S u p e r io r ,

ZYXWVUTSRQPONMLKJIHGFEDCBA
m id d le , in fe flo r c e r v ic a l g a n g litl
• FAR from TARGET
• A c e ty lc h o lin e tran.~mitter
• N ic .o c in ic T c a p tO r
T,

PARAVERTEBRAL CHAIN !POSTGANGlIONIC FIBREl

orSYMPATHETICTRUNl<-GANGLlA
• Unmyelinated 'C'-fibre
• LONG fibre (adrenergic)
• Preganglionic ~bres [rom lateral hom T, - L';J reach
s y m p 4 1 t .h e t ic PONMLKJIHGFEDCBA
t r u n k v i a s p ir u l
nerve a n d ITARGET !
rsm i Ibr,wche..s) - c o m m u n ic s n te s • U s u a lly noradrenaline tr a n s m itte r

• P r e g a n g lio n ic s p ls n c h n ic nerves .synapM. in

• tt-!~-reuptOT5
periphcr~1 g .1 n g l i a .l c o c " ~ c ,s u p e r i o f / snd [except sweat glands and some cholinergic fibres supplying
inferior m e s e n te r ic I arterioles in s k e le ta l muscle]

• Proganglionie ~bres synap~ directly on to

A drens! m o d u li • •

~
0 ---
0 ---
o

liiJ/ PARASYMPATHETIC l

I CRANIOSACRAL OUTFLOW illl, VIII, IX, X,S •. ,,;I o P r e g a n g lio n ic f ih r e .: CD p o s tfla n g liO ll1 c fibres

CRANIAL NERVES I PREGANGLIONIC FIBRE I

C o n s tr ic to r
• Myelin.ted 'B'-fibre
• Hence 'WHITE'
Ill •.•- - - - - - - - - - - - - - { < O o } - - - - - « pupillae • LONG fib ••
Edinger-Westphal nucleus Ciliary Cili"ry
g a n g lio n m u s c le IGANGLlONI
· S yn ap se

VII •.....- - - - - - - - - - - - - r - 1 ~o jl- - - - ...•

-- Lacrimal gland • CLOSE to TARGET (usually in wall. of viscera)
saliva-v n u c l e u s • Acervchcline t r o l n s m i t t e : r
S u p e r io r Ptervgopalacine
N a s o p a la tin e : • N ic o tin ic recepror
g~'nglion
glands
'- - { < o } - - - - - ,- -
Submandibular ! POSTGANGLIONIC FIBRE I
Submandibular gland • Unmyelinated 'C'-fibre
~Anglion Sublingual gland • SHORT fibre
• C h o lin e r g ic

IX •.•- - - - - - - - - - - - - - f< O o jf- - - - - - - Parotid gland !TARGET I

(n (u lo r saH vary nucleus O tic g a n g lio n
• Acervicholine transmitte>
• M u s c .lT in ic recepror
X •.....- - - - - - - - - - - - - r - 1 ~01,1-- Cardiac plexus
D orsal m o to r n u c le u s .

Pulmonary plexus

'--1< ••..- Abdomen

SACRAL NERVES

• P rc .'J A " S /io 7 lic fib r u arise

from I d te r A I g r e y h o ,? ,
KJIHGFEDCBA
of s s c r .• •1 5 e s m e " u 5 "M
=t= Bladder
Uterus! genital.
Hindgut
of spin .•1cord line. Pelvic floor!
 SPINAL CORD, T, - L';J
!GANGLlON!lparave"ebral!
• Synapse

0-1-jihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
0- -
0- -
S u p e r io r ,

ZYXWVUTSRQPONMLKJIHGFEDCBA
m id d le , in fe flo r c e r v ic a l g a n g litl
• FAR from TARGET
• A c e ty lc h o lin e tran.~mitter
• N ic .o c in ic T c a p tO r
T,

PARAVERTEBRAL CHAIN !POSTGANGlIONIC FIBREl

orSYMPATHETICTRUNl<-GANGLlA
• Unmyelinated 'C'-fibre
• LONG fibre (adrenergic)
• Preganglionic ~bres [rom lateral hom T, - L';J reach
s y m p 4 1 t .h e t ic PONMLKJIHGFEDCBA
t r u n k v i a s p ir u l
nerve a n d ITARGET !
rsm i Ibr,wche..s) - c o m m u n ic s n te s • U s u a lly noradrenaline tr a n s m itte r

• P r e g a n g lio n ic s p ls n c h n ic nerves .synapM. in

• tt-!~-reuptOT5
periphcr~1 g .1 n g l i a .l c o c " ~ c ,s u p e r i o f / snd [except sweat glands and some cholinergic fibres supplying
inferior m e s e n te r ic I arterioles in s k e le ta l muscle]

• Proganglionie ~bres synap~ directly on to

A drens! m o d u li • •

~
0 ---
0 ---
o

liiJ/ PARASYMPATHETIC l

I CRANIOSACRAL OUTFLOW illl, VIII, IX, X,S •. ,,;I o P r e g a n g lio n ic f ih r e .: CD p o s tfla n g liO ll1 c fibres

CRANIAL NERVES I PREGANGLIONIC FIBRE I

C o n s tr ic to r
• Myelin.ted 'B'-fibre
• Hence 'WHITE'
Ill •.•- - - - - - - - - - - - - - { < O o } - - - - - « pupillae • LONG fib ••
Edinger-Westphal nucleus Ciliary Cili"ry
g a n g lio n m u s c le IGANGLlONI
· S yn ap se

VII •.....- - - - - - - - - - - - - r - 1 ~o jl- - - - ...•

-- Lacrimal gland • CLOSE to TARGET (usually in wall. of viscera)
saliva-v n u c l e u s • Acervchcline t r o l n s m i t t e : r
S u p e r io r Ptervgopalacine
N a s o p a la tin e : • N ic o tin ic recepror
g~'nglion
glands
'- - { < o } - - - - - ,- -
Submandibular ! POSTGANGLIONIC FIBRE I
Submandibular gland • Unmyelinated 'C'-fibre
~Anglion Sublingual gland • SHORT fibre
• C h o lin e r g ic

IX •.•- - - - - - - - - - - - - - f< O o jf- - - - - - - Parotid gland !TARGET I

(n (u lo r saH vary nucleus O tic g a n g lio n
• Acervicholine transmitte>
• M u s c .lT in ic recepror
X •.....- - - - - - - - - - - - - r - 1 ~01,1-- Cardiac plexus
D orsal m o to r n u c le u s .

Pulmonary plexus

'--1< ••..- Abdomen

SACRAL NERVES

• P rc .'J A " S /io 7 lic fib r u arise

from I d te r A I g r e y h o ,? ,
KJIHGFEDCBA
of s s c r .• •1 5 e s m e " u 5 "M
=t= Bladder
Uterus! genital.
Hindgut
of spin .•1cord line. Pelvic floor!
 G)MYOGENIC PONMLKJIHGFEDCBA
@HYPOXIA CD MET ABOLlTES G) VASOACTIVE SU BST ANCES
• vasodilation • v s s o d ils tio n • vasodilation
• v a s o c o n s tr ic tio n
in response to except LUNGS
[ = hypoxic vasoconstriction
J ICO,,-/. pH, ADP, AMP,
adenosine, K+.l
bradykinin, hi.<,amine, NO
• v a s o c o n s tr ic tio n
srrercb
e.g. BTain angiotensin 11
Kidney

ENDOCRINE
I

r @NORADRENALlNE
r CD ADH
1
[v••.•opressinl
(!)ADRENALlNE
, LOW concentration vasoconstriction la) A n .- ,io r e n s in "

vasodilation II~ ,) vasoconstriction

'HIGH concentration
vasoconstriction la!

N EU RAL (, anerioles]

Postganglionic u-receprcrs ---+va5ocon.s.triction esp. k ia n e y .s / s k in

Postganglionic Il,-recepcors _vasodilation esp, s k e le ts ! m u s c le
Equal numbers a == ~1 e.g. s to m s c h , in u ..s e in e s . coronary v e s s e ls

C e n tr s l c o - in n e r v s c io n , e..3. muscle activation sends impulse. from cerebral cortex to C-V centre
Regulated by

< Rtfl..,. es, e.3. baroreceptor reflex

,. Central control ---+ temperature regulation

PARASYMPATHETIC VASODILATION ---. genical organ. IErection)

. ---~ . ~ -~ = = --
-----" -~ ~ ~ . -~-
 G)MYOGENIC PONMLKJIHGFEDCBA
@HYPOXIA CD MET ABOLlTES G) VASOACTIVE SU BST ANCES
• vasodilation • v s s o d ils tio n • vasodilation
• v a s o c o n s tr ic tio n
in response to except LUNGS
[ = hypoxic vasoconstriction
J ICO,,-/. pH, ADP, AMP,
adenosine, K+.l
bradykinin, hi.<,amine, NO
• v a s o c o n s tr ic tio n
srrercb
e.g. BTain angiotensin 11
Kidney

ENDOCRINE
I

r @NORADRENALlNE
r CD ADH
1
[v••.•opressinl
(!)ADRENALlNE
, LOW concentration vasoconstriction la) A n .- ,io r e n s in "

vasodilation II~ ,) vasoconstriction

'HIGH concentration
vasoconstriction la!

N EU RAL (, anerioles]

Postganglionic u-receprcrs ---+va5ocon.s.triction esp. k ia n e y .s / s k in

Postganglionic Il,-recepcors _vasodilation esp, s k e le ts ! m u s c le
Equal numbers a == ~1 e.g. s to m s c h , in u ..s e in e s . coronary v e s s e ls

C e n tr s l c o - in n e r v s c io n , e..3. muscle activation sends impulse. from cerebral cortex to C-V centre
Regulated by

< Rtfl..,. es, e.3. baroreceptor reflex

,. Central control ---+ temperature regulation

PARASYMPATHETIC VASODILATION ---. genical organ. IErection)

. ---~ . ~ -~ = = --
-----" -~ ~ ~ . -~-
1 PHOTORECEPTOR I
.[f2@_PHOTOPIC------oIRODI-sCOTOPIC

I LOCAL CONTRAST PRESERV=A~T~180~N5Ilill~r_----<. ~ § ~ ±]~ ~ ~ ~

., ON/OH RETIN~L CHANN ELS LATERAL INH IBITION

BIPOLAR CELLS HORIZONTAL CELLS

GANGLION CELLS AMACRINE CELLS
LGN
VISUAL CORTEX

IIMPORTANTFEATURESI
.1 PHOTORECE PTYo\iiRSj~---· 81C2EQN~TBR~E2-S~U!!R~R~0?1uIiN~D~1
ON/OFF CHANNELS ----01 I

CLASSIFICATION OF V IS IO N 1 LIGHT I [Awaren •.•.• of light and intensity modificationl

1 COLOUR I iDiff<rentiare quality of light by wavelength!

1 CONTRAST I iDiscriminate pans of a visual image'

1 LIGHT SENSE I • INTENSITY due to • Lighr source.

o Object rejlecrance

1 BRIGHTNESS I o PHOTOPIC VISION SCOTOPIC VISION

• lV \c a s u r c .d in u n it o f luminance High levels of illumination Low levels of illumination

o candela/m1 e.g. DAYLIGHT e.g, NIGHT VISION
H iSh eneTgysignal r.IS"P;";A""'T"IA"'-L'S"-U"'M 7MA""'"''''T''IO=N-:-'
Low-enew lishr siST'al
• p h o to m e tr ic u n it
o RADIANCE corrected for spectral Excellencvisual acuity of central fieldZYXWVUTSRQPONMLKJIHGFEDCBA
efficiencyof standardized eye G ood c o lo u r v is io n
I C one d r iv e n Idue. to cone s ig n a l le a v in g

g a n g lio n c e ll re.fraccory to s lo w e r r o d
s i3 1 l.a 1 a n d a l.s o d u e . to r o d s a tu r a tio n
I Surround.domin..anr! in g o ln g lio n cell
cenere-surround

I QUALITATIVE DIFFERENCE I

--
• Between perception of b r is h c n e s s and dsrkness
• N ot just v a r ia tio n in intensirv
• Carried by TlNO DIFFERENT POPULATIONS OF CELLS. Often with opposite r.spons"'/'.g. §and @cells
00
1 PHOTORECEPTOR I
.[f2@_PHOTOPIC------oIRODI-sCOTOPIC

I LOCAL CONTRAST PRESERV=A~T~180~N5Ilill~r_----<. ~ § ~ ±]~ ~ ~ ~

., ON/OH RETIN~L CHANN ELS LATERAL INH IBITION

BIPOLAR CELLS HORIZONTAL CELLS

GANGLION CELLS AMACRINE CELLS
LGN
VISUAL CORTEX

IIMPORTANTFEATURESI
.1 PHOTORECE PTYo\iiRSj~---· 81C2EQN~TBR~E2-S~U!!R~R~0?1uIiN~D~1
ON/OFF CHANNELS ----01 I

CLASSIFICATION OF V IS IO N 1 LIGHT I [Awaren •.•.• of light and intensity modificationl

1 COLOUR I iDiff<rentiare quality of light by wavelength!

1 CONTRAST I iDiscriminate pans of a visual image'

1 LIGHT SENSE I • INTENSITY due to • Lighr source.

o Object rejlecrance

1 BRIGHTNESS I o PHOTOPIC VISION SCOTOPIC VISION

• lV \c a s u r c .d in u n it o f luminance High levels of illumination Low levels of illumination

o candela/m1 e.g. DAYLIGHT e.g, NIGHT VISION
H iSh eneTgysignal r.IS"P;";A""'T"IA"'-L'S"-U"'M 7MA""'"''''T''IO=N-:-'
Low-enew lishr siST'al
• p h o to m e tr ic u n it
o RADIANCE corrected for spectral Excellencvisual acuity of central fieldZYXWVUTSRQPONMLKJIHGFEDCBA
efficiencyof standardized eye G ood c o lo u r v is io n
I C one d r iv e n Idue. to cone s ig n a l le a v in g

g a n g lio n c e ll re.fraccory to s lo w e r r o d
s i3 1 l.a 1 a n d a l.s o d u e . to r o d s a tu r a tio n
I Surround.domin..anr! in g o ln g lio n cell
cenere-surround

I QUALITATIVE DIFFERENCE I

--
• Between perception of b r is h c n e s s and dsrkness
• N ot just v a r ia tio n in intensirv
• Carried by TlNO DIFFERENT POPULATIONS OF CELLS. Often with opposite r.spons"'/'.g. §and @cells
00
 LGN

I LIGHT I
jihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA E·W INTERBLOB >,J

SUPERIOR
V, • COLLlCULUS

~ PULVINAR
I MECHANISMS I ?

-\ PHOTORECEPTORSI

IIN LIGHT I
IIN DARK I
• IC...• • High levels of cGMP
• Hyperpol",ize [.cGMp ..• CloseNa·/Cal+ infl,,)(~ ' · I;!
PONMLKJIHGFEDCBA
- N. "Ca" influxZYXWVUTSRQPONMLKJIHGFEDCBA
• Allows 'D d r k C u r r e n t '
• Graded hyperpolArization Il intensity of illumination
• -4 sm V m em brane p o te n tia l
• • OUtput of exciratorv amino acids

-ICONE 1- PHOTOPIC -I RODS I-SCOTOPIC

4 -5 m iflio ll
80·110 million
Peak density in fovea [aoo ooo/mm'! Peak d e n s ity in a h o r iz o n ta l e llip tic a l r in g b e tw e e n

Foveola is deficient in@cones !BLUE) nerve head and m a c u la

(s u p e r io r ret ina 160 o o o l m m 1 j

IRESPONSE!
IRESPONSE!
High rhr es hold \Virh reg,uds [0 background Lowest. absolute threshold to flashes on dark
light background

I
G rA ded o v e r J (o S ' u n iu lig h t inte.nsity G raded o v e r J lo g u n its (iglu i n t e n s i t y above
•.bove bacic..'Vound background
F aster response t i m e Slower r e c o v e r y
(})TYPES of phococbernicals with peak Peak sensitivity at 496 nm
absorbanc es a, ligh, w avele!!!!.,hs of Sensitive '0 LOW ENERGY BLUE LIGHT
445, 535 and 570 nm ® e~ ! R e d lig h t r e q u ir e s J lo g : u n its g r e a te r illu m in a n c e
u n d e r s a m e . c o n d itio n s
Easily saturated with increased ligh, intensi,y
IBluching 10% of pigment caoses reo-fold
increase in threshold!

I BEYOND PHOTORECEPTORS I
G
NOTE:

e I LOCAL

•. S h o u ld
CONTAAST

remain constant w ith

PRESERVATION

changes i n illumination
I~
Absolute levels of ligh,

• Based ~c!IO 1- irrelevant o f rvpe o f definicion Ii.e. W e b e r ' s L 1 W , Mich4d~n C o n t r a . o ; t )

• e.g.0 H BANDS 1,865/' Border contrast
• e.g. - Simuit.anc.ou,s conrrasc. N e u t r a l o b ' e " b T i h t e r o r darker de nding
EJ on adjacent region. ABSOLUTE ILLUMINANCE VARIABL
•...
00
W
 LGN

I LIGHT I
jihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA E·W INTERBLOB >,J

SUPERIOR
V, • COLLlCULUS

~ PULVINAR
I MECHANISMS I ?

-\ PHOTORECEPTORSI

IIN LIGHT I
IIN DARK I
• IC...• • High levels of cGMP
• Hyperpol",ize [.cGMp ..• CloseNa·/Cal+ infl,,)(~ ' · I;!
PONMLKJIHGFEDCBA
- N. "Ca" influxZYXWVUTSRQPONMLKJIHGFEDCBA
• Allows 'D d r k C u r r e n t '
• Graded hyperpolArization Il intensity of illumination
• -4 sm V m em brane p o te n tia l
• • OUtput of exciratorv amino acids

-ICONE 1- PHOTOPIC -I RODS I-SCOTOPIC

4 -5 m iflio ll
80·110 million
Peak density in fovea [aoo ooo/mm'! Peak d e n s ity in a h o r iz o n ta l e llip tic a l r in g b e tw e e n

Foveola is deficient in@cones !BLUE) nerve head and m a c u la

(s u p e r io r ret ina 160 o o o l m m 1 j

IRESPONSE!
IRESPONSE!
High rhr es hold \Virh reg,uds [0 background Lowest. absolute threshold to flashes on dark
light background

I
G rA ded o v e r J (o S ' u n iu lig h t inte.nsity G raded o v e r J lo g u n its (iglu i n t e n s i t y above
•.bove bacic..'Vound background
F aster response t i m e Slower r e c o v e r y
(})TYPES of phococbernicals with peak Peak sensitivity at 496 nm
absorbanc es a, ligh, w avele!!!!.,hs of Sensitive '0 LOW ENERGY BLUE LIGHT
445, 535 and 570 nm ® e~ ! R e d lig h t r e q u ir e s J lo g : u n its g r e a te r illu m in a n c e
u n d e r s a m e . c o n d itio n s
Easily saturated with increased ligh, intensi,y
IBluching 10% of pigment caoses reo-fold
increase in threshold!

