OKAP practice questions: free MCQs with answers and a scored practice test, by BCSC section

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OKAP practice questions with answers

Free OKAP practice questions from OphthoMentor's public library, one from each of the 13 BCSC sections in section order, then a second from the first two. Pick an answer to see whether it is right, then read the explanation; each question links to its own page. Every item is an original single-best-answer question written in the OKAP's style, and none is a released OKAP item.

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1. Question 1 · General medicine

   72-year-old man with a previous myocardial infarction

   Waiting for a retinal laser appointment, a 72-year-old man with a previous myocardial infarction slumps unconscious in his chair. He is not breathing normally and has no carotid pulse. Staff start chest compressions, and the defibrillator monitor shows rapid, chaotic, irregular deflections of varying amplitude with no identifiable QRS complexes or P waves. The emergency team arrives within a minute, and intravenous access is already in place from his clinic visit. Which intervention should the team deliver next?

   • ASynchronized direct-current cardioversion
   • BIntravenous amiodarone loading dose
   • CUnsynchronized direct-current shock
   • DTranscutaneous cardiac pacing

   Show the answer and explanationAnswer and explanation

   Answer: C. Unsynchronized direct-current shock

   Pulselessness with a chaotic, uncoordinated tracing is ventricular fibrillation, the most ominous arrhythmia: it is fatal if untreated and a major cause of sudden cardiac death outside hospital. Cardiopulmonary resuscitation must begin without delay, and immediate unsynchronized defibrillation is the primary therapy. Sustained ventricular tachycardia with hemodynamic compromise, severe heart failure or ongoing ischemia instead receives synchronized cardioversion, while stable tachycardia may be converted with lidocaine, procainamide or amiodarone. Slow ventricular tachycardia without heart disease may be well tolerated, yet it can degenerate into fibrillation.

   Clinical pearl: For recurrent ventricular tachycardia, amiodarone is usually the preferred drug when the patient can tolerate its side effects.

2. Question 2 · Fundamentals

   Bilateral vestibular schwannomas: diagnosis

   Tinnitus and slowly worsening hearing in both ears bring a 22-year-old woman to clinic. Magnetic resonance imaging shows bilateral vestibular schwannomas, a dumbbell-shaped spinal schwannoma and two small intracranial meningiomas. Her mother had similar tumors removed. On her skin there are a few small, slightly hyperpigmented plaques with excess hair, but no axillary or inguinal freckling. She is referred for a baseline eye examination. Which ocular finding is most frequently present in patients with her disorder?

   • AEpiretinal membrane over the macula
   • BOptic nerve sheath meningioma
   • CPosterior subcapsular lens opacity
   • DLisch nodules on the iris surface

   Show the answer and explanationAnswer and explanation

   Answer: C. Posterior subcapsular lens opacity

   Bilateral vestibular schwannomas, a spinal schwannoma and meningiomas in a young adult with an affected parent indicate NF2-related schwannomatosis (formerly neurofibromatosis type 2). Juvenile posterior subcapsular cataract is its commonest ocular finding, reported in 60%–81% of patients, and is one of its diagnostic criteria. Other capsular or cortical opacities in young patients are also believed to be related. Epiretinal membrane is the next most frequent ocular finding. Annual ophthalmic examination is part of multidisciplinary care, and cataract surgery can be beneficial. A young adult with posterior subcapsular or capsular cataract and no steroid, trauma, uveitis or metabolic cause should therefore be asked about hearing loss and a family history of the disorder.

   Clinical pearl: Early age at symptom onset and an intracranial meningioma at diagnosis both signal a higher risk of severe disease and death.

3. Question 3 · Clinical optics

   Dissatisfaction with new spectacles: management

   A patient who has just collected new spectacles says only that he "cannot get on with them". What should come first in evaluating his complaint?

   • ARemake the lenses in another material with flatter base curve
   • BRepeat the cycloplegic refraction and prescribe from the new result
   • CReassure him about neural adaptation and review in several weeks
   • DQuestion him on the exact nature of his symptom

   Show the answer and explanationAnswer and explanation

   Answer: D. Question him on the exact nature of his symptom

   Dissatisfaction with new spectacles is worked up symptom-first: establish whether the trouble is at distance or near, with static or moving objects, and whether there is blur, distortion or diplopia. Next verify lens power, optical centers and the refraction, then compare old and new pairs parameter by parameter: prism and slab-off, base curve, thickness, multifocal design and position, progressive alignment and model, vertex distance, pantoscopic tilt, and material. Identical lensmeter power with a new base curve can still cause swimming or fishbowl distortion. A lens clock, reading surface powers that sum to about the net power, confirms it, and remade lenses should match the old base curve.

   Clinical pearl: If a well-tolerated base curve is to be kept in the new spectacles, it must be written on the prescription, because otherwise the optician is free to change it.

4. Question 4 · Pathology & tumors

   Mechanism: 29-year-old woman has had a red, watering

   A 29-year-old woman has had a red, watering, mildly sore right eye for 5 days. Acuity is 20/30 (0.7). Fluorescein outlines a narrow branching lesion with bulbous terminations in the lower cornea. Its margins are raised, gray and opaque, and take up rose bengal. Corneal sensation in that eye is reduced. A scraping is taken from the margin of the lesion and sent for cytology. What would the scraping most likely show?

