2025 NBEO PART 1 ACTUAL EXAM QUESTIONS WITH
ANSWERS 2025/2026 GRADED A+
Bilateral corneal arcus
Bilateral limbal girdle of Vogt
Bilateral 3+ nuclear sclerosis of the lens
Bilateral crocodile shagreen - Nuclear sclerosis is caused by changes to the optical
clarity of the lens. As we age, proteins precipitate out of the lens matrix, causing the
lens to become cloudy and altering its density. As time passes, the lens will also begin
to change color from clear to a yellow/brown in a process called lens brunescence.
Cataracts also generally cause a myopic shift with an increase in against-the-rule
astigmatism, leading to decreased distance vision but improved near vision.
Corneal arcus is caused by lipid deposition in the peripheral cornea. There remains a
characteristic clear zone between the lipid and the limbus. Arcus does not generally
interfere with vision.
Crocodile shagreen and limbal girdle of Vogt are also benign corneal findings commonly
seen in the elderly. Crocodile shagreen appears in the peripheral cornea as polygonal
white opacities. Limbal girdle of Vogt is noted at the 3 o'clock and 9 o'clock
interpalpebral positions as white crescent-shaped opacities.
Long-term use of corticosteroids can lead to the formation of which of the following
types of cataract?
Nuclear sclerotic
Posterior subcapsular
Cortical
Anterior subcapsular - The possible formation of posterior subcapsular cataracts (PSC)
is a common concern in patients undergoing long-term treatment with corticosteroid
therapy. PSCs have been associated with the use of systemic, topical, ophthalmic,
topical dermatologic, nasal aerosol, and inhalation type steroids. This relationship is
likely dose-dependent, and the usual time from beginning steroid treatment to the onset
of lens changes is 1 year (with a dosage of 10 mg/day of prednisone) but has been
observed in as short as 2 months with as little as 5 mg/day. Patients with PSC formation
may complain of an increase in light sensitivity, photophobia, glare, or difficulty reading.
If visual acuity is notably decreased, surgical removal of the lens may be warranted.
Berger's space is created by an interval between which two structures?
The posterior surface of the cornea and the anterior face of the iris
The anterior face of the lens and the posterior surface of the iris
The equator of the lens and the ciliary body
The posterior face of the lens and the anterior vitreous - Berger's space is created by
the separation between the posterior face of the lens and the anterior face of the
vitreous.
,The space between the equator of the lens and the ciliary body is known as the
circumlental space.
Patients with a history of homocystinuria are MOST likely to experience crystalline lens
subluxation in which of the following directions?
Down and outward
Up and outward
Down and inward
Up and inward - Common ocular sequelae that have been associated with a diagnosis
of homocystinuria include ectopia lentis (bilateral crystalline lens subluxation), retinal
detachment, and secondary glaucoma. In most cases of ectopia lentis, the lens is more
likely to be displaced downward and inward in homocystinuria (as compared to upward
and outward in Marfan's syndrome). Additionally, in homocystinuria, the lens zonules
are markedly abnormal, the lens does not accommodate, and up to 1/3 of the cases of
lens subluxation eventually completely dislocate into the vitreous or anterior chamber.
Due to the severity of systemic and cardiovascular complications associated with
homocystinuria (thrombosis and occlusion), patients presenting with ectopia lentis
should be screened for this disease using the sodium nitroprusside test to measure
homocysteine in the urine.
Purkinje images are caused by reflections of objects on the cornea and lens. Which of
the four images moves forward with accommodation?
III
I
II
IV - There are four Purkinje images. The first image is caused by reflection from the
anterior corneal surface and is the brightest of the images. The first image is roughly the
same size as the object. The second Purkinje image is formed by the posterior surface
of the cornea and almost coincides with the first Purkinje image. The third Purkinje
image is the largest and is caused by reflection off of the anterior plane of the crystalline
lens. The fourth Purkinje image is the smallest and is inverted, formed by reflection off
of the posterior surface of the lens.
During the process of accommodation the anterior surface of the lens moves forward.
The image that is reflected off of this surface is Purkinje III. Purkinje image III will be
seen to move forward during accommodation.
The ligaments that suspend the lens (zonules) are embryonically derived from what
structure?
The lens capsule
The tertiary vitreous
The lens epithelium
The primary vitreous - The zonules are attached to the posterior and anterior surfaces
of the lens and connect to the pars plana of the ciliary body. The primary vitreous
develops from weeks 3 through 9. The secondary vitreous then begins to form and
,condenses the primary vitreous forming Cloquet's canal. Developmentally, the tertiary
vitreous is secreted last; the zonules are comprised of condensed tertiary vitreous.