I BEYOND PHOTORECEPTORS I
G
NOTE:

e I LOCAL

•. S h o u ld
CONTAAST

remain constant w ith

PRESERVATION

changes i n illumination
I~
Absolute levels of ligh,

• Based ~c!IO 1- irrelevant o f rvpe o f definicion Ii.e. W e b e r ' s L 1 W , Mich4d~n C o n t r a . o ; t )

• e.g.0 H BANDS 1,865/' Border contrast
• e.g. - Simuit.anc.ou,s conrrasc. N e u t r a l o b ' e " b T i h t e r o r darker de nding
EJ on adjacent region. ABSOLUTE ILLUMINANCE VARIABL
•...
00
W
 • Hyperpolarize to light • Depolarizes to lighr
FLAT@ INVACINATINC@ • 'TRIAD'
• Dendrires branch
in outer If) IPL • Dendrites branch in inneraZYXWVUTSRQPONMLKJIHGFEDCBA
' h IPL

~ RODBIPOLAR ~

llcANCLlON CELL! • J million

• Cenre-surrcund recepcivezyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
field
• ON·CENTRE or OFF·CENTRE RECEPTIVE field
• Better response [0 sm.l.$ C6 thAn unifoTm illumination
• ALL or NONE spike isc "'ge

Further Subdivision fOfSpatial Summation

• TONIc/SUSTAINED response • TRANSIENT/PHASIC response

~ ·INON·lINEAR! SPATIAL SUMMATION
• Recepcive field IllNEARI
SPATLAL SUMMATION
\X CELL I '-1
Y":'C-E-L~L
I • High fTe.QlIency
temporal response
• PATTERN DISCRIMINATION MOTION DETECTION in field
• Fast conducting _ MACN OCE LLU LAR LCN
~
• Canglion celts from a !DUALSYSTEM! of parallel regular mosaic of ION·CENTRE! and !OFF.CENTRE!
channels that sample retina.l image. independenrlv
• Crearer IROD CONVERGENCE!lh,ln cone convergence on to ganglion cell

ON·CENTRE Cell. OFF·CENTRE Cells

• Layers s, 6 • Layers 3,4
• Circular receptive. fields
• Spatially opponent

\CORTEXI
• ®and@ channels convergeon [0 single cells in COrtex
• ®'lnd@ channels have NO ROLE in crienraeion and direction selectionSRQPONMLKJIHGFEDCBA
• M d in c .lin a > n tr .J 5 ( over wide range -
• R .e c e p tiv e fie ld - narrallel non-concentric antagonist strips

I IMPORTANT FEATURES I
• IPHOTORECEPTORS f--- ICENTRE.SURROUND I • ION and OFF CHANNELS I
• CONE • Enhances edges/contrast • Increase contrast e::rc,!2tion
• ROD • Reduce sensitivity of ganglion • Allows ~ itX'"Cl'il~T~A;"T"'O"""R"'Y"'!
transrni •.•ion
cell to changes in lnten.,ity of of light jncr~ment Ordecrement
diffuse light
• Increased sensitivity to patterned
.nimufus

-
QC)
c.",
 • Hyperpolarize to light • Depolarizes to lighr
FLAT@ INVACINATINC@ • 'TRIAD'
• Dendrires branch
in outer If) IPL • Dendrites branch in inneraZYXWVUTSRQPONMLKJIHGFEDCBA
' h IPL

~ RODBIPOLAR ~

llcANCLlON CELL! • J million

• Cenre-surrcund recepcivezyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
field
• ON·CENTRE or OFF·CENTRE RECEPTIVE field
• Better response [0 sm.l.$ C6 thAn unifoTm illumination
• ALL or NONE spike isc "'ge

Further Subdivision fOfSpatial Summation

• TONIc/SUSTAINED response • TRANSIENT/PHASIC response

~ ·INON·lINEAR! SPATIAL SUMMATION
• Recepcive field IllNEARI
SPATLAL SUMMATION
\X CELL I '-1
Y":'C-E-L~L
I • High fTe.QlIency
temporal response
• PATTERN DISCRIMINATION MOTION DETECTION in field
• Fast conducting _ MACN OCE LLU LAR LCN
~
• Canglion celts from a !DUALSYSTEM! of parallel regular mosaic of ION·CENTRE! and !OFF.CENTRE!
channels that sample retina.l image. independenrlv
• Crearer IROD CONVERGENCE!lh,ln cone convergence on to ganglion cell

ON·CENTRE Cell. OFF·CENTRE Cells

• Layers s, 6 • Layers 3,4
• Circular receptive. fields
• Spatially opponent

\CORTEXI
• ®and@ channels convergeon [0 single cells in COrtex
• ®'lnd@ channels have NO ROLE in crienraeion and direction selectionSRQPONMLKJIHGFEDCBA
• M d in c .lin a > n tr .J 5 ( over wide range -
• R .e c e p tiv e fie ld - narrallel non-concentric antagonist strips

I IMPORTANT FEATURES I
• IPHOTORECEPTORS f--- ICENTRE.SURROUND I • ION and OFF CHANNELS I
• CONE • Enhances edges/contrast • Increase contrast e::rc,!2tion
• ROD • Reduce sensitivity of ganglion • Allows ~ itX'"Cl'il~T~A;"T"'O"""R"'Y"'!
transrni •.•ion
cell to changes in lnten.,ity of of light jncr~ment Ordecrement
diffuse light
• Increased sensitivity to patterned
.nimufus

-
QC)
c.",
 -I LEVEL OF: I IRETINA I ICONES - Trichomatic receptcrs
HORIZONTAL CELL
BIPOLAR CELL
• C~ntre-surround
• On/off pathway
GANGLION CELL • Colouropponency
• T onic/Phasic cells

1LGN I • Parvoc;ellularpathway

IVISUALCORTEX I zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
• Fovea! repre5e.nt.l,rion
• Doeble opponencv
• Blob cells
• V4

• Colour perception is a p.uallel pathway

.1~R~ElT!EIN~A~11 =======;:========~;>
Trichornanc receprcrsL' !:!&ill
CHROMATIC PATHWAY 1 -I PARVOCELLULAR
;>IVISUAL CORTEX
1 _'COLOUR 1
1

k[ivity
• Opponencv ACHROMATIC PATHWAY - Magnocdlular ---- •• Motian
[Luminance] Depth

tTl

@~sg~~QJ '"
~'"
Hence, HERING'S THEORY OF COLOUR
ICOLOUR VISIONI IHISTORY OF COLOURSPECTRUMI
OPPONENCY ..•..•
VI

Sensory phenomenon Maxwdl ,.8561, Helmholtz i.8671 c:

..•
I
• @Basiehues ~m.t~RElNIBI.UE.1 n
Poorly undersrood mechanism
ITRICHOMATICTHEORyl
8,5% popularion consclln'cy • l.£6!BIQJ and P I processesaZYXWVUTSRQPONMLKJIHGFEDCBA
Related co colours of .su"oundingc; • (j) Receprortypes ~ e <D
44a 535 567
ccoes • R e d -C re e n - muc,ually exclusive. ~
SRQPONMLKJIHGFEDCBA
~
Combination of: • B lu e - Y e llo w - mutually exclusive
• 'Hues' due [0 overlap of specrral
'i!lhC from surrounding objects • Achromatic dimension IBLACK WHITE I
1 light fro m object> sensiuviev
opponent system - accounts for PINK,
ffiJ srate of lighe adaptation
'BUT, HERING 1.8781ASI(F.D: I .MAROONer.c.
• Other colour combmartons are HUES
YELLOW should thus be a mixture of
Red/Green but inscead i. PRI.MAR Y • ICONCLUSION 1
• 'Reddish-Gr«n' jar Bluish-Yellow] is ® BASIC COLOURS coded by(j)-
never seen in nature. opponent process
IRED-GREEN IIBLUE - yElLOW l"IACK-wRITE I

MECHANISMS
• Colour channels in parallel to luminance channels
• Colour chAnne.ls re..spond [0 Ichanges in w.lvclcngthlAnd are processed I indep(.ndendy I and ~ [0

IchAnges in light intt.nsi(yllluminanceJ

ICONES 1 • (j)C\asses
• Spectra! characteristic {photop;gmenr.sJ
• Retinal location <DMACULNNASAl RETINA 0 (2) CONES = 1° eccentric

1HORIZONT AL CELL Cb' Spatial organization

• RECEPTIVE FIELD Centre-surround

-"
1BIPOLAR CELL • Orv'offpathways
• RECEPTIVE FIELD ON-untrelOFF-centre
QC
 -I LEVEL OF: I IRETINA I ICONES - Trichomatic receptcrs
HORIZONTAL CELL
BIPOLAR CELL
• C~ntre-surround
• On/off pathway
GANGLION CELL • Colouropponency
• T onic/Phasic cells

1LGN I • Parvoc;ellularpathway

IVISUALCORTEX I zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
• Fovea! repre5e.nt.l,rion
• Doeble opponencv
• Blob cells
• V4

• Colour perception is a p.uallel pathway

.1~R~ElT!EIN~A~11 =======;:========~;>
Trichornanc receprcrsL' !:!&ill
CHROMATIC PATHWAY 1 -I PARVOCELLULAR
;>IVISUAL CORTEX
1 _'COLOUR 1
1

k[ivity
• Opponencv ACHROMATIC PATHWAY - Magnocdlular ---- •• Motian
[Luminance] Depth

tTl

@~sg~~QJ '"
~'"
Hence, HERING'S THEORY OF COLOUR
ICOLOUR VISIONI IHISTORY OF COLOURSPECTRUMI
OPPONENCY ..•..•
VI

Sensory phenomenon Maxwdl ,.8561, Helmholtz i.8671 c:

..•
I
• @Basiehues ~m.t~RElNIBI.UE.1 n
Poorly undersrood mechanism
ITRICHOMATICTHEORyl
8,5% popularion consclln'cy • l.£6!BIQJ and P I processesaZYXWVUTSRQPONMLKJIHGFEDCBA
Related co colours of .su"oundingc; • (j) Receprortypes ~ e <D
44a 535 567
ccoes • R e d -C re e n - muc,ually exclusive. ~
SRQPONMLKJIHGFEDCBA
~
Combination of: • B lu e - Y e llo w - mutually exclusive
• 'Hues' due [0 overlap of specrral
'i!lhC from surrounding objects • Achromatic dimension IBLACK WHITE I
1 light fro m object> sensiuviev
opponent system - accounts for PINK,
ffiJ srate of lighe adaptation
'BUT, HERING 1.8781ASI(F.D: I .MAROONer.c.
• Other colour combmartons are HUES
YELLOW should thus be a mixture of
Red/Green but inscead i. PRI.MAR Y • ICONCLUSION 1
• 'Reddish-Gr«n' jar Bluish-Yellow] is ® BASIC COLOURS coded by(j)-
never seen in nature. opponent process
IRED-GREEN IIBLUE - yElLOW l"IACK-wRITE I

MECHANISMS
• Colour channels in parallel to luminance channels
• Colour chAnne.ls re..spond [0 Ichanges in w.lvclcngthlAnd are processed I indep(.ndendy I and ~ [0

IchAnges in light intt.nsi(yllluminanceJ

ICONES 1 • (j)C\asses
• Spectra! characteristic {photop;gmenr.sJ
• Retinal location <DMACULNNASAl RETINA 0 (2) CONES = 1° eccentric

1HORIZONT AL CELL Cb' Spatial organization

• RECEPTIVE FIELD Centre-surround

-"
1BIPOLAR CELL • Orv'offpathways
• RECEPTIVE FIELD ON-untrelOFF-centre
QC
 ) Small dendritic and receprive field size ) Large dendritic and receptive field size
4 Sustained [tonic] response 4 Short [phasic] respon.eaZYXWVUTSRQPONMLKJIHGFEDCBA
5 Project to I PARVO ~t U LAR lavers of LGN 5 Project (0 IMACNOCElLULARI lavers of LGN
6 MA N ~l ~l ROPPO"EN ·PROCESSOR] 6 .MAIN PROCESSOR OF LUMINANCE CONTRAST
Colour blind
. Low-coutrase
Colour selective
sensitivity
.. High-contrast
Low resolucion
sensitivity

. Slow
High f'c..o;otutlon
Fast

RED- CREEN OPPONENTbaZYXWVUTSRQPONMLKJIHGFEDCBA

vs BLUE- YELLOWOPPONENT e..g. Red - Green QpponencY@<e.nrrel@sunound

• Smaller receptive field size

• Clear spatia! resolution
and antagonism
• Higher temporal resolution
• larger receprive field size
• Poor spatial resolution

• lower onset latency

e V zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
~
-
Red Centre
- flllllllll~

zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Creen surround

• Flickerjusion frequency
~ 60-70 Hz
- lower temporal resolurion

• Flick.r fusion fr<qu"ncy

-)5 Hz
<D t> (t)( 0-
ganglion cell
=
Yellow
stimulatcs
tT'l
Cl>
Cl>

'"
'<

IRAPID SEQUENCE STIMULlII SIMILAR TO RODS I e$> /e both ~

..•
c:
IRESOLVED fASTEJVEASIER I ,15, ...•
1"1

..•
c:
n
.:.

• Relay bration, par",lIe1 channels

• @Iayers
@tOpogr,1phicdl m" oS 0 contralateral halo visual f,e;;ld;"""=-rr,.,-,..,...,,,,,,,,===-="
Reccptivefields- .IR U ARS .MMETRI AL and ISPATIAlLY OPPONENT I
VU. • Laver .• ) - 6
• Colour- opponent receptive [ie.lds
• Relay for colour vision

IVISUAL CORTEX I • Large.rrepresentation of fovea

• Field - includes DOUBLE OPPONENCY
• R£c"ivesI PARVOCELLULARI<E> and MACNOCELLULAR 9 pathways

*
• No analysis of vision occurs ac(2) -

POSSIBLE PATHWAYS

EJ
ITHIN STRIPE I (colour) @ (colour!
® =:;>- ~ ITHICK STRIPEI [sre••sopsis] IMIDDLE TEMPORAL! (: movement
stereopsis
~ IPALESTRIPE Ilanalysis ?

• MagnocellularIPARVOCELLULAR- BLOB - THIN STRIPE - pathway

9~ -- IVcw!> -- LAYERS'+J
• BLOB CELLS
-- e --
[colour conrras t]

• COLOUR
• Low Acuity
 ) Small dendritic and receprive field size ) Large dendritic and receptive field size
4 Sustained [tonic] response 4 Short [phasic] respon.eaZYXWVUTSRQPONMLKJIHGFEDCBA
5 Project to I PARVO ~t U LAR lavers of LGN 5 Project (0 IMACNOCElLULARI lavers of LGN
6 MA N ~l ~l ROPPO"EN ·PROCESSOR] 6 .MAIN PROCESSOR OF LUMINANCE CONTRAST
Colour blind
. Low-coutrase
Colour selective
sensitivity
.. High-contrast
Low resolucion
sensitivity

. Slow
High f'c..o;otutlon
Fast

RED- CREEN OPPONENTbaZYXWVUTSRQPONMLKJIHGFEDCBA

vs BLUE- YELLOWOPPONENT e..g. Red - Green QpponencY@<e.nrrel@sunound

• Smaller receptive field size

• Clear spatia! resolution
and antagonism
• Higher temporal resolution
• larger receprive field size
• Poor spatial resolution

• lower onset latency

e V zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
~
-
Red Centre
- flllllllll~

zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Creen surround

• Flickerjusion frequency
~ 60-70 Hz
- lower temporal resolurion

• Flick.r fusion fr<qu"ncy

-)5 Hz
<D t> (t)( 0-
ganglion cell
=
Yellow
stimulatcs
tT'l
Cl>
Cl>

'"
'<

IRAPID SEQUENCE STIMULlII SIMILAR TO RODS I e$> /e both ~

..•
c:
IRESOLVED fASTEJVEASIER I ,15, ...•
1"1

..•
c:
n
.:.

• Relay bration, par",lIe1 channels

• @Iayers
@tOpogr,1phicdl m" oS 0 contralateral halo visual f,e;;ld;"""=-rr,.,-,..,...,,,,,,,,===-="
Reccptivefields- .IR U ARS .MMETRI AL and ISPATIAlLY OPPONENT I
VU. • Laver .• ) - 6
• Colour- opponent receptive [ie.lds
• Relay for colour vision

IVISUAL CORTEX I • Large.rrepresentation of fovea

• Field - includes DOUBLE OPPONENCY
• R£c"ivesI PARVOCELLULARI<E> and MACNOCELLULAR 9 pathways

*
• No analysis of vision occurs ac(2) -

POSSIBLE PATHWAYS

EJ
ITHIN STRIPE I (colour) @ (colour!
® =:;>- ~ ITHICK STRIPEI [sre••sopsis] IMIDDLE TEMPORAL! (: movement
stereopsis
~ IPALESTRIPE Ilanalysis ?

• MagnocellularIPARVOCELLULAR- BLOB - THIN STRIPE - pathway

9~ -- IVcw!> -- LAYERS'+J
• BLOB CELLS
-- e --
[colour conrras t]

• COLOUR
• Low Acuity
 MACNOCELLULAR LAYER
PARVOCELLULAR LAYER
• <DLa~rs I. and.!
• @La~rs 13 - 6)
• • x cen troll 10° 2 X o"rioheral field
receptive fields
·· 8 -aZYXWVUTSRQPONMLKJIHGFEDCBA
. 0 % of LCN-volume
L~ckof colourooponency
• IcoloUR
• Sustdin~d response .. ·· T, ansie.nc Tc,spon.se
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ur~ receprive field
··Small receptive field
Receive input from slowlm~dium·vclocity ",",ons ··Receive input from fast velocity axons
Send high.velociey signal to srriare cortex
·S~nd slowlmedium·vclocity signal to striat~ cortex
·· Reup';vc
Up [0 lD% lack clearcur. eolcur se.n.sitivity
fidd 80% - COLOU R OPPON ENT
· High-contrast sensitivity

CENTRE·SURROUND

10% - CENTRE·ON LY
COLOUR OPPONENT
BROADBAND
• If(tLAY STAtiON FOR CONTRAST viSION I
STATION
.• IRELAYCONTRAST
Uuful
HIGH
FoilCoLOuRVlslONI
for viSUAl ~ctivicy only in the. pr(.5Cf\U of

fV[UALCOIl.TEXI • Luger rc.pre.~(nlA1C10n of fovea

• Cell grouping based on • Field [iuc. Double opponellcy!
• OCUIM dominance
·OricHr.ation
• Lovers
• Receive MACNOC[lLULAR 9 and PARVOCELLULAR(E)pathway.
• No analysis of visio» occurs at€)

~
ITHINSTRIPE
ITHICKSTRIPE!