   • ABasophilic intranuclear inclusions with epithelial necrosis
   • BLarge eosinophilic cytoplasmic inclusions in intact cells
   • CEosinophilic intranuclear inclusions with multinucleate cells
   • DNuclear and cytoplasmic inclusions with marked cytomegaly

   Show the answer and explanationAnswer and explanation

   Answer: C. Eosinophilic intranuclear inclusions with multinucleate cells

   The dendrite forms when virus reactivated in the trigeminal ganglion travels down corneal nerves and infects the overlying epithelium. Its raised opaque margin is not scar but swollen, infected cells heaped at the advancing edge. Those cells show ballooning degeneration, fusion into multinucleate forms, and Cowdry type A eosinophilic inclusions within the nucleus, with marginated chromatin. Herpes simplex epithelial keratitis usually resolves on its own but may recur or become chronic, and it occurs at any age. Deep corneal involvement can instead provoke a granulomatous reaction at Descemet membrane. Varicella-zoster virus produces the same multinucleate cells and intranuclear inclusions, so cytology does not separate the two, whereas chlamydial inclusions are basophilic and lie in the cytoplasm. In a neonate, herpetic conjunctivitis usually appears in the second week of life, and vesicles on the lids or skin are the clue.

   Clinical pearl: The margin of an epithelial ulcer, not its floor, holds the diagnostic cells. A scraping taken from the bed usually returns debris and inflammatory cells alone.

5. Question 5 · Neuro-ophthalmology

   64 year old man woke with painless right visual loss

   A 64 year old man woke with painless right visual loss. The disc is segmentally swollen and hyperemic with two marginal flame hemorrhages, there is a dense altitudinal defect, and the retina is normal with no visible emboli. Which feature of his condition makes a carotid and cardiac embolic evaluation unnecessary?

   • AOnset on waking, implicating nocturnal hypotension
   • BAbsence of visible emboli in the retinal arterioles
   • CSmall-vessel ischemia within the nerve head
   • DSegmental rather than diffuse disc swelling

   Show the answer and explanationAnswer and explanation

   Answer: C. Small-vessel ischemia within the nerve head

   Painless loss with segmental hyperemic disc swelling, flame hemorrhages and an altitudinal defect marks a typical nonarteritic infarct of the nerve head. The nerve head is perfused by the circle of Zinn and Haller, an anastomotic ring fed mainly by the short posterior ciliary arteries, with pial and choroidal contributions, and these small vessels are rarely occluded by emboli. Carotid stenosis and cardiac emboli have not been shown to cause this infarct, so carotid duplex and echocardiography add nothing in typical cases. The retina, supplied by the central retinal artery, looks normal. Within the nerve head, central retinal artery branches feed only the surface nerve fiber layer, while short posterior ciliary branches supply the prelaminar region and the circle supplies the lamina cribrosa. Because the circle is often incomplete and may be split into superior and inferior halves, the infarct tends to involve one half of the nerve head, giving the altitudinal defect.

   Clinical pearl: Patients with typical nonarteritic nerve head infarction still have their vascular risk factors treated to lower stroke risk.

6. Question 6 · Pediatrics & strabismus

   Diagnosis: 2-year-old boy is referred

   Born at 28 weeks, a 2-year-old boy is referred because his visual behavior varies from day to day. He notices moving objects more readily than still ones, holds bright favorite toys close and turns slowly toward anything new. Pupils react briskly, discs and maculae are normal, there is no nystagmus, and cycloplegic refraction is +1.00 diopter in each eye. Head circumference is normal, and he has had no seizures, shunt or meningitis. Brain magnetic resonance imaging is arranged. Which lesion is the imaging most likely to show?

   • ABilateral occipital cortical infarcts
   • BAqueductal stenosis with hydrocephalus
   • CPeriventricular leukomalacia
   • DPolymicrogyria of the cerebral cortex

   Show the answer and explanationAnswer and explanation

   Answer: C. Periventricular leukomalacia

   Poor visual behavior with normal eyes, fluctuating attention, a delayed response to new or complex targets and a preference for bright, moving objects held close indicate cerebral visual impairment, a loss of visual function from injury to the brain. Periventricular leukomalacia, resulting from perinatal hypoxia, prematurity or both, is a leading cause, and birth at 28 weeks makes it the likeliest lesion here. Any pediatric neurologic disease can be responsible, including intrauterine infection, intracranial hemorrhage, seizures, meningitis, encephalitis and accidental or nonaccidental trauma, but each is less frequent. The neurological damage is usually permanent and stable on imaging.

   Clinical pearl: Optic atrophy, refractive error, ocular motor apraxia or strabismus can coexist with cerebral visual impairment, yet none explains the full extent of the poor visual behavior.

7. Question 7 · Oculoplastics

   Diagnosis: Excision of a squamous cell carcinoma

   Six months after excision of a squamous cell carcinoma of the right forehead, a 71-year-old man develops aching in the right brow and numbness of the right forehead. Over the next four weeks he develops double vision. There is 2 mm of right ptosis, limited elevation and abduction, and reduced sensation in the first trigeminal division. The excision scar is flat and mobile with no palpable mass. Prednisolone started elsewhere eased the pain for two weeks before the deficits progressed. Which process best explains his evolving deficits?

   • ARecurrent carcinoma invading the orbit directly
   • BGiant cell arteritis with ocular motor palsies
   • CPerineural tumor spread along the skull base
   • DCavernous sinus syndrome from unrelated inflammatory disease

   Show the answer and explanationAnswer and explanation

   Answer: C. Perineural tumor spread along the skull base

   First-division sensory change followed by diplopia and ptosis after a cutaneous squamous cell carcinoma strongly suggests perineural spread. The tumor tracks along sensory nerves and can recur this way despite clear margins. Sensory symptoms may precede other cranial neuropathies by weeks to months and are often mislabeled as trigeminal neuralgia. The involved nerve is usually enlarged and enhancing on magnetic resonance imaging, but subtle change is missed without a clear history. Immunosuppression or an inherited predisposing syndrome raises the risk of this cancer, and immunosuppression also worsens its prognosis. Basal cell carcinoma can spread the same way, and spread can surface years after excision. Apex lesions are tiny, so a normal routine head scan does not exclude it, and fat-suppressed, contrast-enhanced magnetic resonance imaging of the orbit and skull base is needed, with biopsy of an enhancing nerve to confirm.

