Spot the Diagnosis: 15 Ophthalmology Case Quizzes
Last updated: October 2026
Fifteen short clinical cases, each built around the "giveaway" clue examiners love. Read the case, make your diagnosis, then open the answer to see which clue should have clinched it.
How to use: cover the answer, commit to one diagnosis, and say your reasoning out loud as you would in a viva.
Case 1
A 28-year-old high myope has had flashes and a shower of new floaters for 2 days. On slit-lamp examination, pigment granules are seen floating in the anterior vitreous.
Reveal diagnosis
Retinal tear / rhegmatogenous retinal detachment. Pigment in the anterior vitreous ("tobacco dust", Shafer sign) strongly suggests a retinal break. Do a full indented peripheral examination.
Case 2
A 30-year-old overweight woman reports headaches, transient visual obscurations lasting seconds on standing, and a "whooshing" sound in her ears. Both optic discs are swollen; vision is normal.
Reveal diagnosis
Idiopathic intracranial hypertension. Pulsatile tinnitus and transient visual obscurations are classic. Exclude venous sinus thrombosis and a mass with MRI and MR venography before lumbar puncture. See papilloedema.
Case 3
A 68-year-old with atrial fibrillation has sudden painless loss of vision in one eye to counting fingers. The retina is pale and the fovea is bright red. Blood columns in the arterioles appear segmented.
Reveal diagnosis
Central retinal artery occlusion. The cherry-red spot appears because the fovea has no inner retina to whiten, so the choroid shows through. Segmented blood columns are "box-carring". Refer urgently through the stroke pathway.
Case 4
A soft contact lens wearer who rinses lenses with tap water has severe eye pain that seems out of proportion to the modest corneal findings. There is a ring-shaped stromal infiltrate and the corneal nerves look thickened.
Reveal diagnosis
Acanthamoeba keratitis. Pain out of proportion, a ring infiltrate and radial perineuritis are the clues. Tap water exposure is the classic risk factor. See microbial keratitis.
Case 5
Parents notice a white glow in one pupil of their 18-month-old child in flash photographs. Ultrasound shows an intraocular mass with high internal reflectivity and shadowing.
Reveal diagnosis
Retinoblastoma. Leukocoria with intralesional calcification on ultrasound (or CT) is retinoblastoma until proven otherwise. See retinoblastoma genetics.
Case 6
Day 3 after an uneventful cataract operation, the patient returns with increasing pain, worse vision, a 1.5 mm hypopyon, and no red reflex.
Reveal diagnosis
Acute post-operative endophthalmitis. Pain plus reduced vision plus hypopyon after surgery needs an urgent tap and intravitreal antibiotics. See emergencies on call.
Case 7
A 42-year-old developed sudden neck pain while lifting heavy weights. He now has mild ptosis and a smaller pupil on the same side. The anisocoria is greater in dim light.
Reveal diagnosis
Horner syndrome from carotid artery dissection. A painful acute Horner needs urgent CT or MR angiography of the neck. See pupil examination.
Case 8
A 35-year-old woman of Asian descent has headache, ringing in the ears and blurred vision in both eyes. There is bilateral granulomatous anterior uveitis and multiple serous retinal detachments. Months later, she develops white eyelashes and patchy skin depigmentation.
Reveal diagnosis
Vogt-Koyanagi-Harada disease. Bilateral granulomatous panuveitis with serous detachments plus meningeal, auditory and integumentary signs. See VKH.
Case 9
A 74-year-old has sudden profound vision loss in one eye. He has had jaw pain while chewing for 2 weeks. The optic disc is swollen and chalky white.
Reveal diagnosis
Arteritic anterior ischaemic optic neuropathy (giant cell arteritis). Start high-dose steroids immediately to protect the fellow eye. See GCA.
Case 10
A 25-year-old myopic man notices blurring and haloes after playing basketball. There is a vertical band of pigment on the corneal endothelium and spoke-like iris transillumination defects in the mid-periphery.
Reveal diagnosis
Pigment dispersion syndrome. Krukenberg spindle, radial mid-peripheral transillumination defects and exercise-induced pigment release are classic. See pigment dispersion.
Case 11
A 38-year-old stressed executive, recently using a steroid nasal spray, notices central blur and straight lines looking bent. OCT shows a dome of subretinal fluid and a thick choroid.
Reveal diagnosis
Central serous chorioretinopathy. Stress and corticosteroid exposure (from any route) are the key risk factors. On angiography, look for an "ink-blot" or "smokestack" leak. See CSCR.
Case 12
A 26-year-old woman has blurred vision in one eye over 3 days, pain on moving the eye, and washed-out colours. There is a RAPD, but the optic disc looks normal.
Reveal diagnosis
Retrobulbar optic neuritis. "The patient sees nothing and the doctor sees nothing." Arrange an MRI of the brain and orbits. See optic neuritis.
Case 13
A teenager's spectacles need changing every few months because of rising, irregular astigmatism. When he looks down, the lower lid bulges in a V shape. Fine vertical lines are visible in the posterior corneal stroma.
Reveal diagnosis
Keratoconus. Munson sign and Vogt striae. Get a tomography scan and consider corneal cross-linking if it is progressing. See keratoconus and topography tips.
Case 14
A patient with a long-standing type 2 diabetes reports a sudden shower of red-tinged floaters and dense loss of vision on waking. The fundus cannot be seen; the other eye shows new vessels on the disc.
Reveal diagnosis
Vitreous haemorrhage from proliferative diabetic retinopathy. Perform B-scan ultrasound to exclude a retinal detachment underneath, and treat the fellow eye's PDR.
Case 15
A 60-year-old has double vision when looking to the right. The left eye fails to adduct, and the right eye shows nystagmus when it abducts. Convergence is preserved.
Reveal diagnosis
Left internuclear ophthalmoplegia. The INO is named after the side of the adduction failure (the medial longitudinal fasciculus lesion). In older patients think of stroke; in young patients, multiple sclerosis. See INO.
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