\ PALE STRIPE
!Icolour!
i.tereop.is:

IIAnalysis!
*
:;> @Icolourl
!.MIDDLE TEMPORAL!

?
I' movement)
\. s tereopsrs
POSSIBLE PATHWAYS

CD ®-IVB -lNTERBLOB- PALESTRlPE I

le,® - BLOB - TH IN STRI PE - pathway I le-IVB - THICI<STRIPE-MT -pAthway!
1. pathway.
9,$ ...•IVca/p ...• Uyerol + 3 •..• N;)...•@ e_IVca_IVB- @-@ ~ _ IV~ _ Layero 1 + J - @ - 1
• BLOB CELt5" • INTERBLOB CELLS
[colour contrast! • Cells seleceiveformovement and
stereoscopicdepth [turned to orientation
• High temporal resoludon ofedgosl
• COLOUR • High.resolution border informAtion
• LowAcuity [movingand flicuring lights!
• Colour blind [colourunnecessary in • Colour differenu> indicate borders
motion and depth perception}

....
-
~
 MACNOCELLULAR LAYER
PARVOCELLULAR LAYER
• <DLa~rs I. and.!
• @La~rs 13 - 6)
• • x cen troll 10° 2 X o"rioheral field
receptive fields
·· 8 -aZYXWVUTSRQPONMLKJIHGFEDCBA
. 0 % of LCN-volume
L~ckof colourooponency
• IcoloUR
• Sustdin~d response .. ·· T, ansie.nc Tc,spon.se
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ur~ receprive field
··Small receptive field
Receive input from slowlm~dium·vclocity ",",ons ··Receive input from fast velocity axons
Send high.velociey signal to srriare cortex
·S~nd slowlmedium·vclocity signal to striat~ cortex
·· Reup';vc
Up [0 lD% lack clearcur. eolcur se.n.sitivity
fidd 80% - COLOU R OPPON ENT
· High-contrast sensitivity

CENTRE·SURROUND

10% - CENTRE·ON LY
COLOUR OPPONENT
BROADBAND
• If(tLAY STAtiON FOR CONTRAST viSION I
STATION
.• IRELAYCONTRAST
Uuful
HIGH
FoilCoLOuRVlslONI
for viSUAl ~ctivicy only in the. pr(.5Cf\U of

fV[UALCOIl.TEXI • Luger rc.pre.~(nlA1C10n of fovea

• Cell grouping based on • Field [iuc. Double opponellcy!
• OCUIM dominance
·OricHr.ation
• Lovers
• Receive MACNOC[lLULAR 9 and PARVOCELLULAR(E)pathway.
• No analysis of visio» occurs at€)

~
ITHINSTRIPE
ITHICKSTRIPE!

\ PALE STRIPE
!Icolour!
i.tereop.is:

IIAnalysis!
*
:;> @Icolourl
!.MIDDLE TEMPORAL!

?
I' movement)
\. s tereopsrs
POSSIBLE PATHWAYS

CD ®-IVB -lNTERBLOB- PALESTRlPE I

le,® - BLOB - TH IN STRI PE - pathway I le-IVB - THICI<STRIPE-MT -pAthway!
1. pathway.
9,$ ...•IVca/p ...• Uyerol + 3 •..• N;)...•@ e_IVca_IVB- @-@ ~ _ IV~ _ Layero 1 + J - @ - 1
• BLOB CELt5" • INTERBLOB CELLS
[colour contrast! • Cells seleceiveformovement and
stereoscopicdepth [turned to orientation
• High temporal resoludon ofedgosl
• COLOUR • High.resolution border informAtion
• LowAcuity [movingand flicuring lights!
• Colour blind [colourunnecessary in • Colour differenu> indicate borders
motion and depth perception}

....
-
~
 • MLF • SLOW DRIFTS
• Cerebellum • FLICKS

!FINAL EFFERENT PATHWAY!

!MOVEMENTS!
FRONTOTECTAL OCCIPITOTECTAL
ConJuguL • Non·ConjugAte
pathway AndOCCIPITOCOLLlCULAR

I HORIZONTAL-
• MMR
Conve,fence 'Dlve,gence

VERTlCAL-
• SR/lR •
TORSIONAL o
pathway
! PRETECTAL NUCLEI I

o
1 0 /5 0
!SUPERIORCOLlICULUS!
!CRANIAL NERVE NUCLEI I
C® •
BOTH LEVATORS III 0--
• C.ont'AldteralSR
• Ipsilate,al MR, IR, 10

IV 0--
• Ipsil.u,.1 LR
• Projections to contralateral
fVlaMLFI
MR
VI 0--
+-- 0 VIII! VESTIBULARNUCLEUSI

!ACCESSORYOCULOMOTORNUCLEII
!INlTLATING CENTRES I

m ICORTICAL I
m IRETICULATOR FORMATION I
• Co-mdination
IIOCCIPITAL MOTOR CENTRE f-IFRONTAL EYE FIELDs I • PONTINE RF __ pAthWAY
[orconjugat.e
• Main regions in occipital • Saccades horizontal gaze:
cortex • Voluntary centre
• 4 MAIN UNITS
• lnvoluntolry I BURST UNIT-saccade

1 BURST·TONIC UNIT -saccadt/st<.tdygaze

) TONIC UNIT -ey< position
~ !SUPERlORCOLLlCULUsl • PAUSING UNIT - pausing with movement
• Very few optic tract (1bfes terminate here
• lnitiate Ttfkx movt.mentof eyes in response
to visual stimulus ~ !MLF/INTERSTITIAL NUCLEUS OF CAJAL!
• +/_cordin.lte Head/Eyc. movement with Body
• Conjusate vertical and tOfslon move.menu

~ !VESTIBULARNUCLEUS I ~ !CEREBELLUM I
• Feedbackcentre
• Modify ,.fle.xand voluntary ey<movements

!USEFULPOINTS TO MENTION I
ITYPES OF EYE MOVEMENTS I
.IHERlNC5 LAW I
mevemenc
• of voluntary GOnjug.1t~ eve
• PURSUIT
• YOKE MUSCLES- LIVMR, SIVIO, IRISO, LEVATORS • SACCADE
• POSITION MAINTENENCE
.• IEqu.dem'syIJ~/IEqu.l1 directionl
• VERCENCE INON·CONJUGATEI
• NON·OPTIC (VESTIBULAR)
 • MLF • SLOW DRIFTS
• Cerebellum • FLICKS

!FINAL EFFERENT PATHWAY!

!MOVEMENTS!
FRONTOTECTAL OCCIPITOTECTAL
ConJuguL • Non·ConjugAte
pathway AndOCCIPITOCOLLlCULAR

I HORIZONTAL-
• MMR
Conve,fence 'Dlve,gence

VERTlCAL-
• SR/lR •
TORSIONAL o
pathway
! PRETECTAL NUCLEI I

o
1 0 /5 0
!SUPERIORCOLlICULUS!
!CRANIAL NERVE NUCLEI I
C® •
BOTH LEVATORS III 0--
• C.ont'AldteralSR
• Ipsilate,al MR, IR, 10

IV 0--
• Ipsil.u,.1 LR
• Projections to contralateral
fVlaMLFI
MR
VI 0--
+-- 0 VIII! VESTIBULARNUCLEUSI

!ACCESSORYOCULOMOTORNUCLEII
!INlTLATING CENTRES I

m ICORTICAL I
m IRETICULATOR FORMATION I
• Co-mdination
IIOCCIPITAL MOTOR CENTRE f-IFRONTAL EYE FIELDs I • PONTINE RF __ pAthWAY
[orconjugat.e
• Main regions in occipital • Saccades horizontal gaze:
cortex • Voluntary centre
• 4 MAIN UNITS
• lnvoluntolry I BURST UNIT-saccade

1 BURST·TONIC UNIT -saccadt/st<.tdygaze

) TONIC UNIT -ey< position
~ !SUPERlORCOLLlCULUsl • PAUSING UNIT - pausing with movement
• Very few optic tract (1bfes terminate here
• lnitiate Ttfkx movt.mentof eyes in response
to visual stimulus ~ !MLF/INTERSTITIAL NUCLEUS OF CAJAL!
• +/_cordin.lte Head/Eyc. movement with Body
• Conjusate vertical and tOfslon move.menu

~ !VESTIBULARNUCLEUS I ~ !CEREBELLUM I
• Feedbackcentre
• Modify ,.fle.xand voluntary ey<movements

!USEFULPOINTS TO MENTION I
ITYPES OF EYE MOVEMENTS I
.IHERlNC5 LAW I
mevemenc
• of voluntary GOnjug.1t~ eve
• PURSUIT
• YOKE MUSCLES- LIVMR, SIVIO, IRISO, LEVATORS • SACCADE
• POSITION MAINTENENCE
.• IEqu.dem'syIJ~/IEqu.l1 directionl
• VERCENCE INON·CONJUGATEI
• NON·OPTIC (VESTIBULAR)
~ W
Occipiro-
parieral Midbrain
pathway
r.o[ovea

• Pathway-s initiated
C!>
from:
CD
lob. prerectal I HORIZONTAL MVTS I ozyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
B 'd i n s r e m
• Midbrain
area • Pons
• PPRF InT.Vt uuc.l
• riMLF

• Stimulus: Moving carget NEARfo".~

• LatenGY: ~llJms
• Velociry:~Jodegr...ws I~ccur~,"!yl
up to .00 degr...ws
• Control: continuous
• T ests : DOLLS HEAD
ROTATION
OI<N
ISACCADES ]

• T ests : REFIXATION
ROTATION
CALORlCS
OKN

CD POSITION MAINTENANCE @VERGENCE iNon-Conjugat. mve .s. : CD NON-OPTIC REFLEX (VESTIBULAR)

• function: Align visual axes during • Function: ~intain eye position wirb clMng(.~ in
• Function: Maintain eye. position on Head and Body movement.
a u,'gCt aecomodaticn to maintain
[oveal fixation when target • Pathway:
• Pathway: aZYXWVUTSRQPONMLKJIHGFEDCBA
falls on non-corr•• ponding
Occipico-
J te parietal
I~
• Pathway;
points on z-axis

Anrerior
occipitoparie.t.ll

1
area
M ic lb r d in
~pretectal
MidbTain/pons
~.tru
pteteccal area

.--:---:~/-,,.-\---'-------,
HORIZONTAL
MVTS .

• Stimulus: Visual interest

and attention
• Velocity: • RAPID
Flicks and • Srimulu.s: Retinal disparity
miCTosacc..ade.s
• Latency; 160 ms
• Velocicy: < 10 degrees/s
• SLOW • Control: Continuous? unknown
Drifts • Test: DISTANT - TO-NEAR
ACCOMMODATION
~ W
Occipiro-
parieral Midbrain
pathway
r.o[ovea

• Pathway-s initiated
C!>
from:
CD
lob. prerectal I HORIZONTAL MVTS I ozyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
B 'd i n s r e m
• Midbrain
area • Pons
• PPRF InT.Vt uuc.l
• riMLF

• Stimulus: Moving carget NEARfo".~

• LatenGY: ~llJms
• Velociry:~Jodegr...ws I~ccur~,"!yl
up to .00 degr...ws
• Control: continuous
• T ests : DOLLS HEAD
ROTATION
OI<N
ISACCADES ]

• T ests : REFIXATION
ROTATION
CALORlCS
OKN

CD POSITION MAINTENANCE @VERGENCE iNon-Conjugat. mve .s. : CD NON-OPTIC REFLEX (VESTIBULAR)

• function: Align visual axes during • Function: ~intain eye position wirb clMng(.~ in
• Function: Maintain eye. position on Head and Body movement.
a u,'gCt aecomodaticn to maintain
[oveal fixation when target • Pathway:
• Pathway: aZYXWVUTSRQPONMLKJIHGFEDCBA
falls on non-corr•• ponding
Occipico-
J te parietal
I~
• Pathway;
points on z-axis

Anrerior
occipitoparie.t.ll

1
area
M ic lb r d in
~pretectal
MidbTain/pons
~.tru
pteteccal area

.--:---:~/-,,.-\---'-------,
HORIZONTAL
MVTS .

• Stimulus: Visual interest

and attention
• Velocity: • RAPID
Flicks and • Srimulu.s: Retinal disparity
miCTosacc..ade.s
• Latency; 160 ms
• Velocicy: < 10 degrees/s
• SLOW • Control: Continuous? unknown
Drifts • Test: DISTANT - TO-NEAR
ACCOMMODATION
 BlACI< and WH ITE check<rboard rever •• 1
~~~----'
f - /
$
1 PATTERN ONSET - Gr~y.creen tocheckerboard.
J FLASH _IndivIdual van.b,htY, u se ful In
"ubj('cL~ not fix ...•cmg and therefore. children. Amphcude
ImV) \ ~a-w e
·t \..

b -wave
(-WAVe

_ Constsrencv between he.mispheres

-- ----
amphtudel ••Vi
100 100
Timelmsl

METHOD: Corneal electrode. can be contact lens

Of non,ontaCt 1(.1\S
• PHOTORECEPTOR CELL BODY SRQPONMLKJIHGFEDCBA
• C o m c.omponentlRod component
Tlmelms)
• BIPOLAR CELLS DRIVING MOLLERCELLS .
• 1'100 larency
- most u~ful • Rod bipolar cell response is largest
_ usually eoMt.iI.nt
USE: • OPTIC NERVE DEMYELINATION e.g. M? - VEP delay • RPE
• ISCHAEMIC LES IONS - Altered wave ampllrude . • Very little used
• COMPRESSIVE LESIONS - Delav and altered amplorudt
• MACULAR DISEASE - d.laycd VEP

TYPES OF ERG (0 SINCLE BRICH. WHITE L1C1·iT fLASHiSBLFI

IPERCI- flu r e m ERG
• Mi.xed Rod/Cont. response

• Alrem,lCing BI~lCkaed \V'hitc chcckv followed @SCOTOPICERC

by reverve IMtlern {1-6 H:l • Dim right (while or blue) below cone r hre shotd
• Pure. Rod re.· .pon.~
AmplltudelflVI
CD 30Hz Hickur
• cone response. only
• sinusoidal wave-like response

@ PHOTOPIC ERG
• Background to saturate rods
• B~isht flash - cone response only
JS 50 '- 00 Time] msl

• P lO

• N9f
•

•
Probably GANClION
GANCLlON
• Secondary
CELL origin
CELL ORIGIN
phenomenon to PSD
r ,..,. "..,.
.•••••••••
C> <:>
c·
.
CD OSCILLATION
~9in ar IsoHz - to - 1000H z
Filrer out a- and b- waves
RESPONSE

• Oscilt.uory waves ove-Iav on a.sc.ending limb of b-wave

• Probable HORIZONTAL CElUAMACRINE
USE: • C E N T flA L R E T IN A - M A C U L A /G A N G l IO N CELLS
CfLLORIClN
• Further inrerprecauon of VE P
(- Glaucoma, Ocul.r Hvperrension]
USE: • PERIPHERAL RETINA
• Ceneraeed by cells di., .•1to gAnglion cell.
C O N D IT IO N S :
• MACULOPATHY -Abnormal P50 '~UAL CIRCULATIOr OF ~ETINA
~ -choroidal circulation b-wave -recinal circulation
- Normal N 9 s 1 P s o ratio
CONDITIONS: • PIGMENTARY RETINOPATHY
• OPTIC NEUROPATHY
• Abnormal N 9 5 J Normal i'so • CONGENITAL STATIONARY NIGHT
• Recr03"ade gan.q-lion cell degeee-arion BLINDNESS
• CENTRAL RETINAL ARTERY} N . E
OCCLUSION eganve RC
• RETINOSCHISIS Ab. sent b-wave
NB: • oseillatory r•.• pon •• abnormal in
EARLY Ipr.-prolif<ra,.) DIABETIC RETINOPATHY
 BlACI< and WH ITE check<rboard rever •• 1
~~~----'
f - /
$
1 PATTERN ONSET - Gr~y.creen tocheckerboard.
J FLASH _IndivIdual van.b,htY, u se ful In
"ubj('cL~ not fix ...•cmg and therefore. children. Amphcude
ImV) \ ~a-w e
·t \..

b -wave
(-WAVe

_ Constsrencv between he.mispheres

-- ----
amphtudel ••Vi
100 100
Timelmsl

METHOD: Corneal electrode. can be contact lens

Of non,ontaCt 1(.1\S
• PHOTORECEPTOR CELL BODY SRQPONMLKJIHGFEDCBA
• C o m c.omponentlRod component
Tlmelms)
• BIPOLAR CELLS DRIVING MOLLERCELLS .
• 1'100 larency
- most u~ful • Rod bipolar cell response is largest
_ usually eoMt.iI.nt
USE: • OPTIC NERVE DEMYELINATION e.g. M? - VEP delay • RPE
• ISCHAEMIC LES IONS - Altered wave ampllrude . • Very little used
• COMPRESSIVE LESIONS - Delav and altered amplorudt
• MACULAR DISEASE - d.laycd VEP

TYPES OF ERG (0 SINCLE BRICH. WHITE L1C1·iT fLASHiSBLFI

IPERCI- flu r e m ERG
• Mi.xed Rod/Cont. response

• Alrem,lCing BI~lCkaed \V'hitc chcckv followed @SCOTOPICERC

by reverve IMtlern {1-6 H:l • Dim right (while or blue) below cone r hre shotd
• Pure. Rod re.· .pon.~
AmplltudelflVI
CD 30Hz Hickur
• cone response. only
• sinusoidal wave-like response

@ PHOTOPIC ERG
• Background to saturate rods
• B~isht flash - cone response only
JS 50 '- 00 Time] msl

• P lO

• N9f
•

•
Probably GANClION
GANCLlON
• Secondary
CELL origin
CELL ORIGIN
phenomenon to PSD
r ,..,. "..,.
.•••••••••
C> <:>
c·
.
CD OSCILLATION
~9in ar IsoHz - to - 1000H z
Filrer out a- and b- waves
RESPONSE

• Oscilt.uory waves ove-Iav on a.sc.ending limb of b-wave

• Probable HORIZONTAL CElUAMACRINE
USE: • C E N T flA L R E T IN A - M A C U L A /G A N G l IO N CELLS
CfLLORIClN
• Further inrerprecauon of VE P
(- Glaucoma, Ocul.r Hvperrension]
USE: • PERIPHERAL RETINA
• Ceneraeed by cells di., .•1to gAnglion cell.
C O N D IT IO N S :
• MACULOPATHY -Abnormal P50 '~UAL CIRCULATIOr OF ~ETINA
~ -choroidal circulation b-wave -recinal circulation
- Normal N 9 s 1 P s o ratio
CONDITIONS: • PIGMENTARY RETINOPATHY
• OPTIC NEUROPATHY
• Abnormal N 9 5 J Normal i'so • CONGENITAL STATIONARY NIGHT
• Recr03"ade gan.q-lion cell degeee-arion BLINDNESS
• CENTRAL RETINAL ARTERY} N . E
OCCLUSION eganve RC
• RETINOSCHISIS Ab. sent b-wave
NB: • oseillatory r•.• pon •• abnormal in
EARLY Ipr.-prolif<ra,.) DIABETIC RETINOPATHY
 · ··V· _INNEIl/OUTERCANTHI

+ ®
-10· ut~,al
• Record Fi><~d eve mov~m~nu at r~gula, intervals during both
DARK ADAPTATION andtmnLlGHT ADAPTATION '''PPTQ>t·15min"""h!
• Principle: Reco,ding eomeo-rcrinal pot~ntial
• Minimum signal in dark - DARl< TROUGH lOT!
• Maximum ~ignal in light = LIGHT PEAl< (LP!
LP
• ARDEN INDEX = DT 12:110%Normal)

USE: RPE _PHOTORECEPTOR INTERACTION

CONDITION: • PIGMENT RETINOPATHY
• METABOllClfOXIC CONDITIONS AFFECTING
RPE. ,Choroidal c;irculationl

U'~ful-!. BEST'S DISEASE (VlTELLlFORM MACULAR DYSTROPHYIzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

a .Abnonna.I EOG even in .symptomatic carriers
• REDUCED EOG, NORMAL ERG
• Apical mcmbra~ Of RPE affecud
 · ··V· _INNEIl/OUTERCANTHI

+ ®
-10· ut~,al
• Record Fi><~d eve mov~m~nu at r~gula, intervals during both
DARK ADAPTATION andtmnLlGHT ADAPTATION '''PPTQ>t·15min"""h!
• Principle: Reco,ding eomeo-rcrinal pot~ntial
• Minimum signal in dark - DARl< TROUGH lOT!
• Maximum ~ignal in light = LIGHT PEAl< (LP!
LP
• ARDEN INDEX = DT 12:110%Normal)

USE: RPE _PHOTORECEPTOR INTERACTION

CONDITION: • PIGMENT RETINOPATHY
• METABOllClfOXIC CONDITIONS AFFECTING
RPE. ,Choroidal c;irculationl

U'~ful-!. BEST'S DISEASE (VlTELLlFORM MACULAR DYSTROPHYIzyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

a .Abnonna.I EOG even in .symptomatic carriers
• REDUCED EOG, NORMAL ERG
• Apical mcmbra~ Of RPE affecud
 -\BACULA l/loth I

®(!)