   Clinical pearl: After excision of a facial squamous cell carcinoma, new trigeminal pain or numbness suggests perineural spread and warrants skull base imaging even when the scar looks healed.

8. Question 8 · Cornea & external disease

   Uncomplicated traumatic hyphaema: diagnosis

   Four days after a cricket ball struck his right eye, a 15-year-old boy wakes with sudden pain and worse vision. On admission his hyphaema measured 1 mm with a pressure of 18 mmHg, and he has used a shield, cycloplegic and topical corticosteroid since. Fresh bright red blood now fills the lower half of the chamber above darker, older blood, and the pressure is 38 mmHg. Haemoglobin electrophoresis showed only HbA, his clotting screen is normal, and he has no diabetes or iris new vessels. Which event best explains the deterioration?

   • ASickled erythrocytes obstructing the trabecular meshwork
   • BBleeding from iris neovascularisation
   • CBleeding from an undiagnosed clotting disorder
   • DSecondary haemorrhage as the clot retracts

   Show the answer and explanationAnswer and explanation

   Answer: D. Secondary haemorrhage as the clot retracts

   Uncomplicated traumatic hyphaema generally has a good prognosis whatever its size. The most feared event is rebleeding. It affects a minority of eyes, usually within the first week, when the clot lyses and retracts. About half of eyes that rebleed develop raised pressure, which can cause glaucoma and optic atrophy. Blood, endothelial damage and high pressure together also risk corneal blood staining. Care aims to prevent rebleeding and control pressure. Conventional measures are a shield, restricted activity, head elevation, avoiding systemic non-steroidal drugs and straining, and topical corticosteroid, although trials have not shown that they prevent rebleeding or improve vision. Antifibrinolytics may reduce rebleeding but are now seldom used, since they did not improve final vision and can cause side effects. Rebleeding is most likely between days 3 and 7, so restricted activity and close review matter most in that window. A small, uncomplicated hyphaema in a child can usually be managed at home with restricted activity and close follow-up.

   Clinical pearl: Early corneal blood staining appears as yellow granular change with loss of fibrillar detail in the posterior stroma, so look for it at each visit while the pressure is high.

9. Question 9 · Uveitis

   Sympathetic ophthalmia

   Eight days after primary repair of a large corneoscleral laceration, an eye is grossly disorganized, with no perception of light and a total hemorrhagic retinal detachment, and the fellow eye is quiet. Which action most reduces the risk of sympathetic ophthalmia?

   • AEnucleation only after inflammation appears in the fellow eye
   • BEnucleation of the injured eye within two weeks
   • CProphylactic oral immunosuppression
   • DVitrectomy to repair the detachment

   Show the answer and explanationAnswer and explanation

   Answer: B. Enucleation of the injured eye within two weeks

   Sympathetic ophthalmia, a bilateral granulomatous panuveitis, follows accidental or surgical trauma to one eye, probably as a T-cell autoimmune response to uveal antigens the injury exposes. Onset before 2 weeks is uncommon, and about 80% of cases arise by 3 months and about 90% within a year. Because the disease is rare and its inflammation usually controllable, primary removal is not routine, and absent light perception at presentation does not by itself justify it. Enucleation is reserved for a grossly disorganized globe with no visual potential, like this one, and is done within 2 weeks, before the disease usually begins.

   Clinical pearl: Enucleation, although debated, may be preferred to evisceration because it leaves no residual uveal tissue to sensitize the fellow eye.

10. Question 10 · Glaucoma

    Chronic glaucoma after cataract surgery: management

    Three years after uncomplicated phacoemulsification in her left eye, a 74-year-old woman has chronic open-angle glaucoma in that eye, diagnosed a year after surgery. Pressure is 26 mm Hg on a prostaglandin analogue and a beta-blocker, and a superior field defect has deepened across two reliable examinations. Gonioscopy shows an angle open to the ciliary band in every quadrant, moderately pigmented, with no peripheral anterior synechiae. The conjunctiva is healthy and freely mobile all round. Acuity is 20/30 (0.7) and the intraocular lens sits centered in the capsular bag. What should be offered next to lower this eye's pressure?

    • ATrabeculectomy with mitomycin C
    • BSelective laser trabeculoplasty
    • CGlaucoma drainage device implantation
    • DTransscleral cyclophotocoagulation

    Show the answer and explanationAnswer and explanation

    Answer: B. Selective laser trabeculoplasty

    Chronic glaucoma after cataract surgery is managed on the same ladder as primary open-angle glaucoma. Medication or laser trabeculoplasty can come first, and trabeculoplasty may be effective in pseudophakic eyes whose angle lacks extensive peripheral anterior synechiae, as here. Incisional surgery is usually reserved for pressure uncontrolled by maximal medication, trabeculoplasty or both. The choice then weighs the conjunctiva and previous surgery: trabeculectomy with mitomycin C suits healthy conjunctiva, a tube suits scarred conjunctiva, and after previous cataract surgery either is reasonable, since tubes have failed less often than trabeculectomy in such eyes. Cyclodestruction, traditionally reserved for poor visual potential or eyes unsuited to incisional surgery, is now also used in selected sighted eyes but is not a first step.

    Clinical pearl: Before trabeculoplasty in a pseudophakic eye, check by gonioscopy that the angle is free of extensive synechiae and, if the posterior capsule is disrupted, of vitreous.