A 42-year old patient reports that her right eye has been watery and she has mild pain,
redness, and swelling in the lower medial canthal region. You suspect dacryocystitis as
the cause of her symptoms. Which of the following procedures is NOT appropriate when
further evaluating this possible diagnosis?
Digital palpation of the medial canthal area
Dilation and irrigation of the lacrimal system
Extraocular muscle motility
Gram stain and blood agar cultures of discharge
Exophthalmometry - The evaluation of a patient suspected of dacryocystitis should
involve a detailed case history including a discussion of any previous episodes with
similar symptoms, or the presence of any concomitant ear, nose, or throat
irritation/infection. External examination of the patient should include the application of
gentle pressure to the lacrimal sac region in order to attempt to express any discharge
from the punctum; this should be done bilaterally. If any discharge can be recovered, a
Gram stain or blood agar culture is helpful in determining the type of bacteria present. In
addition to these tests, extraocular motility and evaluation for the presence of proptosis
should be completed to rule out orbital cellulitis. In atypical, severe, or non-responding
cases, a computed tomography scan (CT) should be considered. It is important to
remember that probing, dilation, and/or irrigation of the lacrimal system should not be
attempted during an acute infection of the lacrimal gland. This may cause the infection
to spread to other areas such as the throat.
A common cause of epiphora in infants is caused by a small membrane that covers
over which of the following structures?
The lacrimal gland
The canaliculus
The valve of Hasner
The puncta - It is common for mothers of young infants to note that one eye (or both
eyes) of her infant constantly tears in conjunction with the presence of mucopurulent
discharge. This epiphora results from a blockage of the nasolacrimal passageway
caused by a membrane covering the valve of Hasner. The majority of blockages will
self-resolve without intervention (80-90% of infants) within the first 12 months of life.
Treatment may include massage of the nasolacrimal sac several times a day in an effort
to rupture the membrane.
An 81-year old female reports that her eye has been watering more frequently over the
past month; you decide to administer the primary Jones dye test (Jones I). After 5
minutes, the application of a cotton-tipped applicator to the inferior turbinate reveals the
presence of dye in the area. Taking this into consideration, what is the MOST likely
cause of the patient's epiphora complaint?
Dysfunction of the valve of Hasner
Partial nasolacrimal duct obstruction
Punctal stenosis
, Hypersecretion of tears
Complete nasolacrimal duct obstruction - The primary Jones dye test can be utilized to
determine the patency of the nasolacrimal system. 1-2 drops of fluorescein are instilled
into the inferior fornix of the eyes while the patient is in an upright position and blinking
her eyes normally. After a period of 5 to 10 minutes, a cotton-tipped applicator is used
to swab the undersurface of the inferior turbinate on each side of the nasal passage.
When the primary Jones dye test is positive (dye is recovered from the inferior turbinate
of the nose), practitioners may conclude that the system is patent and that no significant
blockage of the nasolacrimal drainage structure is likely. However, minor stenosis or
physiologic dysfunctions cannot be completely ruled out. Patients who have a positive
result on the Jones I test are more likely to experience symptoms of epiphora that are
secondary to primary oversecretion of tears, rather than a dysfunction in lacrimal
drainage (as in the above question).
When the primary Jones dye test is negative, the probability of an obstruction or
dysfunction in lacrimal drainage is much greater; however, this test alone is not
sufficient to document this conclusion. The secondary Jones dye test is then necessary
to determine the severity and location of the obstruction.
Oral acyclovir is most effective for patients presenting with eyelid findings associated
with herpes zoster if administered within which of the following periods following the
onset of the disease?
10-12 hours
72 hours
4-5 days
24 hours
7-10 days - Oral acyclovir is the mainstay of therapy for patients diagnosed with herpes
zoster ophthalmicus. This systemic treatment is maximally beneficial if it is initiated
within 72 hours from the onset of the disease (usually the appearance of eyelid lesions).
The use of oral acyclovir typically results in quick resolution of skin vesicles, decreases
the amount of pain the patient experiences, and reduces the duration of viral shedding
and appearance of new lesions. Acyclovir has also been shown to significantly reduce
the incidence of ocular findings such as episcleritis, keratitis, and iritis. The
recommended dosage is 800mg orally 5 times per day for 7-10 days.
Numerous reports have suggested that increased tear film osmolarity is a key
consequence in dry eye. Although osmolarity is not easily measured in the clinical
setting, tear osmolarity increases in most dry eye sub-types due to which of the
following processes?