_ Macula fibre" CENTRAL

• Nasal [ibres: MEDIAL
_ Temporal [ibres: LATERAL

~ @tn1C Gil1i~",MAJ
lpsilareral Temporal

- Courralaeeral
fibres: UNCROSSED

NasAl fibres:!CROSSED
(f Inferior retinal:
lbr.,.

Superior retinal:
fibres

\\~Q .
CDI . 1 5 1 ')\1 . 91WcfRAs::~1

~
'JP..\ Contralateral
_ 900 inward
NasaVlpsil
twist.
tiT
a era
: SUIK.rior re.tinal fibres: MEDIAl.
emporal ""inA.

lnfenor r<tlnal [ibres: LATERAL

• Macular fibres gradually surface ..
® l.GN
- Contralateral NaSAl ~bres: LAYERS I
• IpsIlateral Temporal fibres: LAYERS ,4" 6.
_ Macular fibr es : DORSAL "), s ·
• Superior reeinal fibr"-S: VENTRO
- lnferior retinal fibres. DORSO~i£!'~\~~'

RADIATION
• Superior retinal [ibres: - SUlKrior fibr.,.. • N~ivl"'lp5i1ateral TemporaVcontral,ueral
- Run directly po •• eriorlv, _.a retina.
• To superior lip of - Superior retinal fibres: SUPERIOR UP CA
Colcarinc Suleu s _ .. SULCUS. LCARINE
Infe"orrwnal fibr.,.: INFERIOR UP CA
• Inferior retinal fibr.,.: • Inferior fibr.,.. SULCUS . LCARINE
- Swing out LAterally. r cm
- Macular fibres: POSTERIOR I ~m.
• Infcrolatcral to Anterior
tip of Temporal horn of .
LAteral Ventricle.
• '"! um inwards to inferior
hp of Calcarine Sulcus. aZYXWVUTSRQPONMLKJIHGFEDCBA
 -\BACULA l/loth I

®(!)

_ Macula fibre" CENTRAL

• Nasal [ibres: MEDIAL
_ Temporal [ibres: LATERAL

~ @tn1C Gil1i~",MAJ
lpsilareral Temporal

- Courralaeeral
fibres: UNCROSSED

NasAl fibres:!CROSSED
(f Inferior retinal:
lbr.,.

Superior retinal:
fibres

\\~Q .
CDI . 1 5 1 ')\1 . 91WcfRAs::~1

~
'JP..\ Contralateral
_ 900 inward
NasaVlpsil
twist.
tiT
a era
: SUIK.rior re.tinal fibres: MEDIAl.
emporal ""inA.

lnfenor r<tlnal [ibres: LATERAL

• Macular fibres gradually surface ..
® l.GN
- Contralateral NaSAl ~bres: LAYERS I
• IpsIlateral Temporal fibres: LAYERS ,4" 6.
_ Macular fibr es : DORSAL "), s ·
• Superior reeinal fibr"-S: VENTRO
- lnferior retinal fibres. DORSO~i£!'~\~~'

RADIATION
• Superior retinal [ibres: - SUlKrior fibr.,.. • N~ivl"'lp5i1ateral TemporaVcontral,ueral
- Run directly po •• eriorlv, _.a retina.
• To superior lip of - Superior retinal fibres: SUPERIOR UP CA
Colcarinc Suleu s _ .. SULCUS. LCARINE
Infe"orrwnal fibr.,.: INFERIOR UP CA
• Inferior retinal fibr.,.: • Inferior fibr.,.. SULCUS . LCARINE
- Swing out LAterally. r cm
- Macular fibres: POSTERIOR I ~m.
• Infcrolatcral to Anterior
tip of Temporal horn of .
LAteral Ventricle.
• '"! um inwards to inferior
hp of Calcarine Sulcus. aZYXWVUTSRQPONMLKJIHGFEDCBA
 ~ Sup.,ior c<,re~\laT
• Passes be.twun pos.terior urebral artery and Superior cerebellar Artery
:/- ••• .,._-';;.\ •....:._ artery~LOiV

\ ~ posterior cerebral
artery~
MIDDLE CRANIAL FOSSA
posterior communicatinS • Runs la,eral ••nd par..tld to posterior c.ommunic.lting artery
artery • Pieras dura latcral to posterior clinoid prOCUS to cnter later.1 wall of
uvemous Sinus

• InitiAlly, high in IAleMI wall of cavernous .sinult

• Then descends medial eo IV and V aZYXWVUTSRQPONMLKJIHGFEDCBA
: : ~ e c t i v e . proprioceptive fibre,. fro~ V . jme se ncephalic nucleus!
" " " 'V U sympathetic fIbre. from Internal carorid plexus

• Divides SRQPONMLKJIHGFEDCBA
in r o S u p e r io T A n d I n fe d o r d iv is io l1 s

SUPERIOR
OF III N DIVISION • Enters orbit through Superior Orbital fissure within th e common ten dimous nng

INFERIOR DIVISION
OFIIIN SUPERIOR DIVISION - Runs lateral co opri N
- Runs below Superior Rectus
- Pierces Superior Rectus
-~uPpli es lEVATORwith. MOTOR .•nd
SYMPATHETIC fibres In<ernA' C a rorid plG><u,

INFERIOR DIVISION - ~i", .•bcve Inferior Rectus .•nd Inferior Oblique

- upphes·, PARASYMPATHETIC fibres to cili••
ganghon (tnf.rol .•ter .•1to Optic Nerv.) ry

FUNCTION ·SSupplies Superior ReGtus.!· Levator [inc. SYMPATHETIC [ibr ,

• uppli •• Me,hal Rectus I es
: Supplies Inferior Rectus.!· Inferior Oblique
_postgangl,onic
Supphes preganghonie p.r ••.•ym heti [ib
par as ymp a rhenc suppl y t 0 sp himeterpatpup,lI
enc.•e, and
..
re. ciliary
to clhary ganglion
muscle 8
 ~ Sup.,ior c<,re~\laT
• Passes be.twun pos.terior urebral artery and Superior cerebellar Artery
:/- ••• .,._-';;.\ •....:._ artery~LOiV

\ ~ posterior cerebral
artery~
MIDDLE CRANIAL FOSSA
posterior communicatinS • Runs la,eral ••nd par..tld to posterior c.ommunic.lting artery
artery • Pieras dura latcral to posterior clinoid prOCUS to cnter later.1 wall of
uvemous Sinus

• InitiAlly, high in IAleMI wall of cavernous .sinult

• Then descends medial eo IV and V aZYXWVUTSRQPONMLKJIHGFEDCBA
: : ~ e c t i v e . proprioceptive fibre,. fro~ V . jme se ncephalic nucleus!
" " " 'V U sympathetic fIbre. from Internal carorid plexus

• Divides SRQPONMLKJIHGFEDCBA
in r o S u p e r io T A n d I n fe d o r d iv is io l1 s

SUPERIOR
OF III N DIVISION • Enters orbit through Superior Orbital fissure within th e common ten dimous nng

INFERIOR DIVISION
OFIIIN SUPERIOR DIVISION - Runs lateral co opri N
- Runs below Superior Rectus
- Pierces Superior Rectus
-~uPpli es lEVATORwith. MOTOR .•nd
SYMPATHETIC fibres In<ernA' C a rorid plG><u,

INFERIOR DIVISION - ~i", .•bcve Inferior Rectus .•nd Inferior Oblique

- upphes·, PARASYMPATHETIC fibres to cili••
ganghon (tnf.rol .•ter .•1to Optic Nerv.) ry

FUNCTION ·SSupplies Superior ReGtus.!· Levator [inc. SYMPATHETIC [ibr ,

• uppli •• Me,hal Rectus I es
: Supplies Inferior Rectus.!· Inferior Oblique
_postgangl,onic
Supphes preganghonie p.r ••.•ym heti [ib
par as ymp a rhenc suppl y t 0 sp himeterpatpup,lI
enc.•e, and
..
re. ciliary
to clhary ganglion
muscle 8
from superior colliculub
• P..,;slateral to Superior cerebellar peduncle - around lateral aspect of midbrain

view

Superior cerebellar
peduncle

• Runs be-twe-en posterior eerebral SRQPONMLKJIHGFEDCBA

and 5upe.rior cerebellar artery
.1 : r u r y

Superior cerebellar
artery IBELOW!

• Ple.TCe5 dura nur posterior cllnoid proc;.e..ss

posterior cere-brAt
artery IABOVEI

o Enrers lateral wall of Cavern S- nus

o Crossed medially by d.scend?~: .-:J 1I'I ne.rve

"L USCIOUS
- } • Eneers orbit throu h 5 .
SUPEROLATEKAL'pe"ororbiu.1 fissure OUTSIDE d
Lacrimal N -. Fancy LFT ~ to common tendinous ring an
Frontal N ...-..: TartS
Sit
IV TROCHLEAR
Nak.ed
NERVE
In
Superior division
Anricipacion"
of III N
Nasociliary N Abducent N VI

Inferior division of
lllN

o Passes medially above Le

• Terminates in 5U eri vator muscle
o FUNCTION- ~Mor surff_"bceof superior oblique muscle
. . otor, res to superror . oblique. muscle.

Superior -. In(orSlon
Superior oblique Depress ion
view
muscle. Lateral roration

Trochlea

•
from superior colliculub
• P..,;slateral to Superior cerebellar peduncle - around lateral aspect of midbrain

view

Superior cerebellar
peduncle

• Runs be-twe-en posterior eerebral SRQPONMLKJIHGFEDCBA

and 5upe.rior cerebellar artery
.1 : r u r y

Superior cerebellar
artery IBELOW!

• Ple.TCe5 dura nur posterior cllnoid proc;.e..ss

posterior cere-brAt
artery IABOVEI

o Enrers lateral wall of Cavern S- nus

o Crossed medially by d.scend?~: .-:J 1I'I ne.rve

"L USCIOUS
- } • Eneers orbit throu h 5 .
SUPEROLATEKAL'pe"ororbiu.1 fissure OUTSIDE d
Lacrimal N -. Fancy LFT ~ to common tendinous ring an
Frontal N ...-..: TartS
Sit
IV TROCHLEAR
Nak.ed
NERVE
In
Superior division
Anricipacion"
of III N
Nasociliary N Abducent N VI

Inferior division of
lllN

o Passes medially above Le

• Terminates in 5U eri vator muscle
o FUNCTION- ~Mor surff_"bceof superior oblique muscle
. . otor, res to superror . oblique. muscle.

Superior -. In(orSlon
Superior oblique Depress ion
view
muscle. Lateral roration

Trochlea

•
 -Runs • Forwards.
• Upw.ud.s
• Lacerallv in subarachnoid space

• Crosses over tip of petrOUS t~mpmal bone.

IAnchored by reflection of dur •. - Petr05pheroidalligament of Gruber
_ resembling •. cana! =
00 re110'5C •.nal]

POSTERIOR CRANIAL FOSSA aZYXWVUTSRQPONMLKJIHGFEDCBA

r - - - ~ ~ - - Posterior
-
process
clinoid

.- ...•..--\..,..--.30...- Oor .•um • Pierces du.,a infe.rola.teral to dorsum se.llae.

"'11 ae

J00<~'~-11I

• Runs within cavernous sinus lacera] to internal carotid artery

~~~IV
~ V.

zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
• Passes into orbit throu h .
_ wichin common ce.nd! .Ju~nor
~rbit.tl fissure,
- Passes [orward to enter ;~~;~~~U-';=:f~t.diaIIIY
arer a rectus muscle.
Supeno- divrsron
oflllN
ABDUCENT N VI - FUNCTION - laterally
motor supply to laur.1 rt.ctu 5 musc~e which
. rotates rbe eye
N.socilidry N
InferioT division of
IIIN
 -Runs • Forwards.
• Upw.ud.s
• Lacerallv in subarachnoid space

• Crosses over tip of petrOUS t~mpmal bone.

IAnchored by reflection of dur •. - Petr05pheroidalligament of Gruber
_ resembling •. cana! =
00 re110'5C •.nal]

POSTERIOR CRANIAL FOSSA aZYXWVUTSRQPONMLKJIHGFEDCBA

r - - - ~ ~ - - Posterior
-
process
clinoid

.- ...•..--\..,..--.30...- Oor .•um • Pierces du.,a infe.rola.teral to dorsum se.llae.

"'11 ae

J00<~'~-11I

• Runs within cavernous sinus lacera] to internal carotid artery

~~~IV
~ V.

zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
• Passes into orbit throu h .
_ wichin common ce.nd! .Ju~nor
~rbit.tl fissure,
- Passes [orward to enter ;~~;~~~U-';=:f~t.diaIIIY
arer a rectus muscle.
Supeno- divrsron
oflllN
ABDUCENT N VI - FUNCTION - laterally
motor supply to laur.1 rt.ctu 5 musc~e which
. rotates rbe eye
N.socilidry N
InferioT division of
IIIN
IIMPOll..TAAt:.0r MI~tlA\.AD.A~~1
• ViSUAl perception i.. b.••• d on ILOCALCONTAAS'f] ra,her than ambient levels of illuminance
~ILATEAAL INHI8ITION] And N OFF RE IN'" I A NE
• Visual system must dereer both (DARK) and I H spots in order to regis[e.r an imAge.
• Therefore, better to respond ,0 changes in ILtcl-lTUQ ArMS
_ Ambient dark-to-light can be lo.-fold Ent.osllY chans·1

• Between IROb-OEJ>ENDENT land f!;:ONE-OEPENDENT Ivision

Chang •• in: • 01TEMPOAAlACUITY I

.0 SRQPONMLKJIHGFEDCBA
Vi UA A U1 • spAcial n,.sotuc1on
-<D S.E RA S I IVI ..-1'URJ<INJESHIFT'
.IROO-DEPENDENT
mAX. se.nsltiv;ty at
VISION
blue I; he
1

VI I
nu.,x . sensltive At TU.dI reen light

_I RANGE I= 0- 9 log units [incr ease in threshold [rom absolute threshold)

• Sensitivity = thT~hold

[ITCHT ADAPTATl ' I

To • t sensitivirv
• Extracr contrast

• Takes up tOlu.con[1
• Reduce light input y
~= lo-)ofold
• ILATERAL INHIBITIONI -/Altered steady state. conecntrAcionl
- HOflzontaVAmAcrine Cells lof photosensitive pigments I
NB: Unit of IRt.tin.agilluminoince -ION/OFbRETtNALg~1§!!tLSI
&TROLAN (TJ - BlpolAr/ anghonll /. rtc.>c
= Illuminance ILl .x pupil ar •.• IPI . PhotochemicAls ~
/mm1 ) I HORIZONTAL CELL FEEDBACl<THEORyJ
~nd .. ~ Reti".ldeh d &
y e.
photosensirive ~
1~
·
- LIGHT CONE I HORIZONTAL CELL!
pigment5

Vitamin A
°PStnS

Hyperpolarize Hvperpolarize • Poorly understood molecular basi .

+ICGMPI
Depolarize ICONESI+--/TO +
ALTER CAIN 1
,.
-loo..
I ----,.-
mterna mc..s..scngcT'
ICa
1+ ••..•is:
+
I intracellular
and Delay
• +IPHOTOCHEMICALSI •• +lsENSITIVITY 1
• Signifi,:"nt effect with ILl!!< diffusel
light stimulus causinq N8: 10% Bluc.hcd photopisnKn, eau••
BRJ[FERAND SMAL ERCO"'[ RES""'" El loo-fold Kn&1tiviry 1os5.
ehan for small apor of light SE

• Horizontal Cell spatially

IDISCRETfl'S Oi'l5(imuli
IIMPOll..TAAt:.0r MI~tlA\.AD.A~~1
• ViSUAl perception i.. b.••• d on ILOCALCONTAAS'f] ra,her than ambient levels of illuminance
~ILATEAAL INHI8ITION] And N OFF RE IN'" I A NE
• Visual system must dereer both (DARK) and I H spots in order to regis[e.r an imAge.
• Therefore, better to respond ,0 changes in ILtcl-lTUQ ArMS
_ Ambient dark-to-light can be lo.-fold Ent.osllY chans·1

• Between IROb-OEJ>ENDENT land f!;:ONE-OEPENDENT Ivision

Chang •• in: • 01TEMPOAAlACUITY I

.0 SRQPONMLKJIHGFEDCBA
Vi UA A U1 • spAcial n,.sotuc1on
-<D S.E RA S I IVI ..-1'URJ<INJESHIFT'
.IROO-DEPENDENT
mAX. se.nsltiv;ty at
VISION
blue I; he
1

VI I
nu.,x . sensltive At TU.dI reen light

_I RANGE I= 0- 9 log units [incr ease in threshold [rom absolute threshold)

• Sensitivity = thT~hold

[ITCHT ADAPTATl ' I

To • t sensitivirv
• Extracr contrast

• Takes up tOlu.con[1
• Reduce light input y
~= lo-)ofold
• ILATERAL INHIBITIONI -/Altered steady state. conecntrAcionl
- HOflzontaVAmAcrine Cells lof photosensitive pigments I
NB: Unit of IRt.tin.agilluminoince -ION/OFbRETtNALg~1§!!tLSI
&TROLAN (TJ - BlpolAr/ anghonll /. rtc.>c
= Illuminance ILl .x pupil ar •.• IPI . PhotochemicAls ~
/mm1 ) I HORIZONTAL CELL FEEDBACl<THEORyJ
~nd .. ~ Reti".ldeh d &
y e.
photosensirive ~
1~
·
- LIGHT CONE I HORIZONTAL CELL!
pigment5

Vitamin A
°PStnS

Hyperpolarize Hvperpolarize • Poorly understood molecular basi .