11. Question 11 · Lens & cataract

    Diagnosis: Full-term newborn boy is referred

    A full-term newborn boy is referred after an abnormal red reflex is noted on the postnatal check. Examination under anesthesia shows a small, hazy cornea, a hypoplastic iris and a shallow anterior chamber, with full ocular motility. B-scan ultrasonography demonstrates an attached retina of normal appearance but no lens tissue anywhere within the globe. Development elsewhere is normal. Failure of which embryologic tissue best explains the absent lens?

    • ANeuroectoderm of the adjacent optic vesicle
    • BSurface ectoderm overlying the optic vesicle
    • CPosterior cells of a formed lens vesicle
    • DThe stalk connecting lens vesicle to ectoderm

    Show the answer and explanationAnswer and explanation

    Answer: B. Surface ectoderm overlying the optic vesicle

    The lens arises only from surface ectoderm. Once the optic vesicles reach the surface, inductive signaling, including bone morphogenetic proteins, drives the overlying ectoderm to thicken into a lens placode, which invaginates as a lens pit and pinches off as a lens vesicle. If that ectoderm never responds, no lens forms, even though the optic vesicle still differentiates into retina. A normally formed retina alongside a completely absent lens therefore isolates the surface ectoderm as the tissue that failed, and because the lens normally guides corneal and iris development, primary aphakia usually comes with anterior segment malformation. Posterior cells of the lens vesicle elongate into the primary fibers, while the anterior wall persists as the lens epithelium, which adds new fibers at the equator throughout life. The same surface ectoderm also forms the corneal and conjunctival epithelium, the lacrimal gland and the eyelid skin.

    Clinical pearl: Lens induction runs on a tight schedule: the optic vesicles reach the surface around day 25, inductive signals, including bone morphogenetic proteins, drive placode formation around day 27, and the lens pit appears around day 29, so the decisive window closes before the end of the first month.

12. Question 12 · Retina & vitreous

    Panretinal photocoagulation: management

    Panretinal photocoagulation is to be split over three sessions for an eye with new vessels at the disc and along both temporal arcades, heaviest superotemporally where a fibrovascular sheet lies on the arcade. Which region should the first session treat?

    • AThe nasal quadrants adjacent to the disc
    • BThe inferior peripheral retina
    • CThe superior peripheral retina
    • DThe retina surrounding the fibrovascular sheet

    Show the answer and explanationAnswer and explanation

    Answer: B. The inferior peripheral retina

    Panretinal photocoagulation is usually confined to retina outside the temporal vascular arcades, and the initial course is split over two to three sessions. When proliferative disease is very severe, the inferior fundus is treated first: blood from a vitreous hemorrhage sinks and would hide that retina, leaving it impossible to treat. Each session should leave the horizontal 3 and 9 o'clock meridians untreated, because the long ciliary nerves run there. Sparing them protects accommodation, pupillary function and corneal sensation.

    Clinical pearl: Splitting panretinal treatment into two or three sessions is meant to lessen the risk that macular edema threatens central vision, yet Protocol F showed no long-term acuity advantage over a single session.

13. Question 13 · Refractive surgery

    Diagnosis: Uneventful bilateral cataract surgery

    Eight weeks after uneventful bilateral cataract surgery with a diffractive trifocal lens, a 64-year-old woman is pleased with her right eye, but the left looks smeared at every distance. Left unaided acuity is 20/40 (0.5) and N8. Refraction is +0.50 −1.00 × 90, giving 20/20 (1.0), and keratometry shows matching corneal cylinder. The diffractive rings sit concentric with the pupil, retroillumination gives an even red reflex, tear break-up time is 12 seconds without staining, and macular optical coherence tomography is normal. What best explains the poor unaided vision in her left eye?

    • AEarly opacification of the posterior capsule
    • BInstability of the precorneal tear film
    • CUncorrected residual refractive astigmatism
    • DDisplacement of the diffractive optic from center

    Show the answer and explanationAnswer and explanation

    Answer: C. Uncorrected residual refractive astigmatism

    Multifocal optics split incoming light between foci and are more sensitive to residual refractive error than monofocal lenses. Residual astigmatism above about 0.75 D often leaves poor quality of vision after multifocal implantation, even when the spherical equivalent is near plano, as in her left eye. Cylinder matching the keratometry and full recovery to 20/20 (1.0) with correction confirm a refractive cause. Even 0.50 D of residual cylinder can reduce acuity with these optics, and multifocal and extended-depth-of-focus lenses come in toric versions, so corneal astigmatism is planned for before implantation. Residual error can also be managed with spectacles, contact lenses or lens exchange, the last ideally before capsular fibrosis.

    Clinical pearl: Corneal cylinder of less than 2.00 D remaining after a presbyopia-correcting lens can be reduced with limbal relaxing or arcuate incisions, made by blade or femtosecond laser, or with supplementary surface ablation or LASIK.

14. Question 14 · General medicine

    Diagnosis: Retired engineer of 73 has seen children

    A retired engineer of 73 has seen children and small animals in his living room almost daily for 6 months and is sometimes unsure whether they are real. His wife describes a year of forgetfulness, with confused days alternating with clear ones, and says he shouts and flails in his sleep as if acting out dreams. Mild rigidity and slowed movements appeared only recently. Acuity is 20/25 (0.8) in each eye, with normal fundi and fields, and he takes no medication. Which underlying disorder best explains his presentation?