The lipid layer is altered in most dry eye states, leading to ion pairing
Decreased capillary exchange leads to ionic bonding
Patients with dry eye tend to blink less than normals, leading to increased evaporation
Reactive oxygen species are increased in the tears of most dry eye sub-types; this
increases osmolarity
In aqueous tear deficiency, the lacrimal gland produces more ionic species
ANSWERS 2025/2026 GRADED A+
Bilateral corneal arcus
Bilateral limbal girdle of Vogt
Bilateral 3+ nuclear sclerosis of the lens
Bilateral crocodile shagreen - Nuclear sclerosis is caused by changes to the optical
clarity of the lens. As we age, proteins precipitate out of the lens matrix, causing the
lens to become cloudy and altering its density. As time passes, the lens will also begin
to change color from clear to a yellow/brown in a process called lens brunescence.
Cataracts also generally cause a myopic shift with an increase in against-the-rule
astigmatism, leading to decreased distance vision but improved near vision.
Corneal arcus is caused by lipid deposition in the peripheral cornea. There remains a
characteristic clear zone between the lipid and the limbus. Arcus does not generally
interfere with vision.
Crocodile shagreen and limbal girdle of Vogt are also benign corneal findings commonly
seen in the elderly. Crocodile shagreen appears in the peripheral cornea as polygonal
white opacities. Limbal girdle of Vogt is noted at the 3 o'clock and 9 o'clock
interpalpebral positions as white crescent-shaped opacities.
Long-term use of corticosteroids can lead to the formation of which of the following
types of cataract?
Nuclear sclerotic
Posterior subcapsular
Cortical
Anterior subcapsular - The possible formation of posterior subcapsular cataracts (PSC)
is a common concern in patients undergoing long-term treatment with corticosteroid
therapy. PSCs have been associated with the use of systemic, topical, ophthalmic,
topical dermatologic, nasal aerosol, and inhalation type steroids. This relationship is
likely dose-dependent, and the usual time from beginning steroid treatment to the onset
of lens changes is 1 year (with a dosage of 10 mg/day of prednisone) but has been
observed in as short as 2 months with as little as 5 mg/day. Patients with PSC formation
may complain of an increase in light sensitivity, photophobia, glare, or difficulty reading.
If visual acuity is notably decreased, surgical removal of the lens may be warranted.
Berger's space is created by an interval between which two structures?
The posterior surface of the cornea and the anterior face of the iris
The anterior face of the lens and the posterior surface of the iris
The equator of the lens and the ciliary body
The posterior face of the lens and the anterior vitreous - Berger's space is created by
the separation between the posterior face of the lens and the anterior face of the
vitreous.
,The space between the equator of the lens and the ciliary body is known as the
circumlental space.
Patients with a history of homocystinuria are MOST likely to experience crystalline lens
subluxation in which of the following directions?
Down and outward
Up and outward
Down and inward
Up and inward - Common ocular sequelae that have been associated with a diagnosis
of homocystinuria include ectopia lentis (bilateral crystalline lens subluxation), retinal
detachment, and secondary glaucoma. In most cases of ectopia lentis, the lens is more
likely to be displaced downward and inward in homocystinuria (as compared to upward
and outward in Marfan's syndrome). Additionally, in homocystinuria, the lens zonules
are markedly abnormal, the lens does not accommodate, and up to 1/3 of the cases of
lens subluxation eventually completely dislocate into the vitreous or anterior chamber.
Due to the severity of systemic and cardiovascular complications associated with
homocystinuria (thrombosis and occlusion), patients presenting with ectopia lentis
should be screened for this disease using the sodium nitroprusside test to measure
homocysteine in the urine.
Purkinje images are caused by reflections of objects on the cornea and lens. Which of
the four images moves forward with accommodation?
III
I
II
IV - There are four Purkinje images. The first image is caused by reflection from the
anterior corneal surface and is the brightest of the images. The first image is roughly the
same size as the object. The second Purkinje image is formed by the posterior surface
of the cornea and almost coincides with the first Purkinje image. The third Purkinje
image is the largest and is caused by reflection off of the anterior plane of the crystalline
lens. The fourth Purkinje image is the smallest and is inverted, formed by reflection off
of the posterior surface of the lens.
During the process of accommodation the anterior surface of the lens moves forward.
The image that is reflected off of this surface is Purkinje III. Purkinje image III will be
seen to move forward during accommodation.
The ligaments that suspend the lens (zonules) are embryonically derived from what
structure?
The lens capsule
The tertiary vitreous
The lens epithelium
The primary vitreous - The zonules are attached to the posterior and anterior surfaces
of the lens and connect to the pars plana of the ciliary body. The primary vitreous
develops from weeks 3 through 9. The secondary vitreous then begins to form and
,condenses the primary vitreous forming Cloquet's canal. Developmentally, the tertiary
vitreous is secreted last; the zonules are comprised of condensed tertiary vitreous.