+ICGMPI
Depolarize ICONESI+--/TO +
ALTER CAIN 1
,.
-loo..
I ----,.-
mterna mc..s..scngcT'
ICa
1+ ••..•is:
+
I intracellular
and Delay
• +IPHOTOCHEMICALSI •• +lsENSITIVITY 1
• Signifi,:"nt effect with ILl!!< diffusel
light stimulus causinq N8: 10% Bluc.hcd photopisnKn, eau••
BRJ[FERAND SMAL ERCO"'[ RES""'" El loo-fold Kn&1tiviry 1os5.
ehan for small apor of light SE

• Horizontal Cell spatially

IDISCRETfl'S Oi'l5(imuli
 r~
~ @mul = so-foldAdaptation
l_-_-
--
__
+-=,_=_=-=.(,~ ~ ~ -~ -_ ~-~- -=-_'""'_w-_-__.••.•.-\ [!<OOS]
minUlU

llTl1"
io mi»
40min
+se.nsitivitV

,o·fold
6ooo-fold
lsooo-fold

° w W ~ ~ ~
IRODS]
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
I CONES]
[!1inute5 in dArk] • Slower
• Faster • More dark adapting
( At molecular lev~l] Ac.tivue.d recovery processes • Less dark adapting • Up to 100:1Rod:Ganglion cell
include: • Chemical eventS OCGur conY'(. nee resulting in
• ARRESTIN
4~rimts rL~tef th'ln Rods summ.U,on and + ~n5itiv;tY
•.GTP ase
• Guanylate Cvcl ase (rege"erate cGM?)

CONCLUSION:
• .1 Main mechanisms
• M.ainly.1C (R£tinaD level
• Speed vs Range
• tmpoTtAnl for extracc.ion of IOGal connast
 DilAtor
pupillAc
muscle.

[PUPILLARY RESPONSE}) • PhysiologiCAl

Tremor 'Hippus'
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
• Oi.a.m~te.r 1 - 9mm
~ ----@on.trictiO;]

o MIDBRAIN
o MIDBRAIN
· Oarknu.\
• lisht - Direct
_Con~nsu •al
(9 LOSS Of SUPRANUCLEAR INHIBlTlON OF E.- W NUCLEUS
0SUPRANUCLEAR INHIBITION OF E- W NUCLEUS
• F.ltigue.
• AI~Tt
CD HYPOTHALAMIC SyMPATH HIC ACfIVATION • SI«p
• Excitemtnt
CD VISUAL CORTEX
• Nur.-object I.CGOmmocLuion
• fur
@VlSUALCORTE.)(
• O:'su.nt.-objt.c.t ~c.c;.o-mmc><Uticm

MODIFICATION BY DRUGS • Act .u syndpses - peripherally

cenrrallv
-c

!MYDRIASIS!

'!Sympathetic I
~--+------'<
r----....:..-

Direct
• cocaine stimulation
• amphetamine • botulinum • Atropine of a·reuptors
toxin • scopolamine • Adrenaline
• homatropine • ph~nyl~phrin.
• cvclcpenrolate • e.phe.driM
• tropicamide

• cocaine.

I MYOSIS I
-I CholinergiC I

r.-----
o----~~~------~
< Acervcholinesrerase
inhibitors

· opi.ttt.S
• barbiturates
 DilAtor
pupillAc
muscle.

[PUPILLARY RESPONSE}) • PhysiologiCAl

Tremor 'Hippus'
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
• Oi.a.m~te.r 1 - 9mm
~ ----@on.trictiO;]

o MIDBRAIN
o MIDBRAIN
· Oarknu.\
• lisht - Direct
_Con~nsu •al
(9 LOSS Of SUPRANUCLEAR INHIBlTlON OF E.- W NUCLEUS
0SUPRANUCLEAR INHIBITION OF E- W NUCLEUS
• F.ltigue.
• AI~Tt
CD HYPOTHALAMIC SyMPATH HIC ACfIVATION • SI«p
• Excitemtnt
CD VISUAL CORTEX
• Nur.-object I.CGOmmocLuion
• fur
@VlSUALCORTE.)(
• O:'su.nt.-objt.c.t ~c.c;.o-mmc><Uticm

MODIFICATION BY DRUGS • Act .u syndpses - peripherally

cenrrallv
-c

!MYDRIASIS!

'!Sympathetic I
~--+------'<
r----....:..-

Direct
• cocaine stimulation
• amphetamine • botulinum • Atropine of a·reuptors
toxin • scopolamine • Adrenaline
• homatropine • ph~nyl~phrin.
• cvclcpenrolate • e.phe.driM
• tropicamide

• cocaine.

I MYOSIS I
-I CholinergiC I

r.-----
o----~~~------~
< Acervcholinesrerase
inhibitors

· opi.ttt.S
• barbiturates
 during binocular vision
Nasal Retina _ Temporal field Ivice versa)

Percepuon of relative depth

Relits on binocular disparity
Object lies in Panum/s Sp.lCC
B,
Al F,
A,AJF,F/B,B1: Contsponding points
P d n u m ~ ~ A r t..l
• Non-corresponding points on r e r i n a tha.t
allow fusion
P s n u m 's S p .lU
Space around Horopter where slightly

I
non-cotTc..sponding poinu are seen ,15
.s i n 9 l e with d e p c h P a c h o l o ." i C J I zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s i o l o g i c .l l
Objects in front of, or behind Horopt<T!Panum's space
• Deviation of one.
Sma.lIest at fixation point
Near-object diplopiaSRQPONMLKJIHGFEDCBA

I
C r o s s e d /H e r e r o n r m o u s :
Increases in periphery eye from [ixat.ion
point
U n c r o s $ u I /H o m o n o m o C J .s : Far-objecr diplopia
Normally SUPPRESSED to allow binocular single vision

MAIN:
• Evidence ae tevel of ~~lvI5U"'[C()RTEXI
IH;scoricaIJTYPES OF BINOCULAR
• Smlple CI.ls.sifk.u.ion
V IS IO N iWorth '90"
J'
0mmm
Topographical organizatioll (Retinal Correspondence!

0~~ma~~ I Transferred by p.traflt;1 channels from:

photoreceptor -- bipolar cell .• gangl;ol1 cel! LGN
;e+®cel!~')
V' C
.. IS .• orrex,
of two separ ace image!!
Pt;rception

Ipsilateral-layers 1,4, 6
C<lntr.llareral-Iayer.\ 1, J~S
/"'" CIRCULAR RECEPTIVE

I
Sensory Motor
T~ imagr.s sun • MaintenAnu of sensory FIELD
and lOc~rpTeted fusion by ~ ON/OFF CELLS
COLOUR CODING
as O~ ImAge .----- +-~
IHorizollr..IIIVertiuH cIC"'=yc='lov-e,-.-.nce-1 CONTRALATERAL
IPSILATERAL EYE
EYE

• Perception of two slightly

o .- · · t· · :- ,: '<
LGN Layers " 1 IVB
diff(.n~nt imA.ges and. interpretAtion
•.• one image with DEPTH MOTION DETECTION
IV"MT,MST)

LGN layer s IV c a COLOUR CODING/ORIENTATION

l! 4 .li. 6 (BloMnt<rblob" J - V ,)
IVcll.IVA

• L .." .r IV - incoming .isnals are MONOCU LAR Ifrom each

• L l y e r l l ,l I I , V , V I-c o n v e rS " to BINOCULAR CELLS eye)
• BINOCULARCELl5 • S"e~ltlVe. to ulspancy
~. . (non--corTtsponding poirus!
• Driven by each eve

[In research ••• sel:

P .u v o c e llu t" r : T u n e d Nur, Tuned Far, Tuned zero, Tuned inhibit
Mdf!Docelful ••r: Near and FAr neurones ory
• MaJOrity of SeriAt. «lis A T < binocular

-
• Able to detect dispArity
N
• Able ro mAior.dindlignmont
" [magnoceflul ar MOTION DETECTION )- VERGENCE <J>
 during binocular vision
Nasal Retina _ Temporal field Ivice versa)

Percepuon of relative depth

Relits on binocular disparity
Object lies in Panum/s Sp.lCC
B,
Al F,
A,AJF,F/B,B1: Contsponding points
P d n u m ~ ~ A r t..l
• Non-corresponding points on r e r i n a tha.t
allow fusion
P s n u m 's S p .lU
Space around Horopter where slightly

I
non-cotTc..sponding poinu are seen ,15
.s i n 9 l e with d e p c h P a c h o l o ." i C J I zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
P h y s i o l o g i c .l l
Objects in front of, or behind Horopt<T!Panum's space
• Deviation of one.
Sma.lIest at fixation point
Near-object diplopiaSRQPONMLKJIHGFEDCBA

I
C r o s s e d /H e r e r o n r m o u s :
Increases in periphery eye from [ixat.ion
point
U n c r o s $ u I /H o m o n o m o C J .s : Far-objecr diplopia
Normally SUPPRESSED to allow binocular single vision

MAIN:
• Evidence ae tevel of ~~lvI5U"'[C()RTEXI
IH;scoricaIJTYPES OF BINOCULAR
• Smlple CI.ls.sifk.u.ion
V IS IO N iWorth '90"
J'
0mmm
Topographical organizatioll (Retinal Correspondence!

0~~ma~~ I Transferred by p.traflt;1 channels from:

photoreceptor -- bipolar cell .• gangl;ol1 cel! LGN
;e+®cel!~')
V' C
.. IS .• orrex,
of two separ ace image!!
Pt;rception

Ipsilateral-layers 1,4, 6
C<lntr.llareral-Iayer.\ 1, J~S
/"'" CIRCULAR RECEPTIVE

I
Sensory Motor
T~ imagr.s sun • MaintenAnu of sensory FIELD
and lOc~rpTeted fusion by ~ ON/OFF CELLS
COLOUR CODING
as O~ ImAge .----- +-~
IHorizollr..IIIVertiuH cIC"'=yc='lov-e,-.-.nce-1 CONTRALATERAL
IPSILATERAL EYE
EYE

• Perception of two slightly

o .- · · t· · :- ,: '<
LGN Layers " 1 IVB
diff(.n~nt imA.ges and. interpretAtion
•.• one image with DEPTH MOTION DETECTION
IV"MT,MST)

LGN layer s IV c a COLOUR CODING/ORIENTATION

l! 4 .li. 6 (BloMnt<rblob" J - V ,)
IVcll.IVA

• L .." .r IV - incoming .isnals are MONOCU LAR Ifrom each

• L l y e r l l ,l I I , V , V I-c o n v e rS " to BINOCULAR CELLS eye)
• BINOCULARCELl5 • S"e~ltlVe. to ulspancy
~. . (non--corTtsponding poirus!
• Driven by each eve

[In research ••• sel:

P .u v o c e llu t" r : T u n e d Nur, Tuned Far, Tuned zero, Tuned inhibit
Mdf!Docelful ••r: Near and FAr neurones ory
• MaJOrity of SeriAt. «lis A T < binocular

-
• Able to detect dispArity
N
• Able ro mAior.dindlignmont
" [magnoceflul ar MOTION DETECTION )- VERGENCE <J>
 Based on anatomy/physiology of virtual pathway: [Alternating • Corresponding pointszyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
suppres sion of
Eyes have overlapping visual fields • Use of each eye)
Retinal correspondence [including size, colour • Never simultaneous binocular perception

I
and brightness) • e.g. Asber (1953) "RETINAL RIVALRY"
Partial decussation at optic chiasm,
therefore" each visual cortex codes for ~ ~
contralateral visual field
Binocular cells at visual cortex
EXPLAINS: STEREOPSIS
• Fusion of retinal image disparity
Gobin (1971) "MOSAIC VIEWING"
Point sampling of information in field

EXPLAINS: SINGLE IMAGE PERCEPTION

 outer layer - Tight junctions
lipophilic, Hydrophobic
[S:ONJUNCTIVA] lipophHic dfU~ re.stTVOlf . 1
Unionized d";~ penetrate, e.g. ChioT.:U'IlphtnJGO
• Alters avaHabHity for corneal • STROMA
Absorption Hydrophilic, lipophobic, aullul.r
• Non-specificdrugbiSdyiS~EMICCIRCULATION Allows diff.aion - solut'5 ,< 500 kD.
• Drug abSOfpuon -. . Hydrophobicdrug r~rvo", .
• Increased with v,uod,lators ionized dru~s penetrate e.g. Pilocarpine
• ENDOTHELIUM ..SRQPONMLKJIHGFEDCBA
ITEARFlLM} .. N or rare limiting . ,., . .
• Volum<7111
(incru.K5 pr<_blonk,ngJ Allows STROMNAG~EOUS tommunocu,on
• Bl1nking maintains volume. b
• Drained byn""'IA,rim~1du;tWU~TIARi'NG
• Topical drugs ASSOC.
WIth • DILUTION {SCLERA]
• PROTEIN BINDING • High., permubility than COfO<a
@LOOD_OCULARBARRIERS!
• DRAINAGE • Lo;" permubil:iJub)pBLYSACCHARIDE GEL
• lighc PfeShUft on G.ln.1.i1c.uH ,e4uas drainAge CiliAry<pith<lium • Pen<tTat<S • COLLAGEN FIBRIL MATRIX
lns vusels • PERIVASCULAR SPACES
IRIS AND CILIARY BODY RPEaZYXWVUTSRQPONMLKJIHGFEDCBA
A n d re tinAIve.ssels

• PIGMENTATION - drug bindingl.low rel",s< • Ban't.f to most moluulr..s. ..

• Some. penetrAtion by small lipophilic
• U,UT.lK .activicy
• MET ABO L1SM - PhAS<SI and 1 mole.Gute..s .
~ REDUCE ACTION • DamAgedin injury/inflAmmatoon

tTl
!ROUTES Of ADMIN ISTRATION I '"
[1\CTOlts IN V O L VED I ~'"
-IOSMOLA.RITY! .[EE] '!VISCOSITYr--.IUPIDSOLUBILlTyr PRESERVATIVES! EFFECTOF ..•..•
V'l

C
• Influenced by 50Iute.:-
(not prO(eiH~!
• LimiredTear
buffer canacnv
• Drug rerencicn • Corn ea 1p<n<".rion SURFACTANTS
• Incrust. corneal
SYSTEMIC DRUCS
• lnfuence- Blink
..•n
..•
C
• Tears equilibrate-
non-isosmolar solution by
CORNEAL WATER TRANSPORT
!TYPE.SOF TOPICAL APPLICATION!
• Irritation penetrat.icn
• lrritarion/comeal
.l<squ.mAcion/
oculari"ituion
• e.g.
frequency
- I tar secreeion
General an.<sthtsi.
Amihi."Amille
-
o
~

.~ ·IOINTME.NT~~ISUSTAINED f---.IFILTERPAPERS:r~tpsl---l L1DSCRUB!

• Aqueous medium ·Oil·b.ue.d • More. spread RELEASE I
• Sodium [luorescein~'. • Treaemenr of
• Cht.lp/easylte.ss xide-effecrs • Prolong contact time • Less dLxtt~ri(y • 50ft concact lenses • Rose Bengal bfepharicis
• Vision unimpaired • Blurredvision needed - •.\Ctab reservoir • No risk. of t.Xce..s.s • Solucion or oinrmenr
• Short duration • Toxic [0 internal eye • OCURrc.s • Eliminates- • Apply co lid margin
• Ccmmcnesc fonn - plastic. device P d e r u ..tjin o 5 .t
- drug-impregnated contamination
Ig.cQ{},..1\.INJEcnoN) - reservoir
T11~A~D~V~A~N~T~A~(~;~ES~!;::=-------""1 DISADVANTA.GES!
• AdministrAtion of large. doses that would • Painf,,1
pOOf"ly penetrate cornea • Ris-k of local complicacicns
• LOCAtion precise • Similar result with repeat eonical adminlscearion

!TYPES Of OCULAR INJECTIONI

-ISUBCONJUNCTIVAL f-----olSUBTENON f---ol RETROBULBARf---ollNTRACAMERAL I
-!INTRAVITREAL!
• High localconcentrat.icn • Not as good .as sub- • T rearmem of neuritis • Into ANTERIOR CHAMBER • Risks gu.ue.r than
• Drugs wich poor c()TTV,.l1 conjunctival • Anat..Sth£.Sia • Require smAll emocncs ben<fit.<
penerrarion,e.g. anribiccics • Creaeer risks • e.s. during eat.tT.lCt .surgery • Anribioeics in severe
. ws drug delivery • Visccetasric SUbSLltlCe. endcphrhalmitis

-~
fSlSTE;"\(C:'XOMlNt~'T!V\'rool

• Oral
• Intravenous
• [IIIBN~D~ICA~~T!SIO~N~5
r!
• Opt1C neuritis
• Re.tina.1 disease
----------· 1 BLOOD-OCULAR BARRIERS!
• Penerr A ced by lipid-soluble drug.
e.g. chloramphenicol
• Subcutaneous • Uru.1 tract dj5U.seIinU~t1[ion • Poorly penerrated by plasma protein-borne
• Intramuscular drugs
 outer layer - Tight junctions
lipophilic, Hydrophobic
[S:ONJUNCTIVA] lipophHic dfU~ re.stTVOlf . 1
Unionized d";~ penetrate, e.g. ChioT.:U'IlphtnJGO
• Alters avaHabHity for corneal • STROMA
Absorption Hydrophilic, lipophobic, aullul.r
• Non-specificdrugbiSdyiS~EMICCIRCULATION Allows diff.aion - solut'5 ,< 500 kD.
• Drug abSOfpuon -. . Hydrophobicdrug r~rvo", .
• Increased with v,uod,lators ionized dru~s penetrate e.g. Pilocarpine
• ENDOTHELIUM ..SRQPONMLKJIHGFEDCBA
ITEARFlLM} .. N or rare limiting . ,., . .
• Volum<7111
(incru.K5 pr<_blonk,ngJ Allows STROMNAG~EOUS tommunocu,on
• Bl1nking maintains volume. b
• Drained byn""'IA,rim~1du;tWU~TIARi'NG
• Topical drugs ASSOC.
WIth • DILUTION {SCLERA]
• PROTEIN BINDING • High., permubility than COfO<a
@LOOD_OCULARBARRIERS!
• DRAINAGE • Lo;" permubil:iJub)pBLYSACCHARIDE GEL
• lighc PfeShUft on G.ln.1.i1c.uH ,e4uas drainAge CiliAry<pith<lium • Pen<tTat<S • COLLAGEN FIBRIL MATRIX
lns vusels • PERIVASCULAR SPACES
IRIS AND CILIARY BODY RPEaZYXWVUTSRQPONMLKJIHGFEDCBA
A n d re tinAIve.ssels

• PIGMENTATION - drug bindingl.low rel",s< • Ban't.f to most moluulr..s. ..