    • ACharles Bonnet syndrome
    • BParkinson disease with dementia
    • CSporadic Creutzfeldt-Jakob disease
    • DDementia with Lewy bodies

    Show the answer and explanationAnswer and explanation

    Answer: D. Dementia with Lewy bodies

    Dementia with Lewy bodies is a common dementia in which complex, formed visual hallucinations are an early sign in about 70% of patients, so the ophthalmologist may be consulted first. He shows all four core features of the DLB Consortium's fourth consensus report (McKeith et al, 2017): fluctuating cognition, recurrent visual hallucinations, REM sleep behavior disorder and parkinsonism. Lewy bodies are eosinophilic intracytoplasmic inclusions in deep cortical regions, and clinical and pathologic overlap with Alzheimer and Parkinson disease can be considerable. No specific drug treatment exists, although cholinesterase inhibitors have helped selected patients.

    Clinical pearl: Lewy body dementia is, with vascular (multi-infarct) dementia, one of the main types of dementia after Alzheimer disease, which is the commonest.

15. Question 15 · Fundamentals

    Teprotumumab: what does the infused antibody block?

    Eight weeks ago, a 48-year-old woman with active thyroid eye disease began monoclonal antibody infusions at another center. The referral letter does not name the agent. Proptosis has fallen by 3 mm in each eye and her diplopia in upgaze has resolved. Fasting glucose, normal before treatment, is now 9.8 mmol/L, and her Crohn disease has flared with bloody diarrhea after four years in remission. What does the infused antibody block?

    • Athe interleukin-6 receptor
    • Bthe insulin-like growth factor 1 receptor
    • Ctumor necrosis factor alpha
    • Dthe CD20 antigen on B lymphocytes

    Show the answer and explanationAnswer and explanation

    Answer: B. the insulin-like growth factor 1 receptor

    Teprotumumab inhibits the insulin-like growth factor 1 receptor, which is implicated in the inflammation of thyroid eye disease through stimulation of orbital fibrocytes. In trials it reduced proptosis and improved diplopia more than placebo, matching her response. Monitoring must consider hyperglycemia, especially in people with diabetes, and worsening of preexisting inflammatory bowel disease, which together explain her glucose rise and Crohn flare. New hyperglycemia is not among the listed complications of tumor necrosis factor inhibitors, interleukin-6 receptor blockade or B-cell depletion. Blocking the receptor damps the orbital fibroblast signaling that drives glycosaminoglycan and cytokine secretion, and the drug lowers proptosis even in chronic, low-activity disease.

    Clinical pearl: During teprotumumab infusions for active thyroid eye disease, check blood glucose, ask about bowel symptoms and monitor hearing, particularly in patients with diabetes or known inflammatory bowel disease.

OKAP questions by BCSC section

Free OKAP practice test: 26 questions, scored by BCSC section

A free OKAP practice test with 26 original questions, two from each of the 13 BCSC sections in section order, and none of them among the 15 above. Answer every question without feedback, as on the exam, then score it to see your result for each section with the answer and explanation for every question. Aim for about a minute a question, the OKAP's own pace. No account is needed.

1. Question 1 · General medicine

   Referred for chronic blepharitis, a 52-year-old woman with red hair and pale skin asks about several pigmented spots on her face. She freckles easily and never tans, works in an office but gardens every weekend, and had 3 blistering sunburns as a child. She has no personal or family history of skin cancer, takes no immunosuppressive drugs, and none of the spots itches or bleeds. On examination the lesions differ from one another in appearance. Which of her lesions calls for referral to a dermatologist for possible biopsy?

   • A.Cheek macule, 7 mm, with a notched border and mixed brown-black color
   • B.Upper lid papule, 4 mm, round, evenly tan and unchanged since childhood
   • C.Brow macule, 3 mm, oval and uniformly brown with a smooth, regular border
   • D.Lid margin papule, 4 mm, dome-shaped and evenly tan, stable for many years
2. Question 2 · Fundamentals

   Two unrelated girls, aged 4 and 6 years, have the same bilateral anterior segment dysgenesis. Genetic testing finds no sequence variant in any coding exon of either child. Instead, the first girl carries a heterozygous deletion that removes one whole copy of FOXC1, whereas the second carries a duplication that adds a third intact copy of FOXC1. Neither altered segment contains any other gene, and all four parents have normal eyes and normal results on the same testing. Which mechanism best explains how these opposite changes produce the same malformation?

   • A.too much or too little transcription factor activity
   • B.an abnormal protein that blocks the product of the normal allele
   • C.loss of the remaining allele through a second somatic hit
   • D.loss of several neighboring genes within one segment
3. Question 3 · Clinical optics

   Hoping to rely less on spectacles after cataract surgery, a 58-year-old man who spends long hours working at a computer chooses an extended-depth-of-focus intraocular lens targeted for emmetropia in each eye. Corneal astigmatism is below 0.50 diopters in both eyes. Which unaided visual outcome should he be counseled to expect?

   • A.Unaided distance and close reading vision from two discrete foci
   • B.Unaided vision across a range of distances from axial lens movement
   • C.Unaided distance vision, with correction needed for intermediate and near tasks
   • D.Unaided distance and intermediate vision, with glasses for fine print
4. Question 4 · Pathology & tumors

   The right host button from a 2-year-old boy with dense bilateral corneal opacity since the neonatal period and biallelic SLC4A11 variants, whose corneal diameters are 11.5 mm and pressures 12 mmHg, goes for histological examination after penetrating keratoplasty. Which histological finding is expected in this button?