A 42-year old patient reports that her right eye has been watery and she has mild pain,
redness, and swelling in the lower medial canthal region. You suspect dacryocystitis as
the cause of her symptoms. Which of the following procedures is NOT appropriate when
further evaluating this possible diagnosis?
Digital palpation of the medial canthal area
Dilation and irrigation of the lacrimal system
Extraocular muscle motility
Gram stain and blood agar cultures of discharge
Exophthalmometry - The evaluation of a patient suspected of dacryocystitis should
involve a detailed case history including a discussion of any previous episodes with
similar symptoms, or the presence of any concomitant ear, nose, or throat
irritation/infection. External examination of the patient should include the application of
gentle pressure to the lacrimal sac region in order to attempt to express any discharge
from the punctum; this should be done bilaterally. If any discharge can be recovered, a
Gram stain or blood agar culture is helpful in determining the type of bacteria present. In
addition to these tests, extraocular motility and evaluation for the presence of proptosis
should be completed to rule out orbital cellulitis. In atypical, severe, or non-responding
cases, a computed tomography scan (CT) should be considered. It is important to
remember that probing, dilation, and/or irrigation of the lacrimal system should not be
attempted during an acute infection of the lacrimal gland. This may cause the infection
to spread to other areas such as the throat.
A common cause of epiphora in infants is caused by a small membrane that covers
over which of the following structures?
The lacrimal gland
The canaliculus
The valve of Hasner
The puncta - It is common for mothers of young infants to note that one eye (or both
eyes) of her infant constantly tears in conjunction with the presence of mucopurulent
discharge. This epiphora results from a blockage of the nasolacrimal passageway
caused by a membrane covering the valve of Hasner. The majority of blockages will
self-resolve without intervention (80-90% of infants) within the first 12 months of life.
Treatment may include massage of the nasolacrimal sac several times a day in an effort
to rupture the membrane.
An 81-year old female reports that her eye has been watering more frequently over the
past month; you decide to administer the primary Jones dye test (Jones I). After 5
minutes, the application of a cotton-tipped applicator to the inferior turbinate reveals the
presence of dye in the area. Taking this into consideration, what is the MOST likely
cause of the patient's epiphora complaint?
Dysfunction of the valve of Hasner
Partial nasolacrimal duct obstruction
Punctal stenosis
, Hypersecretion of tears
Complete nasolacrimal duct obstruction - The primary Jones dye test can be utilized to
determine the patency of the nasolacrimal system. 1-2 drops of fluorescein are instilled
into the inferior fornix of the eyes while the patient is in an upright position and blinking
her eyes normally. After a period of 5 to 10 minutes, a cotton-tipped applicator is used
to swab the undersurface of the inferior turbinate on each side of the nasal passage.
When the primary Jones dye test is positive (dye is recovered from the inferior turbinate
of the nose), practitioners may conclude that the system is patent and that no significant
blockage of the nasolacrimal drainage structure is likely. However, minor stenosis or
physiologic dysfunctions cannot be completely ruled out. Patients who have a positive
result on the Jones I test are more likely to experience symptoms of epiphora that are
secondary to primary oversecretion of tears, rather than a dysfunction in lacrimal
drainage (as in the above question).
When the primary Jones dye test is negative, the probability of an obstruction or
dysfunction in lacrimal drainage is much greater; however, this test alone is not
sufficient to document this conclusion. The secondary Jones dye test is then necessary
to determine the severity and location of the obstruction.
Oral acyclovir is most effective for patients presenting with eyelid findings associated
with herpes zoster if administered within which of the following periods following the
onset of the disease?
10-12 hours
72 hours
4-5 days
24 hours
7-10 days - Oral acyclovir is the mainstay of therapy for patients diagnosed with herpes
zoster ophthalmicus. This systemic treatment is maximally beneficial if it is initiated
within 72 hours from the onset of the disease (usually the appearance of eyelid lesions).
The use of oral acyclovir typically results in quick resolution of skin vesicles, decreases
the amount of pain the patient experiences, and reduces the duration of viral shedding
and appearance of new lesions. Acyclovir has also been shown to significantly reduce
the incidence of ocular findings such as episcleritis, keratitis, and iritis. The
recommended dosage is 800mg orally 5 times per day for 7-10 days.
Numerous reports have suggested that increased tear film osmolarity is a key
consequence in dry eye. Although osmolarity is not easily measured in the clinical
setting, tear osmolarity increases in most dry eye sub-types due to which of the
following processes?
The lipid layer is altered in most dry eye states, leading to ion pairing
Decreased capillary exchange leads to ionic bonding
Patients with dry eye tend to blink less than normals, leading to increased evaporation
Reactive oxygen species are increased in the tears of most dry eye sub-types; this
increases osmolarity
In aqueous tear deficiency, the lacrimal gland produces more ionic species