• Some. penetrAtion by small lipophilic
• U,UT.lK .activicy
• MET ABO L1SM - PhAS<SI and 1 mole.Gute..s .
~ REDUCE ACTION • DamAgedin injury/inflAmmatoon

tTl
!ROUTES Of ADMIN ISTRATION I '"
[1\CTOlts IN V O L VED I ~'"
-IOSMOLA.RITY! .[EE] '!VISCOSITYr--.IUPIDSOLUBILlTyr PRESERVATIVES! EFFECTOF ..•..•
V'l

C
• Influenced by 50Iute.:-
(not prO(eiH~!
• LimiredTear
buffer canacnv
• Drug rerencicn • Corn ea 1p<n<".rion SURFACTANTS
• Incrust. corneal
SYSTEMIC DRUCS
• lnfuence- Blink
..•n
..•
C
• Tears equilibrate-
non-isosmolar solution by
CORNEAL WATER TRANSPORT
!TYPE.SOF TOPICAL APPLICATION!
• Irritation penetrat.icn
• lrritarion/comeal
.l<squ.mAcion/
oculari"ituion
• e.g.
frequency
- I tar secreeion
General an.<sthtsi.
Amihi."Amille
-
o
~

.~ ·IOINTME.NT~~ISUSTAINED f---.IFILTERPAPERS:r~tpsl---l L1DSCRUB!

• Aqueous medium ·Oil·b.ue.d • More. spread RELEASE I
• Sodium [luorescein~'. • Treaemenr of
• Cht.lp/easylte.ss xide-effecrs • Prolong contact time • Less dLxtt~ri(y • 50ft concact lenses • Rose Bengal bfepharicis
• Vision unimpaired • Blurredvision needed - •.\Ctab reservoir • No risk. of t.Xce..s.s • Solucion or oinrmenr
• Short duration • Toxic [0 internal eye • OCURrc.s • Eliminates- • Apply co lid margin
• Ccmmcnesc fonn - plastic. device P d e r u ..tjin o 5 .t
- drug-impregnated contamination
Ig.cQ{},..1\.INJEcnoN) - reservoir
T11~A~D~V~A~N~T~A~(~;~ES~!;::=-------""1 DISADVANTA.GES!
• AdministrAtion of large. doses that would • Painf,,1
pOOf"ly penetrate cornea • Ris-k of local complicacicns
• LOCAtion precise • Similar result with repeat eonical adminlscearion

!TYPES Of OCULAR INJECTIONI

-ISUBCONJUNCTIVAL f-----olSUBTENON f---ol RETROBULBARf---ollNTRACAMERAL I
-!INTRAVITREAL!
• High localconcentrat.icn • Not as good .as sub- • T rearmem of neuritis • Into ANTERIOR CHAMBER • Risks gu.ue.r than
• Drugs wich poor c()TTV,.l1 conjunctival • Anat..Sth£.Sia • Require smAll emocncs ben<fit.<
penerrarion,e.g. anribiccics • Creaeer risks • e.s. during eat.tT.lCt .surgery • Anribioeics in severe
. ws drug delivery • Visccetasric SUbSLltlCe. endcphrhalmitis

-~
fSlSTE;"\(C:'XOMlNt~'T!V\'rool

• Oral
• Intravenous
• [IIIBN~D~ICA~~T!SIO~N~5
r!
• Opt1C neuritis
• Re.tina.1 disease
----------· 1 BLOOD-OCULAR BARRIERS!
• Penerr A ced by lipid-soluble drug.
e.g. chloramphenicol
• Subcutaneous • Uru.1 tract dj5U.seIinU~t1[ion • Poorly penerrated by plasma protein-borne
• Intramuscular drugs
 ,,"jjr~~~~"""',-==~-I1 Mlh\i(;~ Tlg r juncoons
AR'I~Ii&ic, Hyd phobic
lipophliic dru~ reservoir
Unionized d";g.~ pt.ne.crAte, e.g. Chlorolmphtnlcol
• STROMA •
Hydrophilic, Lipophobic, a«lIul.T aZYXWVUTSRQPONMLKJIHGFEDCBA
r-r- . 5OIu,•• < 500 kD.
....:"A,;:I.:.:lo;..:w.:,:."d;:.i!;ff~u::..i:;;on
IINTRACANAUCUlA~~Cjr.:-~:::=. =-. ~~:'::~:'::,~~"",l-A""L-::P-O-R-::::T-loO-N-'1

b(;"k,"g • P IA L P L fX U .5 • P l4 L PLEXUS • ENDOTHELIUM· P IA L 'P L E X )'}S

PO,.s~erior._._
,,,.,
~()Phthdl
i<
ic artery ! Recu~t
aoph,h.{mic
branches of
.ut<ry
SRQPONMLKJIHGFEDCBA
rate limitin~
N oe
Allows STROMAl~f~US
f! Superior Hypophyse.ll
communication

A!t.bf" ;.)(l
T

: ~ io L ...
IIC
. ING
~;t ra I"i".1
I ISCLERA I ~~;'':.Imic

ORAl A l I BLOOD-OCULAR BARRIERS I . H,ghe' permeabIlity ~n~~R,'''· •• bral

.r pre.s.sure on c.tn.i.hCUI -edoces dr.lfUI • Low pCrTI'\ublhty d nm.Ate
C,I •.•ryepi,h.hum • P.ne".... • M LYSAC I-fARIDEGEL
lnsvustls • COLLAGEN FIBRILMATRIX
,5 AND CILIARY BODY RPE and~tton.l"usels • PERiVASCULAR SPACES
I MENTATION - drug bmdmgl.low •• Ie .lSC
mclecvles
• Ba"lt.t (0 most
• $ura.s.t ACtivity • Sbme penefTuton by .smaIllipophibc
ETABOLlSM-P .•••• Idnd, molecules
REDUCE ACTION • Danugt4 m m urylinfl.Jm1TldCIOn

Eo~re.~~
• PIAL PLEXUS
~ Superior hypop~y.sul artery
6"Internal carotid .artery
eEl Arteeior cerebral artery
Anterior communicacing arrerv
e Middl. cereb •• 1Artery
__ P05tuiOT communicating anerv

t9'htct~
• PIAL PLEXUS

e Anterior choroidal •• <try ~ Pos ce-ior communicating artery

tillEB
• PIAL PLEXUS
!Antenor choroidal areerv !Posterior cerebral artery
~ Middle cerebral .•Ttery ~ (Thalamogenlcul.ue branches)

Anterior cbcrcidal .uury Pcscerior cerebral .Utery

Middle cereb.al artery

m Pas rerior cereb ra 1.,<try 1:3 Middle

6 {Macular
ce-eb •.•1d'ttry
.uea- ana.stomos1.il

CONCLUSION:
• INTERNAL CAROTID ARTERY M' .
• BASILLARARTERY -Ma' - aon.supp.'y to Rwna-opticTadiation
10 supply to OptIC radiacion - Visual C o r t e x
 ,,"jjr~~~~"""',-==~-I1 Mlh\i(;~ Tlg r juncoons
AR'I~Ii&ic, Hyd phobic
lipophliic dru~ reservoir
Unionized d";g.~ pt.ne.crAte, e.g. Chlorolmphtnlcol
• STROMA •
Hydrophilic, Lipophobic, a«lIul.T aZYXWVUTSRQPONMLKJIHGFEDCBA
r-r- . 5OIu,•• < 500 kD.
....:"A,;:I.:.:lo;..:w.:,:."d;:.i!;ff~u::..i:;;on
IINTRACANAUCUlA~~Cjr.:-~:::=. =-. ~~:'::~:'::,~~"",l-A""L-::P-O-R-::::T-loO-N-'1

b(;"k,"g • P IA L P L fX U .5 • P l4 L PLEXUS • ENDOTHELIUM· P IA L 'P L E X )'}S

PO,.s~erior._._
,,,.,
~()Phthdl
i<
ic artery ! Recu~t
aoph,h.{mic
branches of
.ut<ry
SRQPONMLKJIHGFEDCBA
rate limitin~
N oe
Allows STROMAl~f~US
f! Superior Hypophyse.ll
communication

A!t.bf" ;.)(l
T

: ~ io L ...
IIC
. ING
~;t ra I"i".1
I ISCLERA I ~~;'':.Imic

ORAl A l I BLOOD-OCULAR BARRIERS I . H,ghe' permeabIlity ~n~~R,'''· •• bral

.r pre.s.sure on c.tn.i.hCUI -edoces dr.lfUI • Low pCrTI'\ublhty d nm.Ate
C,I •.•ryepi,h.hum • P.ne".... • M LYSAC I-fARIDEGEL
lnsvustls • COLLAGEN FIBRILMATRIX
,5 AND CILIARY BODY RPE and~tton.l"usels • PERiVASCULAR SPACES
I MENTATION - drug bmdmgl.low •• Ie .lSC
mclecvles
• Ba"lt.t (0 most
• $ura.s.t ACtivity • Sbme penefTuton by .smaIllipophibc
ETABOLlSM-P .•••• Idnd, molecules
REDUCE ACTION • Danugt4 m m urylinfl.Jm1TldCIOn

Eo~re.~~
• PIAL PLEXUS
~ Superior hypop~y.sul artery
6"Internal carotid .artery
eEl Arteeior cerebral artery
Anterior communicacing arrerv
e Middl. cereb •• 1Artery
__ P05tuiOT communicating anerv

t9'htct~
• PIAL PLEXUS

e Anterior choroidal •• <try ~ Pos ce-ior communicating artery

tillEB
• PIAL PLEXUS
!Antenor choroidal areerv !Posterior cerebral artery
~ Middle cerebral .•Ttery ~ (Thalamogenlcul.ue branches)

Anterior cbcrcidal .uury Pcscerior cerebral .Utery

Middle cereb.al artery

m Pas rerior cereb ra 1.,<try 1:3 Middle

6 {Macular
ce-eb •.•1d'ttry
.uea- ana.stomos1.il

CONCLUSION:
• INTERNAL CAROTID ARTERY M' .
• BASILLARARTERY -Ma' - aon.supp.'y to Rwna-opticTadiation
10 supply to OptIC radiacion - Visual C o r t e x
 • Fungal • TB - Raynaud's • Leprosy Local tissue ischaemia
• syphilitit IPAINFUL] • Cornea secondarv to~nOUS
_ Her~$ Zostet su..si.~

[PAINLESS I
• MALIGNANT CHANGE
• CHRONIC PERSISTING
• INVASIONof underlying IRare)
• REGENERATION Infl.lmm •• ion and e.s. Marjoiinls Utur
CAUSES/OUTCOME: StTUCUJTe..s
ULCERATION
-+ se If formAtion and _ chronic skin ulcer
e.g. Blood vessels
contr,;acdon -+ H a.morrhag. (usually v<.nous)
• REPAIRand retum ~g. Duodenal ulcer
to NORMALsCNcture con"e.ctl~ tissue _C~cric U1cu
pyloric stenOSIS
,epithelium &. underlying
tissue) .

EXAMPLES

• ~~rIC ULCERATION • CORNEAL U LCE R5

ur In an ..tCld·.~ccr(.tin!i •. rCA"

• Acid Protective. mechanisms Epithelium &

stroma swell --1fiU'N;:;rD::vE~R;;-G;::-;:O::-:-N7:E:-C".-RO-S-IS-1+-
I"filtruion of
• Pepsin • mucus 'I ' inflammAtory
•
•
•
•
•
pH gradicoc
Tight junctions
Rapid R&-ge.nefoltion
PGE,-tmueus+atid
HCO)-
rvpe:
• CENTRAL
IULCER

• pneumococc:.l.VStr<p/Sta h
I

. .
cells
-
<7'\

Msoc.with: • Hypopyon _ c::loudy .~ - primAry mfu[ion

• Anurior/~te'io, s~:;h~a,:ud.tCe
In anterior chamber
Aetiology:
• Helicob ••cur pylori -95% D.U.,7s% G.U. • MARGINAL /p e r ; p h .r y j
______ - ~cute ga..sair:is
SIMPLE -' Associ ••••d with bl .. .
~ - Infl,.tmmatory response • Usuall d epharocon,uncClvuis
Y ue to st~phyfococ.c..al toxin
-4-prouction
RING A. . ••1d"I ' ~ r . s lcoalesce clfcumfe
•• Peripher . t enri.1l1y

""-»0<'"'' with PAN ! LE! W (gentrs'" R..A.

• Due to 5c1e, ••1c.onn
• NSAIDs- PGE. G U---- ecnve [IS$(..Ie.dise.~se/vJ,sculiti5
• Autoimmune C.UtT~ti· . o~l! ~ ~
• lUre. -= Z E C .s [pernicious an.temid) MOOREN'S • Elderly
-, rohn'. Su •.•.•- 1 C. ha!" . • Bilarer ••I,.hallow ulcer
of ACid producricn . P le stlmui..uion
• Unknown utiology
• DENDRITIC (Buneh.lilc.t) ,
• e.g. Herpes simpk.x
• Asscciared with srrom ••1kU.lcitis
Comp(ic.uions:
•• S . .••. nyloric .uno.i.
HCAmns 'BLOCK' SEQUELAE·
aemorrhage 'BLEED' • oPACrry -Sc:.l.rring
• PerfOf.ltion •.••.peritonitis 'BURST'
• ECTATICCICATRIXII<ERA
• Adbeeence + erosion . • DESCEMETOCOELE._ UI TECT ASI.A-sc ••rbulges OUt
• MOllisnolnc clunge. - p.t.ncru..s, liver ceranon I u v e . . ~ Descem '
• PERFORATION _ Ru bulStS OUtdue to I.O.P. <t.< membt ••ne only,
• ANTER ptu re of cornu
IOR STAPHYLOMA _ Prol pass, ibl.0 prol ••pse of iri••• nd Ion.
b lapsed 1fIS and cissue tpithtliue.s
u gtS OUtdue to I.O.P.
 • Fungal • TB - Raynaud's • Leprosy Local tissue ischaemia
• syphilitit IPAINFUL] • Cornea secondarv to~nOUS
_ Her~$ Zostet su..si.~

[PAINLESS I
• MALIGNANT CHANGE
• CHRONIC PERSISTING
• INVASIONof underlying IRare)
• REGENERATION Infl.lmm •• ion and e.s. Marjoiinls Utur
CAUSES/OUTCOME: StTUCUJTe..s
ULCERATION
-+ se If formAtion and _ chronic skin ulcer
e.g. Blood vessels
contr,;acdon -+ H a.morrhag. (usually v<.nous)
• REPAIRand retum ~g. Duodenal ulcer
to NORMALsCNcture con"e.ctl~ tissue _C~cric U1cu
pyloric stenOSIS
,epithelium &. underlying
tissue) .

EXAMPLES

• ~~rIC ULCERATION • CORNEAL U LCE R5

ur In an ..tCld·.~ccr(.tin!i •. rCA"

• Acid Protective. mechanisms Epithelium &

stroma swell --1fiU'N;:;rD::vE~R;;-G;::-;:O::-:-N7:E:-C".-RO-S-IS-1+-
I"filtruion of
• Pepsin • mucus 'I ' inflammAtory
•
•
•
•
•
pH gradicoc
Tight junctions
Rapid R&-ge.nefoltion
PGE,-tmueus+atid
HCO)-
rvpe:
• CENTRAL
IULCER

• pneumococc:.l.VStr<p/Sta h
I

. .
cells
-
<7'\

Msoc.with: • Hypopyon _ c::loudy .~ - primAry mfu[ion

• Anurior/~te'io, s~:;h~a,:ud.tCe
In anterior chamber
Aetiology:
• Helicob ••cur pylori -95% D.U.,7s% G.U. • MARGINAL /p e r ; p h .r y j
______ - ~cute ga..sair:is
SIMPLE -' Associ ••••d with bl .. .
~ - Infl,.tmmatory response • Usuall d epharocon,uncClvuis
Y ue to st~phyfococ.c..al toxin
-4-prouction
RING A. . ••1d"I ' ~ r . s lcoalesce clfcumfe
•• Peripher . t enri.1l1y

""-»0<'"'' with PAN ! LE! W (gentrs'" R..A.

• Due to 5c1e, ••1c.onn
• NSAIDs- PGE. G U---- ecnve [IS$(..Ie.dise.~se/vJ,sculiti5
• Autoimmune C.UtT~ti· . o~l! ~ ~
• lUre. -= Z E C .s [pernicious an.temid) MOOREN'S • Elderly
-, rohn'. Su •.•.•- 1 C. ha!" . • Bilarer ••I,.hallow ulcer
of ACid producricn . P le stlmui..uion
• Unknown utiology
• DENDRITIC (Buneh.lilc.t) ,
• e.g. Herpes simpk.x
• Asscciared with srrom ••1kU.lcitis
Comp(ic.uions:
•• S . .••. nyloric .uno.i.
HCAmns 'BLOCK' SEQUELAE·
aemorrhage 'BLEED' • oPACrry -Sc:.l.rring
• PerfOf.ltion •.••.peritonitis 'BURST'
• ECTATICCICATRIXII<ERA
• Adbeeence + erosion . • DESCEMETOCOELE._ UI TECT ASI.A-sc ••rbulges OUt
• MOllisnolnc clunge. - p.t.ncru..s, liver ceranon I u v e . . ~ Descem '
• PERFORATION _ Ru bulStS OUtdue to I.O.P. <t.< membt ••ne only,
• ANTER ptu re of cornu
IOR STAPHYLOMA _ Prol pass, ibl.0 prol ••pse of iri••• nd Ion.
b lapsed 1fIS and cissue tpithtliue.s
u gtS OUtdue to I.O.P.
 • Loss of nOT11'lalploidy
• Spread by blood, lymphatic., meCA."as;z.