   • A.Thickened laminated Descemet with sparse atrophic endothelium
   • B.Stromal glycosaminoglycan deposits with an intact Descemet membrane
   • C.Horizontal Descemet breaks with thickened rolled edges
   • D.Oblique Descemet breaks with scrolled edges
5. Question 5 · Neuro-ophthalmology

   Forty minutes after suddenly losing sight of objects to his left, a 62 year old man walks into the eye clinic. Acuity, color vision, pupils, optic discs and maculae are normal, and confrontation shows loss of the left half of the field in each eye. Blood pressure is 190/105 mmHg and the pulse is irregular. Which study should he have first?

   • A.Diffusion-weighted magnetic resonance imaging of the brain
   • B.Computed tomographic angiography of the neck vessels
   • C.Noncontrast computed tomography of the brain
   • D.Formal automated perimetry of both eyes
6. Question 6 · Pediatrics & strabismus

   A boy born at 26 weeks' gestation is examined at 35 weeks postmenstrual age. In both eyes the vascularized retina ends in zone II at a ridge with height and width, and no fibrovascular tissue rises from it into the vitreous. Plus disease is present in both eyes. The retinas are attached, the media are clear, and he is stable enough for treatment today. What should be offered to this infant?

   • A.Ablation of avascular retina within 72 hours
   • B.Ablation of avascular retina within two weeks
   • C.Ablation deferred until extraretinal proliferation appears
   • D.Ablation deferred until the next scheduled examination
7. Question 7 · Oculoplastics

   Over six weeks, a 52-year-old woman has developed nasal crusting, right orbital pain and 4 mm of right proptosis. Computed tomography shows a destructive soft-tissue lesion in the ethmoid sinus eroding through the medial orbital wall into the orbit. Serum PR3-ANCA is negative. Urinalysis, renal function and chest radiograph are normal, and she has no hearing or skin symptoms. Which step is most likely to establish the diagnosis?

   • A.Repeat the PR3-ANCA test and wait
   • B.Order broader systemic vasculitis screening
   • C.Biopsy the accessible abnormal sino-orbital tissue
   • D.Start treatment based on the orbital imaging pattern
8. Question 8 · Cornea & external disease

   A scraping from a corneal stromal infiltrate that has not responded to a week of hourly broad-spectrum antibiotic drops shows abundant septate, branching filaments on Gomori methenamine silver stain. Which antifungal regimen is most appropriate?

   • A.Topical amphotericin B drops given hourly
   • B.Topical natamycin suspension given hourly
   • C.Topical voriconazole drops given hourly
   • D.Oral fluconazole with intensive lubricant drops
9. Question 9 · Uveitis

   Over six weeks, a 44-year-old woman has noticed blurred vision in both eyes with no pain. Acuity is 20/30 (0.7) right and 20/40 (0.5) left. The anterior chambers are quiet, and there are 1+ vitreous cells in each eye. Fluorescein angiography shows segmental leakage from venules in both temporal peripheries and sheathing of two peripheral veins on the right, with no capillary nonperfusion. The maculae and optic discs look normal. Which additional finding would most support classifying this as posterior uveitis?

   • A.Heavier leakage from venules at the posterior pole
   • B.Sheathing of further veins in the temporal periphery
   • C.Choroidal infiltrates at the posterior pole
   • D.An increase in vitreous cells in both eyes
10. Question 10 · Glaucoma

    Four days into treatment of acute anterior uveitis with hourly prednisolone acetate and cyclopentolate, pressure is 32 mm Hg in an eye with an open angle and a healthy disc. The patient has no other illness and takes no other medication. How should the raised pressure be treated?

    • A.Latanoprost once each evening
    • B.Topical timolol twice daily
    • C.Oral acetazolamide 250 mg every six hours
    • D.Stopping the corticosteroid drops
11. Question 11 · Lens & cataract

    After phacoemulsification complicated by a posterior capsule tear, the implant sits in the bag and the hydrated clear corneal incision is Seidel negative, with the chamber formed at physiologic pressure. What should be done with the incision before the drapes come off?

    • A.Rehydrate the stroma and retest with fluorescein
    • B.Leave the incision unsutured and shield the eye
    • C.Place a 10-0 nylon suture across the incision
    • D.Apply a bandage contact lens and topical antibiotic
12. Question 12 · Retina & vitreous

    Holding a bottle of high-dose antioxidant and zinc tablets, a 72-year-old woman asks whether they will help her eyes. The right macula shows numerous large soft drusen with pigment clumping and no fluid or hemorrhage, while the left shows a handful of small hard drusen with normal pigment. She has moderate nonproliferative diabetic retinopathy without macular edema in both eyes, and lens opacities that reduce contrast while acuity stays 20/30 (0.7). For which of her findings is this supplementation supported by randomized evidence?

    • A.the macular changes in her right eye
    • B.the macular changes in her left eye
    • C.the diabetic retinopathy in her right eye
    • D.the lens changes reducing her contrast
13. Question 13 · Refractive surgery

    A 26-year-old man with −8.00 dioptres sphere in each eye seeks laser correction. Tomography shows a symmetric bowtie, minimum pachymetry of 512 µm right and 517 µm left, and no posterior island on the standard best-fit-sphere elevation maps. Which analysis would best expose early ectatic change here?

    • A.Enhanced elevation map omitting the thinnest zone
    • B.Standard elevation maps of both corneal surfaces
    • C.Axial curvature maps repeated over the next 2 years
    • D.Pachymetry averaged over the central 3 mm
14. Question 14 · General medicine

    Referred by his optometrist after bumping into door frames, a 47-year-old man has 20/30 (0.7) acuity in each eye and a dense bitemporal hemianopia on automated perimetry. On questioning, he admits to waning libido and impotence that crept up over several years and that he had put down to stress. His facial features, hand size and thyroid examination are normal, and he has no abdominal striae or easy bruising. Imaging shows a 28-mm sellar mass compressing the chiasm. Which hormone is the tumor most likely secreting in excess?