IAETIOLOGY I
.IINHERITEDGENETIC FACTORS I (10% of Cancers] --I ENVIRONMENTAL FACTORS ~

....- __ ..::..~---, ~ --=:::::::::r:---::-=-----:--1 ~~

IA,,,osom .•1 Dominant I 1 Familial I I Aucosom .•1 Recessive I I Chemicat! 1 Physical I I Viral I
(7Multifac(.Orial) (Defective DNA repair! • Polycyclic hvdrocarbons • RADIATION • DNA
(Inherited CAnc~"I e.g. Breasc Cancer e.g, Xeroderrn •• • Aromatic amine..s -UV • Rerrcviruses
• Specific. eissue Ovary CanccT pigme.ncos.il • Asbestos -Ionizing
• Specific marker Colon Cancer etc.
pl)enocype
• lnccmptere
pener-ance
[vari .•ble expresaion]
e.g. Familial retinoblaseonia
MEN
Neurofibromatosis

E NOM E
:..:.M..:....::U:......:..T..:.A.:......:.T...!I....:O~N~...!.I...!.N~~C OF
R.e~ultillg in:
L l
1
__ . __ T

A.CTIVATJON
.
OF ONCOGENE IaZYXWVUTSRQPONMLKJIHGFEDCBA
0 ', CENE
AlTER4.T10N
,AP..OPT05IS
IN REGUt.A110N 0'
'
!N~;IVAnON
UPP~.$SQR GENt::.
OF C.ANCllR ~r
'.' .•

.
Onccgene ;,., mutated cell signAllin~
protein
Srruc(ur.d change in cellular gt.ne
• Apopro.s;'s = '"",summed
• bel-a ene prevents apopecsls
<ell dueh' I • Functions of suppressor gene..~;
<!),&rf:hrfr m o / t e l l / '"
10<: .IRes1.~[s i~ increased cell survival CD' n - negative membrane signals
CROWfH FACTOR e.q. sis 1 5 1 tp J ~ tr a n s d o c tio n
EMBRANE RE EPTOR e.g. <rh B ~-downre!JUloltesCF sign ••(
; PR 1Nl e.g. Ras <D e.f/U *Ire n o c le s » tr a n s c r ip tio n

~ U ;-.AR ll!
rise due to:
E1NS e.g. c-myc
.
<!)lpOINT MUTATION.s I e.g. flAS
"' en SRQPONMLKJIHGFEDCBA
{ 9 0 % &ncreu cancer}
~ 'Molc.cular policem ..m '
ene -
- Kups cell in Cl phase of
01cHR MOSOME TRANSLOCATION/
{oven.xpre..s.sionj
<.3. 8q1 41c-mycl Burkitt's
. Ex.mpl<
Deletion ?f~
cell cycle.

'Jq'4 Rerinobl.~tom.t.
Lymphoma RequIr es 1nact,v •• ion of boch alle] •.s
<DICENE AMPLIFICATION I rhomozygo .•icy of expression]
<.g. N-myc - Neurobl.ucoma
c-erb B1 - Brust C .•ncer

+ ...• •.... ...• ~

r ALTERED CENE

..- EXPRESSION l

•
I PROMOTION l

NEOPLASIA
 • Loss of nOT11'lalploidy
• Spread by blood, lymphatic., meCA."as;z.

IAETIOLOGY I
.IINHERITEDGENETIC FACTORS I (10% of Cancers] --I ENVIRONMENTAL FACTORS ~

....- __ ..::..~---, ~ --=:::::::::r:---::-=-----:--1 ~~

IA,,,osom .•1 Dominant I 1 Familial I I Aucosom .•1 Recessive I I Chemicat! 1 Physical I I Viral I
(7Multifac(.Orial) (Defective DNA repair! • Polycyclic hvdrocarbons • RADIATION • DNA
(Inherited CAnc~"I e.g. Breasc Cancer e.g, Xeroderrn •• • Aromatic amine..s -UV • Rerrcviruses
• Specific. eissue Ovary CanccT pigme.ncos.il • Asbestos -Ionizing
• Specific marker Colon Cancer etc.
pl)enocype
• lnccmptere
pener-ance
[vari .•ble expresaion]
e.g. Familial retinoblaseonia
MEN
Neurofibromatosis

E NOM E
:..:.M..:....::U:......:..T..:.A.:......:.T...!I....:O~N~...!.I...!.N~~C OF
R.e~ultillg in:
L l
1
__ . __ T

A.CTIVATJON
.
OF ONCOGENE IaZYXWVUTSRQPONMLKJIHGFEDCBA
0 ', CENE
AlTER4.T10N
,AP..OPT05IS
IN REGUt.A110N 0'
'
!N~;IVAnON
UPP~.$SQR GENt::.
OF C.ANCllR ~r
'.' .•

.
Onccgene ;,., mutated cell signAllin~
protein
Srruc(ur.d change in cellular gt.ne
• Apopro.s;'s = '"",summed
• bel-a ene prevents apopecsls
<ell dueh' I • Functions of suppressor gene..~;
<!),&rf:hrfr m o / t e l l / '"
10<: .IRes1.~[s i~ increased cell survival CD' n - negative membrane signals
CROWfH FACTOR e.q. sis 1 5 1 tp J ~ tr a n s d o c tio n
EMBRANE RE EPTOR e.g. <rh B ~-downre!JUloltesCF sign ••(
; PR 1Nl e.g. Ras <D e.f/U *Ire n o c le s » tr a n s c r ip tio n

~ U ;-.AR ll!
rise due to:
E1NS e.g. c-myc
.
<!)lpOINT MUTATION.s I e.g. flAS
"' en SRQPONMLKJIHGFEDCBA
{ 9 0 % &ncreu cancer}
~ 'Molc.cular policem ..m '
ene -
- Kups cell in Cl phase of
01cHR MOSOME TRANSLOCATION/
{oven.xpre..s.sionj
<.3. 8q1 41c-mycl Burkitt's
. Ex.mpl<
Deletion ?f~
cell cycle.

'Jq'4 Rerinobl.~tom.t.
Lymphoma RequIr es 1nact,v •• ion of boch alle] •.s
<DICENE AMPLIFICATION I rhomozygo .•icy of expression]
<.g. N-myc - Neurobl.ucoma
c-erb B1 - Brust C .•ncer

+ ...• •.... ...• ~

r ALTERED CENE

..- EXPRESSION l

•
I PROMOTION l

NEOPLASIA
I,"".,.,,_.
~~
,

IH,,_"'."""'''·'·' ",.,.,
, ".

C.u.trointucinal
Pa.ncTus
>.

canur lob~truct:ion/intu.\.Su.sct.ptionJ
cancer (obstructive jaundice]
Cervix caneer l'pelvi.s!ureter - Renal failure.)
'fiiI~C~J.~A~~~
1'-"~'''''
Pituitary adenoma
Adrenal medulla
Renal AdenOCArcinorn~
(CH, ACTH, Prolactin)

(erythropoiet.in)
~~~
\C","",.,~,·_-c.,~·f""""''''
(ACTHI
Hype,calcaemia(PTH
_ Colour bronchus,
. like nepeidel
breASt, kid.ney, ovary
SIADH - Cancer brcecbus (AOH/ANPI
Apex lun~Gancu IHomer's Syndrome) , Ca,cinoid Synd,ome {5·HT, bradykinin I

lup. maligna.nt) [noc due to nutritional dt.",and.s of tumour'

t PituiufY .\d~nom:. IpituirAfY f05sal

Bony dc.suuction of met.15tuis
Cyrokines(by tumou' and ho.<I
Decreased food intak< (Taste, appetitel
. 1Clubbin.~ - luns cancer 11cau.el
Osceoarmrop.a.thy
Decreased fat >toras' [TNFo, IL·r, IFNyl
EpilhdiaVslTomal erosion
ITumour or eros.ion)
Lymphocyte, - .
MO. plasma cell inf;tu •• ion
1 Dermatomyositis -Iunglbrea" cancer
limmunologic:all
TACUTE Iesp. GI tumou,,! le.g. Breast unc.u}
CHRONIC {esp. GI tumou,sl Acanthosis Nisri,",N - Gutric canur
LymphadenopathY 11immuno{og;c.tI!
Granulom.t formAtion
lmmune deficiency ILymphoid 'n.\lignancy! .
1 Cancer of the b,oochu. (obstruction and
1uention of ucruionsl
1 Venous th,ombo>i.,rTh,ombophlebitis
(Thrombosenic tumour produces)
An.umi. {1c.usel

·,11
'"'"~
.•. V>
..•
M

c
!l
c:
 t Ot1<"'~ti sue-
rensicn
I {i
IMPtDEARTERlAL
FLOW
• Mesenteric vein thrombosis
-+ small bowel inf ..arcr.ion
• SerJ.ngolaud k.r~l.. ' c
• C.lVemous ~inus thrombosis

EFFECTS:
SUSCEPTIBILITY:
"j DEGRU OF AEROBIC I
·IANATOMYOFLOCALI--~---·IORGANTEMPERA\Llll,.E,1
METABOLISM .'BLOOD SU'Pl'LY. • • COOLING
• End .trt.CTY Reduced met.abol.tc. .activity
• Imicochondria'
vs.' CoIIate ral blood supply e.g., Open burt.surgery
• capill.1rie:.s/unic mass

l TYP:OF
'15 PEED Of
INS~LT:
ONSET I
SLOW
• ATROPHY
7"'" FAST
• INFARCTION
• Complete
• Incomplete.
• Time fOT ",1I.<e, .•1
circul •.non to
develop P A

SENSITIVITY Of TISSUE:
~ IHIGH SENSITIVITY I e IMODERATE. SENSITIVITY
• BONE
I ~ ILOW SENSITIVI~
~CORNEA
I
• BRAIN/SPINAL CORD
IS seconds - unconsciousness
1. min- ,"eversible cell damage .SKElETAL MUSCLE • H)'ALlNE CARTILAGE
4-5 - c<1IaZYXWVUTSRQPONMLKJIHGFEDCBA
d tu h
·SKIN AVAscular
Tole,,,nt of ischaemia
• HEARTSRQPONMLKJIHGFEDCBA
S min - "functional mAintenance time"
• STOMACH/SMALL INTESTINE
30 rnin (@)7°CI- "Resuscitation time" %
Ifrom io.noxia! M senr I R.n~ S len
co min lif t 10°C temp!
Upper!lm

"R~NALG:ORTEX n ry

• ADRENAL CORTEX
 t Ot1<"'~ti sue-
rensicn
I {i
IMPtDEARTERlAL
FLOW
• Mesenteric vein thrombosis
-+ small bowel inf ..arcr.ion
• SerJ.ngolaud k.r~l.. ' c
• C.lVemous ~inus thrombosis

EFFECTS:
SUSCEPTIBILITY:
"j DEGRU OF AEROBIC I
·IANATOMYOFLOCALI--~---·IORGANTEMPERA\Llll,.E,1
METABOLISM .'BLOOD SU'Pl'LY. • • COOLING
• End .trt.CTY Reduced met.abol.tc. .activity
• Imicochondria'
vs.' CoIIate ral blood supply e.g., Open burt.surgery
• capill.1rie:.s/unic mass

l TYP:OF
'15 PEED Of
INS~LT:
ONSET I
SLOW
• ATROPHY
7"'" FAST
• INFARCTION
• Complete
• Incomplete.
• Time fOT ",1I.<e, .•1
circul •.non to
develop P A

SENSITIVITY Of TISSUE:
~ IHIGH SENSITIVITY I e IMODERATE. SENSITIVITY
• BONE
I ~ ILOW SENSITIVI~
~CORNEA
I
• BRAIN/SPINAL CORD
IS seconds - unconsciousness
1. min- ,"eversible cell damage .SKElETAL MUSCLE • H)'ALlNE CARTILAGE
4-5 - c<1IaZYXWVUTSRQPONMLKJIHGFEDCBA
d tu h
·SKIN AVAscular
Tole,,,nt of ischaemia
• HEARTSRQPONMLKJIHGFEDCBA
S min - "functional mAintenance time"
• STOMACH/SMALL INTESTINE
30 rnin (@)7°CI- "Resuscitation time" %
Ifrom io.noxia! M senr I R.n~ S len
co min lif t 10°C temp!
Upper!lm

"R~NALG:ORTEX n ry

• ADRENAL CORTEX
 EXTRA LUMINAL LUM'~ EXTRA LUMINAL
• External ccmpresaicn • Aruyiosderosis • Thrombosis • Compre.s.sion
• TrAum.l/'.su:rion • Endotheli .•l- • Embol~m
Dysfunction .s
• jckk cell
• Vasculitis

DETAILS:
ATHE.Jl.OSCLEROSIS THROMBOSIS
intimal disease
Proliferative. Solid ma.s/plug from components of
Involving mediumllar~c lllu.'jcllIM/eL·,~[i' blood in" living blood vessel {or heard
Mtcri!!!!
As sociated with Hypcrcholesu:rol,1Cmltl zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
VIRCHOW'S TRIAD:
H vnereens ion Changes jn Intimal vessel surface
Smoking e.g. Aeheroscterosts
Acute vasculitis J% include:
Diabetes
Traumll Athcrom.1tou.\ plaque
Changes in pattern of blood flow Bone
CROSS
R .•ised focal intimal atheroma Changes in constituents of blood Fat
Air
lfibrofatty plaque]
Associated with FATTY STREAI<S Occurs in: Nitrogen ere,
(yellow, at bijurcations] Heart, arteries, capillaries and veins
Effect
Occlusive. in arteries Occlusion/isch .•emial+/- infarction
MICROSCOPIC [core]
lipid coronary, cerebral, femoral
C..allagen V",i .•ble Factors:
CROSS/MICROSCOPIC Tissue. affect«flst.tte of tissue
Smooth muscle cell.
Macrophages Firmly attached to wall Size of embolus
Fibrin/pla",I", m •.•h of clot Blood .•upply {end arterylcollateralsl
+/- T cell immune. reaction
Temperature etc.
EFFECTS EFFECTS
Occlusive in SMALL ARTERI ES Acute/chronic occlusion Sites of impaction:
[myocardial infarction, chronic 75% Lower limb.
[ischaemia]
D es erucrive in LARCE ARTERIES ischaemic heart disease] 10% BT41t"
/Aneurysm, rupture, risk thrombosis] CVA [cerebral arteries I 10% Mesentuic, Renal, Splenic
Embolism s% Upper limbs

Examples:
Chronic ischaemic heart disease [coronary!
C"ngrene of leg [popliteal]
CVA [cerebral]
Acute occlusive thrombosis
(Ulceration of atherosclerotic plaque, and
exposure of subendothelial connective. tissue)
 EXTRA LUMINAL LUM'~ EXTRA LUMINAL
• External ccmpresaicn • Aruyiosderosis • Thrombosis • Compre.s.sion
• TrAum.l/'.su:rion • Endotheli .•l- • Embol~m
Dysfunction .s
• jckk cell
• Vasculitis

DETAILS:
ATHE.Jl.OSCLEROSIS THROMBOSIS
intimal disease
Proliferative. Solid ma.s/plug from components of
Involving mediumllar~c lllu.'jcllIM/eL·,~[i' blood in" living blood vessel {or heard
Mtcri!!!!
As sociated with Hypcrcholesu:rol,1Cmltl zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
VIRCHOW'S TRIAD:
H vnereens ion Changes jn Intimal vessel surface
Smoking e.g. Aeheroscterosts
Acute vasculitis J% include:
Diabetes
Traumll Athcrom.1tou.\ plaque
Changes in pattern of blood flow Bone
CROSS
R .•ised focal intimal atheroma Changes in constituents of blood Fat
Air
lfibrofatty plaque]
Associated with FATTY STREAI<S Occurs in: Nitrogen ere,
(yellow, at bijurcations] Heart, arteries, capillaries and veins
Effect
Occlusive. in arteries Occlusion/isch .•emial+/- infarction
MICROSCOPIC [core]
lipid coronary, cerebral, femoral
C..allagen V",i .•ble Factors:
CROSS/MICROSCOPIC Tissue. affect«flst.tte of tissue
Smooth muscle cell.
Macrophages Firmly attached to wall Size of embolus
Fibrin/pla",I", m •.•h of clot Blood .•upply {end arterylcollateralsl
+/- T cell immune. reaction
Temperature etc.
EFFECTS EFFECTS
Occlusive in SMALL ARTERI ES Acute/chronic occlusion Sites of impaction:
[myocardial infarction, chronic 75% Lower limb.
[ischaemia]
D es erucrive in LARCE ARTERIES ischaemic heart disease] 10% BT41t"
/Aneurysm, rupture, risk thrombosis] CVA [cerebral arteries I 10% Mesentuic, Renal, Splenic
Embolism s% Upper limbs

Examples:
Chronic ischaemic heart disease [coronary!
C"ngrene of leg [popliteal]
CVA [cerebral]
Acute occlusive thrombosis
(Ulceration of atherosclerotic plaque, and
exposure of subendothelial connective. tissue)
 Narrow lumen Intimal fibrosis, thickening, hvperpla .•ia
Ischaemialinfarct distally l.eukocvee infil".uionl + 1 - granulomal+l- Necrosis IfocaVdiffu.e/

ENDOTHELIAL DYSFUNCTION I PAN - Bifurcations, localized, aneurysms

- Fibrinoid necrosis
Response to abnormal stimulus - Healed are as : Transmural scarring
Modifies normal function
Expression of new properties Thromboarteritis obliterans (Buerger's diseasel
SPECT~UM OF D~EASE: Acute/chronic inflammation
small arteries
Ir:E:-:-N""D::-O-::-T:::O:-:H-:-E""L1""'A-:-L-:S-::::Tc-IM-:-U""LA-:-::::T"'-IO~N""")
I zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
r-E-"N'--D-O-T--H-EL-LA-L-'A-CT-=IV-A-T--I-O'"":"N--'JI
segment..11 occlusive. thrombosis
i1 Tobacco hypersensitivity)
t Rapid, reversible
e.g. Histamine _ CONTRACTION
I HOUTsldays, Protein synthe.sis
I cvtokine production .

t.
I Loss of heparin-like surf ace-molecules Raynaud's Phenomenon
l Tissu. fActor e.><prcssion NB IRaynaud's di sease ~ idiopathic)
Sec.ondaty to arterial narrowing
S LE, Scleroderma, atherosclercsis, Buorger's

I
~:'i!!(~~erplasiA Spasm
Fibrin deposition • Thrombo .•is EFFECTS
Decreased rel •••.se EDRF • OCCLUSION Endothelial dysfunctionlActivation
Increased •.bnormal vasoconsrricrion Thrombosis Idistal ischa~mialinf ••rction)
 t lNFI1.ARED 400-760 moltGui.lf di~i.nion

8
)-6
VISIBLE 100- 400
ULTI1.AVlOLET lonizotion IBond., broken)
1_10-1
"
Xray.r.tdiat1on, C.tmma".tdi.acion
.•(uv.cl
!ULTI1.AVlOLET L1GHi)
.~ ..§I}
: A~~~d"'bynudeic Acid etc.
- lcx>-'90nm ONE)
_ Do.'oot , •.••eh Earth 10Z LEIC
• Most d.tmAging light : ~HO~OSENSlTlZlNG • DAMAGES DNNNUC
• ALTERS FUNCTIONAL
radi.ltion EFfECT ACIDS
MOLECULES
_ nucleic ackb/pron.ins

\ABSORP'TlON
-[CORNEA)
IN Eytj _ ~NTERlORCHAMBER}
• lnfra,ed - MelAnin
-~
·UV·A
-!RETlN;;)- PIGMENTS .
• LIGHT _ Photo,ecept.o, pigmentS
_ lnfr •• ed - MelAnin IRPE)
_ )(antnopnylllmocula)
• UV·B Il,io and T,.b. M eshwork)
• lnfT.tred > 1400nm

~
t:
-e
-ITHERMALI
-u p . RETINA
-IMECHANlCAL!
• "-S. YAG re.tin"J
..
...
VI

C
t t~mp '~1O°C sbcck wave Iphotodis,uPti~) ...
n
• Higher exposure feve!
than photochemical
• Excimer fphoto~br.acivel ...
C

- Extrinsic compound Absorbs U V

And be.comc.s toxic
• Indudes photov.aporizing "'.....
N
eff«t (CO,I •• er/
e.g. PUVA ~ psoralen + ~~~_--,
- LIGHT + OXYGEN
/STRUCTURES!

I CORNEA! I LENS! I RETINA!

• U.su.llly re.si.sunt to n.ltur.u • U V·A m.u.imally absorbed •
Visible .and Infr".lre,dr.adi,uion -eacb Rerin ••
UV levels. /TEARFlLM PROTECTION bv Iens •
Us.uaUy photocn.mic.tl cl.nuge (Oi"",tllndirectl
- UV·8 m.u.i"",Uy ab.."bed by cornu • LENS PROTECTS RETINA •
Macular dam~ @PHOTORECEPTORS, RPE
- Epitheliurn/Endotn.lium muim.lly • lnrerjeres with growth .lnd -
High pO, choroidal circul.uion ..• Ri.k of
ab.sorb@160·'Qonm(filteneclbyozone) differentiation of epithelium OXIDATlVE FREE·I1.ADICAL DAMAGE
• EXCESS: PHOTOKEI1.ATITIS (acutel • LENS OPACITY ..• CATAI1.ACT - PROTECTlONIREPAIR PROCESS:
Epith<lia sloughing
Strom ••J s_!ling
• Mainly ANTERIOR CORTEX SRQPONMLKJIHGFEDCBA
0R..tpid outer scgmcnt t\lTnOVe.r ' 1 G - 1 S cUy.sJ
- PROTECTION: YELLOW PIGMENTS @Accumulacionof LIPOFUSCIN in RPE
Endothelial cl.mage In nucleus (Procluct o( RPE ,eMw'" .nd photorecepto,
Absorb UVA diges rion]
PTERYGIUM [chronic} G),hO, in light
Denauned colLosen IRIS MELANIN (3) MELAN IN -1 role
Inflammatory infiltrat. - fr•• ,.dical..,.. vellg.,rr""in binding
Q)MACU LAR YELLOW PIGMENT
-IEYELlD SKIN! -Abso,b, UV
G)VlTAMlNE
- Skin ch.lnS" - Alter.d DNA (dimus)
- Photoch<mic.tl ch.lnge
o Rapid Choroid ••1blood (Iow - Hut ,<mw.1
- CONDlTlONS(DSOLARIFOVEOMACULAR/
-t Hi.stolmill( t PGEl
RETINOPATHY
• Acute UV expcscre - 'SUNBURN' (DSENlLEMACULAR
• Cbecnie • l k n i s n S l t i n c h .J n S O S - WrinkJ.."tF,.«kJu/Uncigine.s
DEGENERATION
• M .lli!J T I • • n t S k i n " " " n s o s - Basal Cell Cal'Cino~Malis=nt Mdanom.v Q)BULL'S EYEMACULOPATHY
Squamoos C.II Ca,cinoma - Oeer ••ting Microseopullndi'«t opthalmoscopy
 t lNFI1.ARED 400-760 moltGui.lf di~i.nion

8
)-6
VISIBLE 100- 400
ULTI1.AVlOLET lonizotion IBond., broken)
1_10-1
"
Xray.r.tdiat1on, C.tmma".tdi.acion
.•(uv.cl
!ULTI1.AVlOLET L1GHi)
.~ ..§I}
: A~~~d"'bynudeic Acid etc.
- lcx>-'90nm ONE)
_ Do.'oot , •.••eh Earth 10Z LEIC
• Most d.tmAging light : ~HO~OSENSlTlZlNG • DAMAGES DNNNUC
• ALTERS FUNCTIONAL
radi.ltion EFfECT ACIDS
MOLECULES
_ nucleic ackb/pron.ins

\ABSORP'TlON
-[CORNEA)
IN Eytj _ ~NTERlORCHAMBER}
• lnfra,ed - MelAnin
-~
·UV·A
-!RETlN;;)- PIGMENTS .
• LIGHT _ Photo,ecept.o, pigmentS
_ lnfr •• ed - MelAnin IRPE)
_ )(antnopnylllmocula)
• UV·B Il,io and T,.b. M eshwork)
• lnfT.tred > 1400nm

~
t:
-e
-ITHERMALI
-u p . RETINA
-IMECHANlCAL!
• "-S. YAG re.tin"J
..
...
VI

C
t t~mp '~1O°C sbcck wave Iphotodis,uPti~) ...
n
• Higher exposure feve!
than photochemical
• Excimer fphoto~br.acivel ...
C

- Extrinsic compound Absorbs U V

And be.comc.s toxic
• Indudes photov.aporizing "'.....
N
eff«t (CO,I •• er/
e.g. PUVA ~ psoralen + ~~~_--,
- LIGHT + OXYGEN
/STRUCTURES!

I CORNEA! I LENS! I RETINA!

• U.su.llly re.si.sunt to n.ltur.u • U V·A m.u.imally absorbed •
Visible .and Infr".lre,dr.adi,uion -eacb Rerin ••
UV levels. /TEARFlLM PROTECTION bv Iens •
Us.uaUy photocn.mic.tl cl.nuge (Oi"",tllndirectl
- UV·8 m.u.i"",Uy ab.."bed by cornu • LENS PROTECTS RETINA •
Macular dam~ @PHOTORECEPTORS, RPE
- Epitheliurn/Endotn.lium muim.lly • lnrerjeres with growth .lnd -
High pO, choroidal circul.uion ..• Ri.k of
ab.sorb@160·'Qonm(filteneclbyozone) differentiation of epithelium OXIDATlVE FREE·I1.ADICAL DAMAGE
• EXCESS: PHOTOKEI1.ATITIS (acutel • LENS OPACITY ..• CATAI1.ACT - PROTECTlONIREPAIR PROCESS:
Epith<lia sloughing
Strom ••J s_!ling
• Mainly ANTERIOR CORTEX SRQPONMLKJIHGFEDCBA
0R..tpid outer scgmcnt t\lTnOVe.r ' 1 G - 1 S cUy.sJ
- PROTECTION: YELLOW PIGMENTS @Accumulacionof LIPOFUSCIN in RPE
Endothelial cl.mage In nucleus (Procluct o( RPE ,eMw'" .nd photorecepto,
Absorb UVA diges rion]
PTERYGIUM [chronic} G),hO, in light
Denauned colLosen IRIS MELANIN (3) MELAN IN -1 role
Inflammatory infiltrat. - fr•• ,.dical..,.. vellg.,rr""in binding
Q)MACU LAR YELLOW PIGMENT
-IEYELlD SKIN! -Abso,b, UV
G)VlTAMlNE
- Skin ch.lnS" - Alter.d DNA (dimus)
- Photoch<mic.tl ch.lnge
o Rapid Choroid ••1blood (Iow - Hut ,<mw.1
- CONDlTlONS(DSOLARIFOVEOMACULAR/
-t Hi.stolmill( t PGEl
RETINOPATHY
• Acute UV expcscre - 'SUNBURN' (DSENlLEMACULAR
• Cbecnie • l k n i s n S l t i n c h .J n S O S - WrinkJ.."tF,.«kJu/Uncigine.s
DEGENERATION
• M .lli!J T I • • n t S k i n " " " n s o s - Basal Cell Cal'Cino~Malis=nt Mdanom.v Q)BULL'S EYEMACULOPATHY
Squamoos C.II Ca,cinoma - Oeer ••ting Microseopullndi'«t opthalmoscopy
 Index
240zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA INDEX OF QUESTION TOPICS
Page No.
Sublect

Renal physiology
Kidney structure
Renal circulation
••• Subject
Tubular tmnsport
•••
45
..-
..
--.--
..
---.-----------=-~- Page No •

ANATOMY
Sodium balance 45
WatcitbalBllce 45 The orbital cavity and paranasal sinuses 1
Renin-angiotensin system
The eyelids
2
Endocrlne physl 45 The lacrimal system
3
The thyroid gland 46 The cornea
4
Glucagon 6 The sclera
5
Insulin 46 The ciliary body
AOH 5
The iris
The pituitary 47 6
The lens
CalCIum metabolism 47 7
Corticosteroids The choroid 7
47
Catechotamines The retina 8
The extraocular muscles 9
CNS physiology 47
The orbital blood vessels 10
Cerebrospinal flUId 48
Spinal tracts The visual pathway 11
48
Tendon reflexes The cranial nerves 12
48
The cerebellum The face and scalp 13
The thyroid gland 14
OCULAR PHYSIOLOGY The cervical sympathetic trunk
49 14
The parotid region 14
Tho lears 49
The eyelidS 50 The cerebral vessels 15
Theoomea 53
The aqueous and ciliary epithelium 55 GENERAL PHYSIOLOGY
The pupil 56
Cardiovascular physiology
The lens 58
Blood flow and regulation 40
The vItreous 59
The retina 61 Capillary exchange 40
ElectrophySIOloglcal investigationS 62 Baroreceptors 41
The extraocular muscles Blood pressure 41
Cardiac cycle 41
PHARMACOLOGY Foetal circulation
101 42
Pharmaook:netics 101baZYXWVUTSRQPONMLKJIHGFEDCBA
Respiratory physiology
DigoXin 101
Gas exchanqs 42
The 8(jrenefglc system 102
The cholinergic system CO 2 binding transport and distribution 43
04
Local anaesthetiCS O 2 binding transport and distribution 43
04
Corticosterolds
 Index
241

240zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Page No.
-
Index
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Subject
Page No.

Carbonic anhydrase Inhibitors

Subject Antibacterial agents and hyperosmotic agents 105
106
Renal physiology 44 Antifungal agents
108
Kidney structure 44 Antiviral agents
108
Renal circulation 44
Tubular transport 45 PATHOLOGY
Sodium balance 45
Cell injury
Water balance 45 124
Chemical mediators 124
Renin-angiotensin system
Inflammation
125
EndoCrine physiOlogy 45 Type I Hypersensitivity
127
The thyroid gland 46 Type It Hypersensitivity
127
Glucagon 46 Type III Hypersensitivity
127
Insulin 46 Type IV Hypersensitivity 127
46 Transplant immunology
AOH 128
The pituitary 47 Atherosclerosis
128
Calcium metabolism 47 Thrombosis
128
47 Infarction ')
CorticOsteroids 128
Catecholamines Oedema
128
Pigmentation 129
CNS physiology 47
Heterotrophic calcification 129
Cerebrospinal fluid 48
Neoplasia
48 129
Spinal tracts Amyloid
Tendon reflexes 48 133
The cerebellum MICROBIOLOGY

OCULAR PHYSIOLOGY S ta p h y lO C O C C U S
49baZYXWVUTSRQPONMLKJIHGFEDCBA 149
S tre p to c o c c u s
49 150
The tears Neisseria
50 151
The eyelids MyCObacteria
53 151
Thecomea Bacilli
The aqueous and ciliary epithelium 55 152
Vaccines 154
56
The pupil C h la m y d ia
58 154
The \ens Exotoxins
59 154
The vitreous Herpes viruses
61 155
The retina Measles
E1eCtJ'OPhyslologicatinvestigationS 62 155
Rubella
156
The extraocular muscleS Adenovirus
!
156
Hepatitis viruses 156
PHARMACOLOGY 101 HIV 157
101 A s p e rg illu s
Pharmacokinetics 157
101 CandkJa
Digoxin 158
102 A c a n th a m o e b a
The adrenergic system 158
The cholinergic system 104 Sterilisation 158
Loc8I anaestheticS 104
CortlCOstero\dS
 Index
241

240zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Page No.
-
Index
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Subject
Page No.

Carbonic anhydrase Inhibitors

Subject Antibacterial agents and hyperosmotic agents 105
106
Renal physiology 44 Antifungal agents
108
Kidney structure 44 Antiviral agents
108
Renal circulation 44
Tubular transport 45 PATHOLOGY
Sodium balance 45
Cell injury
Water balance 45 124
Chemical mediators 124
Renin-angiotensin system
Inflammation
125
EndoCrine physiOlogy 45 Type I Hypersensitivity
127
The thyroid gland 46 Type It Hypersensitivity
127
Glucagon 46 Type III Hypersensitivity
127
Insulin 46 Type IV Hypersensitivity 127
46 Transplant immunology
AOH 128
The pituitary 47 Atherosclerosis
128
Calcium metabolism 47 Thrombosis
128
47 Infarction ')
CorticOsteroids 128
Catecholamines Oedema
128
Pigmentation 129
CNS physiology 47
Heterotrophic calcification 129
Cerebrospinal fluid 48
Neoplasia
48 129
Spinal tracts Amyloid
Tendon reflexes 48 133
The cerebellum MICROBIOLOGY

OCULAR PHYSIOLOGY S ta p h y lO C O C C U S
49baZYXWVUTSRQPONMLKJIHGFEDCBA 149
S tre p to c o c c u s
49 150
The tears Neisseria
50 151
The eyelids MyCObacteria
53 151
Thecomea Bacilli
The aqueous and ciliary epithelium 55 152
Vaccines 154
56
The pupil C h la m y d ia
58 154
The \ens Exotoxins
59 154
The vitreous Herpes viruses
61 155
The retina Measles
E1eCtJ'OPhyslologicatinvestigationS 62 155
Rubella
156
The extraocular muscleS Adenovirus
!
156
Hepatitis viruses 156
PHARMACOLOGY 101 HIV 157
101 A s p e rg illu s
Pharmacokinetics 157
101 CandkJa
Digoxin 158
102 A c a n th a m o e b a
The adrenergic system 158
The cholinergic system 104 Sterilisation 158
Loc8I anaestheticS 104
CortlCOstero\dS
 Index
242zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Index 243zyxwvutsrqponmlk
Page No. Subject
Subject Page No.

STRUCTURED ESSAY PLANS Blood supply to the visual pathway 220

Autonomic nervous system
174 Causes and effects of ulcers 222
Functional differences between the sympathetic and Peptic ulceration 223
parasympathetic nervous system 174 Comeal ulcers 223
Structural differences between the sympathetic and Definition of neoplasia
176
224
parasympathetic nervous system Aetiology of neoplasia
178 224
Mechanisms controlling blood flow Genetic mechanisms of neoplasia
180 226
Mechanisms of photopic and scotopic vision
local effects of neoplasia 226
Local contrast preservation 184
186 Systemic effects of neoplasia 226
Mechanisms underlying pet'Ception of colour
187 Paraneoplastic syndromes 226
History of colour spectrum
Comparison of parvocellular and magnocellular pathways 190 Causes and effects of ischaemia 228
Supranuclear control of ocular ITIQvements 192 Relative sensitivity of tissues to Ischaemia 229
Pursuit and slow eye movements 194 Occlusive disease in muscular arteries 230
Saccadic eye movements
194 Occlusive disease in arterioles 230
Eye position maintenance
195 Atherosclerosis 231
Vergence movements-
195 Thrombosis
195
231
Non-optic (vestibular) reflexes Embolism
196 231
Electrophysiological investigations of the visual pathway
Vasculitis 232
Visual evoked potentials
196
Endothelial dysfunction 232
196
Electroretinogram
197 light and electromagnetic spectrum 234
Pattern electroretinogram
198 Ultraviolet light and absorption by the eye 234
Electro-oculogram
Retinotopic organisation and the visual pathway 200 Mechanisms of light ocular damage 235
The third cranial nerve
202 light damage to the eyelid skin 235
The fourth cranial nerve
204 light damage to the cornea 235
206 light damage to the lens
The sixth cranial nerve 235
Mechanisms of vIsual adaptation
208
light damage to the retina 235
light adaptation
209
Dark adaptation
210
Control of pupillary responses
212
213
Mydriasis
Myosis
213
Anatomical and physiological basis of binocular vision 214
Retinal correspondence
214
Panum's space and area
214
214
Horopter
214
Diplopia
Classification of binocular vision 215
Theories of binocular vision and fusion 216
Factors governing drug penetration into the eye 218
Routes of drug administration to the eye 219
 Index
242zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Index 243zyxwvutsrqponmlk
Page No. Subject
Subject Page No.

STRUCTURED ESSAY PLANS Blood supply to the visual pathway 220

Autonomic nervous system
174 Causes and effects of ulcers 222
Functional differences between the sympathetic and Peptic ulceration 223
parasympathetic nervous system 174 Comeal ulcers 223
Structural differences between the sympathetic and Definition of neoplasia
176
224
parasympathetic nervous system Aetiology of neoplasia
178 224
Mechanisms controlling blood flow Genetic mechanisms of neoplasia
180 226
Mechanisms of photopic and scotopic vision
local effects of neoplasia 226
Local contrast preservation 184
186 Systemic effects of neoplasia 226
Mechanisms underlying pet'Ception of colour
187 Paraneoplastic syndromes 226
History of colour spectrum
Comparison of parvocellular and magnocellular pathways 190 Causes and effects of ischaemia 228
Supranuclear control of ocular ITIQvements 192 Relative sensitivity of tissues to Ischaemia 229
Pursuit and slow eye movements 194 Occlusive disease in muscular arteries 230
Saccadic eye movements
194 Occlusive disease in arterioles 230
Eye position maintenance
195 Atherosclerosis 231
Vergence movements-
195 Thrombosis
195
231
Non-optic (vestibular) reflexes Embolism
196 231
Electrophysiological investigations of the visual pathway
Vasculitis 232
Visual evoked potentials
196
Endothelial dysfunction 232
196
Electroretinogram
197 light and electromagnetic spectrum 234
Pattern electroretinogram
198 Ultraviolet light and absorption by the eye 234
Electro-oculogram
Retinotopic organisation and the visual pathway 200 Mechanisms of light ocular damage 235
The third cranial nerve
202 light damage to the eyelid skin 235
The fourth cranial nerve
204 light damage to the cornea 235
206 light damage to the lens
The sixth cranial nerve 235
Mechanisms of vIsual adaptation
208
light damage to the retina 235
light adaptation
209
Dark adaptation
210
Control of pupillary responses
212
213
Mydriasis
Myosis
213
Anatomical and physiological basis of binocular vision 214
Retinal correspondence
214
Panum's space and area
214
214
Horopter
214
Diplopia
Classification of binocular vision 215
Theories of binocular vision and fusion 216
Factors governing drug penetration into the eye 218
Routes of drug administration to the eye 219