    • A.Growth hormone
    • B.Adrenocorticotropic hormone
    • C.Thyroid-stimulating hormone
    • D.Prolactin
15. Question 15 · Fundamentals

    A patient places four eyedrops (a corticosteroid, an antibiotic, a lubricant and a pressure-lowering drop) accurately in the lower fornix, instilling all four one after another within about thirty seconds, four times each day. Which change to this routine would increase ocular absorption of each drug?

    • A.instill two drops of each medication
    • B.increase each of the four medications to six times daily
    • C.switch the lubricant to a nighttime gel
    • D.separate the four medications by five minutes
16. Question 16 · Clinical optics

    A young adult with no refractive error shifts focus from a distance chart to print held at 25 cm. Which ocular change produces the near focus?

    • A.the zonules tighten and the lens flattens
    • B.the zonules relax and the lens becomes more convex
    • C.the lens moves backward and the anterior chamber becomes deeper
    • D.the cornea steepens and adds refractive power
17. Question 17 · Pathology & tumors

    A 44-year-old man had a deep laceration of the right cheek and lower eyelid cleaned and sutured on the day of injury. At review 3 weeks later the scar was soft, slightly raised and level with the lid margin. He returns 4 months after the injury: the scar is now pale and firm and drawn up along its length, the lid margin sits away from the globe, and the inferior cornea stains with fluorescein. Which phase of healing accounts for this change?

    • A.The acute inflammatory response
    • B.Proliferation of fibroblasts and vessels
    • C.Contraction during wound remodeling
    • D.Regeneration of the injured epithelium
18. Question 18 · Neuro-ophthalmology

    A 44 year old alert woman has an acute nontraumatic right third-nerve palsy that followed within hours of an abrupt severe occipital headache this morning. The right pupil measures 4.5 millimeters and the left 4.0 millimeters, both reactive to light. Which study should she undergo today?

    • A.Magnetic resonance imaging of the brain
    • B.Computed tomographic angiography of the head
    • C.Noncontrast computed tomography of the head
    • D.Catheter cerebral angiography of both carotids
19. Question 19 · Pediatrics & strabismus

    A 5-month-old boy has had a horizontal to-and-fro oscillation of both eyes since the age of 2 months. It is conjugate and uniplanar and increases when he tries to look at a face, though he follows faces and bright toys. The pupils react briskly, the lenses are clear, and dilated examination shows discs of normal size and color with a visible foveal reflex in each eye. His parents' eye examinations are normal. Which course should follow today's examination?

    • A.Observation with review in six months
    • B.Electroretinography with handheld optical coherence tomography
    • C.Eye movement recording with optokinetic drum testing
    • D.Repeat fundus examination after one month
20. Question 20 · Oculoplastics

    Referred for surgery to lift her upper eyelids, a 41-year-old woman reports that the lids sag progressively through the day and are lowest by evening, and that she sees double after reading for half an hour. Margin reflex distance measures 1 mm on the right and 2 mm on the left. After sustained upgaze it measures 0 mm and 1 mm. Two minutes of an ice pack on the closed lids raises both measurements to 3 mm. No therapy has been started, and she takes no regular medication. How should her ptosis be managed at this stage?

    • A.Refer for neurologist-supervised medical treatment
    • B.Fit a ptosis crutch to her spectacles
    • C.Review in the clinic in six months
    • D.Bilateral levator advancement within the next month
21. Question 21 · Cornea & external disease

    Six weeks after treatment of herpes simplex epithelial keratitis, a man remains on topical trifluridine five times daily and prednisolone 1% twice daily. He has no pain. A 3 × 4 mm oval epithelial defect just below centre has smooth, rolled, heaped grey-white edges over grey, slightly thinned stroma and takes little rose bengal. There is no infiltrate and the anterior chamber is quiet. Which change to his treatment is needed?

    • A.Increase the topical antiviral and review weekly
    • B.Stop topical antiviral and protect the surface
    • C.Increase the topical corticosteroid and review weekly
    • D.Cover the defect with a conjunctival flap
22. Question 22 · Uveitis

    Two months of floaters and blurring in both eyes bring a 31-year-old woman to clinic. Acuity is 20/30 (0.7) in each eye. Both eyes have large greasy keratic precipitates, 2+ anterior chamber cells, iris nodules and peripheral retinal vascular leakage on angiography. Her tattooed eyebrows have become raised and nodular, and tissue from one brow shows non-caseating granulomas. A plain radiograph of the thorax and serum calcium are normal. Which course should follow the skin histology result?

    • A.Attribute the uveitis to a local reaction to tattoo pigment
    • B.Investigate for sarcoidosis: ACE, lysozyme, chest CT, biopsy
    • C.Excise the raised tattooed skin and review the eyes
    • D.Start systemic corticosteroid and review in a month
23. Question 23 · Glaucoma

    A 68-year-old man weighing 70 kg is sent from the emergency department with a painful right eye, nausea, vomiting and colored halos since waking six hours ago. Topical drops and intravenous acetazolamide were given there an hour ago, and the pain is unchanged. His renal and cardiac function were checked as normal this morning. The right pressure is 56 mm Hg, the cornea is too hazy for clear iris detail, and the pupil is mid-dilated and fixed. Which intravenous regimen should he receive now?

    • A.Intravenous acetazolamide 10 mg/kg over 30–60 minutes
    • B.Mannitol 20 percent, 3 g/kg by slow infusion
    • C.Mannitol 20 percent, 1 g/kg repeated every 30 minutes
    • D.Mannitol 20 percent, 1 g/kg by slow infusion
24. Question 24 · Lens & cataract

    Needing stronger spectacles every few months, a 9-year-old boy now wears −14.00 diopters sphere in each eye. On dilation both lenses are clear but small and globular, with the whole equator visible inside the pupil. He is otherwise well, but he sits well below the third height percentile, with broad hands, short stubby fingers, and finger joints that extend poorly. Which diagnosis accounts for both his lenses and his build?

    • A.Marfan syndrome
    • B.Classic homocystinuria
    • C.Weill-Marchesani syndrome
    • D.Isolated hereditary microspherophakia
25. Question 25 · Retina & vitreous

    A routine sight test finds reduced left vision in a 40-year-old man, who admits to poor vision in dim light on that side. He recalls no sudden loss of vision. The left iris differs in color from the right, and the left pupil is larger and reacts poorly. The left fundus shows peripheral pigmentation with narrowed retinal vessels, and perimetry shows a constricted left field, worst nasally. The right eye, including its full-field electroretinogram, is normal. Which cause should be sought first?

    • A.Sector retinitis pigmentosa
    • B.Previous ophthalmic artery occlusion
    • C.Autosomal dominant cone dystrophy
    • D.Retained intraocular iron fragment
26. Question 26 · Refractive surgery

    Small-incision lenticule extraction is performed for a 30-year-old man with stable −5.25 D of myopia, regular tomography and a central corneal thickness of 545 µm. After docking, a near-infrared beam is focused at two planned depths within the stroma and then along a short peripheral arc. The surgeon then separates the planes with a spatula and removes the lenticule through a 3-mm incision, leaving the epithelium intact over the treated zone. By which laser–tissue interaction did the beam separate the tissue planes?

    • A.Plasma formation with expanding cavitation bubbles
    • B.Chemical bond breakage by high-energy ultraviolet photons
    • C.Heat-induced shrinkage of stromal collagen
    • D.Riboflavin-sensitized ultraviolet-A crosslinking

OKAP at a glance

What is the OKAP exam, and who takes it?

When is the OKAP exam in 2027?

• Mid-November: registration opens.
• December 31: deadline for programs to register residents. Accommodation requests (extended time or an alternate date) are filed by the program during registration.
• At least 30 days before the exam: payment due; last point to reschedule, cancel or get a refund.
• Late April: score reports released; disputes within 7 days of release.

OKAP exam format: how long is the OKAP?

• Section 1: Update on General Medicine
• Section 2: Fundamentals and Principles of Ophthalmology
• Section 3: Clinical Optics and Vision Rehabilitation
• Section 4: Ophthalmic Pathology and Intraocular Tumors
• Section 5: Neuro-Ophthalmology
• Section 6: Pediatric Ophthalmology and Strabismus
• Section 7: Oculofacial Plastic and Orbital Surgery
• Section 8: External Disease and Cornea
• Section 9: Uveitis and Ocular Inflammation
• Section 10: Glaucoma
• Section 11: Lens and Cataract
• Section 12: Retina and Vitreous
• Section 13: Refractive Surgery

How is the OKAP scored, and what is a good OKAP score or percentile?

• Year 1: 403.17
• Year 2: 506.07
• Year 3: 533.61
• Year 4: 605.60
• All examinees: 481.49 (SD 109.68)

What is OKAP International?

WQE vs OKAP: what is the difference?

• Who: OKAP, residents in every year of training; WQE, graduates who finished residency by the registration deadline (US residents are usually invited to apply in spring of PGY-4).
• Length: OKAP 260 questions in 4 hours 40 minutes; WQE 250 questions in a roughly five-hour session including a tutorial and break (2026).
• Where: OKAP online at your institution with a program proctor; WQE at Pearson test centers, not online.
• Next date: OKAP March 11–14, 2027; WQE Saturday, September 18, 2027.
• Fee: OKAP $390, paid by the program; WQE $2,250 for 2027.
• Scoring: OKAP scaled scores and percentiles, no pass mark; WQE criterion-referenced, with a pass mark of 700 on a 200–1,000 scale per ABO's 2025 results post, and results in 6–8 weeks.

How do you use an OKAP qbank and free OKAP practice questions?

• Pair each BCSC reading block with untimed questions from that section, and read every explanation.
• Log misses by section and topic, as the April Keyword Report does.
• From about 12 weeks out, move to timed mixed blocks at roughly one minute per question.
• Sit at least one full 260-question mock in 4 hours 30 minutes, breaking at the halfway point.

OKAP study plan for the March 11–14, 2027 exam

This timeline follows AAO's 2026–2027 BCSC reading schedule (July 2026 to March 2027), which reserves February 27 to March 10, 2027 for reviewing all volumes.

1. 24 weeks out (late September 2026)Join the reading schedule and pair each weekly block with untimed questions from the matching BCSC section.
2. October–November 2026Catch up on sections the schedule has already covered, add a weekly mixed set, and clear your review queue.
3. 12 weeks out (mid-December 2026)Take a timed mixed baseline block. Confirm your program registers you by December 31 with the correct training level.
4. 8 weeks out (mid-January 2027)Run weak-topic drills on your three lowest sections and practice optics calculations by hand.
5. 4 weeks out (mid-February 2027)Sit a full 260-question timed mock in 4 hours 30 minutes, breaking after 130 questions; review every miss.
6. February 27–March 10, 2027Use the schedule's Review All Volumes period to revisit marked questions, explanations and flowcharts, not new resources.
7. Exam day (March 11–14, 2027)Bring your laptop, power cord and AAO login; arrive at least 10 minutes before your start hour.
8. Late April 2027Use your Keyword Report and AAO's learning plan to rank subtests and set objectives with your program director.

OKAP FAQ