Glaucoma Practice Questions

Q: Which of the following statements is not true regarding trabeculoplasty?

It is useful in inflammatory glaucoma.. **Explanation:** Laser Trabeculoplasty (ALT/SLT) is a procedure used to increase aqueous outflow by applying laser energy to the trabecular meshwork. **Why Option C is the correct answer (The "Not True" statement):** Laser trabeculoplasty is **contraindicated in inflammatory (uveitic) glaucoma**. In an inflamed eye, the trabecular meshwork is often covered by inflammatory debris or peripheral anterior synechiae (PAS). Applying laser energy in this state can exacerbate intraocular inflammation, lead to further formation of synechiae, and cause a severe, refractory spike in intraocular pressure (IOP). It is also generally ineffective in pediatric and developmental glaucomas. **Analysis of Incorrect Options:** * **Option A:** **Argon Laser Trabeculoplasty (ALT)** specifically uses the blue-green argon laser to create small burns in the trabecular meshwork, causing tissue contraction that opens adjacent spaces. * **Option B:** While some immediate reduction occurs, the peak therapeutic effect of trabeculoplasty is typically realized over **4 to 6 weeks** as biological remodeling of the meshwork occurs. * **Option D:** A **transient post-operative rise in IOP** is the most common complication. To prevent this, surgeons often pre-treat the eye with alpha-2 agonists like Brimonidine or Apraclonidine. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** Open-angle glaucoma (POAG) where medical therapy is insufficient or non-compliance is a concern. * **SLT vs. ALT:** Selective Laser Trabeculoplasty (SLT) uses a frequency-doubled Nd:YAG laser. It is "selective" for pigmented cells, causes less thermal damage, and is **repeatable**, unlike ALT. * **Anatomical Requirement:** The anterior chamber angle must be open; the laser is aimed at the junction of the pigmented and non-pigmented trabecular meshwork.

Q: Which of the following procedures does not require dilatation of the pupil?

Gonioscopy. **Explanation:** The correct answer is **Gonioscopy**. **1. Why Gonioscopy is the correct answer:** Gonioscopy is the clinical technique used to visualize the anterior chamber angle. It is a fundamental step in classifying glaucoma into **Open-angle** or **Angle-closure**. Dilating the pupil (Mydriasis) causes the peripheral iris to bunch up toward the angle, which can artificially narrow or close a previously open angle. Therefore, gonioscopy must be performed in a **non-dilated state** (and often in a dark room) to accurately assess the natural state of the drainage angle and to check for "occludability." **2. Why the other options are incorrect:** * **Laser Iridotomy (A):** This procedure actually requires **Miosis** (constriction), not dilatation. Pilocarpine is used to stretch the iris tissue, making it thinner and easier for the laser to penetrate. However, since the question asks what does *not* require dilatation, and Gonioscopy is the standard "undilated" diagnostic procedure, it remains the primary choice. * **Retinoscopy (B):** While "dry" retinoscopy is possible, accurate retinoscopy (especially in children) requires **Mydriasis and Cycloplegia** to relax accommodation and allow light to enter through a larger pupillary aperture for a clearer reflex. * **Fundus Examination (C):** Although the central pole can be seen through an undilated pupil, a comprehensive evaluation of the peripheral retina and a detailed stereoscopic view of the optic disc require **Mydriasis**. **Clinical Pearls for NEET-PG:** * **Gold Standard:** Gonioscopy using a **Goldmann 3-mirror lens** or **Zeiss 4-mirror lens** is the gold standard for angle evaluation. * **Van Herick’s Technique:** A slit-lamp method to estimate angle depth *before* dilatation to prevent inducing acute angle-closure glaucoma. * **Dynamic Gonioscopy (Indentation):** Used to differentiate between appositional closure and permanent synechial closure.

Q: All of the following are seen in Iridocorneal endothelial syndrome except?

Cataract. **Iridocorneal Endothelial (ICE) Syndrome** is a group of rare, typically unilateral conditions characterized by an abnormal corneal endothelial proliferation. This "hammered silver" endothelial layer migrates across the anterior chamber angle and onto the iris surface, leading to secondary angle-closure glaucoma. ### **Explanation of Options:** * **Cataract (Correct Answer):** Cataract is **not** a primary feature of ICE syndrome. While a patient may coincidentally have a cataract due to age or long-term steroid use for glaucoma, it is not part of the diagnostic triad or the underlying pathophysiology of the syndrome. * **Corectopia:** This refers to the displacement of the pupil. In ICE syndrome, the contracting basement membrane (produced by the abnormal endothelium) pulls the iris, leading to pupillary displacement. * **Iris Atrophy:** This is a hallmark of the **Progressive Iris Atrophy** variant of ICE syndrome. The mechanical stretching and ischemia caused by the migrating membrane lead to thinning and hole formation (pseudopolycoria) in the iris. * **Iris Cysts:** While less common than atrophy, "ectropion uveae" and the formation of **pedunculated iris nodules** (Cogan-Reese syndrome) are classic features. These nodules can clinically mimic iris cysts or even melanoma. ### **NEET-PG High-Yield Pearls:** 1. **The ICE Triad:** Includes **Progressive Iris Atrophy**, **Chandler Syndrome** (most common; significant corneal edema), and **Cogan-Reese Syndrome** (iris nodules). 2. **Demographics:** Typically affects **young to middle-aged women** and is almost always **unilateral**. 3. **Pathogenesis:** Linked to the **herpes simplex virus (HSV)** DNA in some studies. 4. **Clinical Sign:** "Beaten bronze" or **"Hammered silver"** appearance of the corneal endothelium on slit-lamp examination. 5. **Complication:** Severe secondary angle-closure glaucoma due to the membrane obstructing the trabecular meshwork.

Q: A 30-year-old woman presents with sudden onset of a right-sided painful red eye accompanied by nausea, vomiting, and headache. What is the most likely diagnosis?

Acute congestive glaucoma. ### Explanation **Correct Option: A. Acute congestive glaucoma** The clinical presentation of sudden onset painful red eye, headache, and systemic symptoms like nausea and vomiting is a classic "textbook" description of **Acute Congestive Glaucoma** (Acute Angle-Closure Glaucoma). * **Mechanism:** It occurs due to a sudden rise in intraocular pressure (IOP) when the drainage angle is blocked. The high IOP causes corneal edema (leading to blurred vision/halos) and stimulates the vagus nerve, resulting in nausea and vomiting. * **Demographics:** While more common in elderly hypermetropes, it can occur in younger patients with predisposing anatomical factors. **Why the other options are incorrect:** * **B. Endophthalmitis:** This is an internal inflammation of the eye, usually occurring **post-surgery** or trauma. While it presents with pain and redness, the absence of a surgical history and the presence of systemic symptoms like vomiting make it less likely than glaucoma. * **C. Eales Disease:** This is an idiopathic peripheral perivasculitis (retinal disease) characterized by **painless** vitreous hemorrhage. It does not present with acute pain or redness. * **D. Trachoma:** A chronic keratoconjunctivitis caused by *Chlamydia trachomatis*. It presents with follicular hypertrophy and scarring over a long period, not as an acute, painful emergency with systemic symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Gonioscopy (to visualize the closed angle). * **Immediate Management:** IV Mannitol (osmotic diuretic) and Acetazolamide to rapidly lower IOP. * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI) – performed in both the affected and the fellow (prophylactic) eye. * **Classic Sign:** A vertically oval, semi-dilated, non-reacting pupil with a "steamy" or "cloudy" cornea.

Q: A patient on long-term steroid therapy develops certain ocular symptoms over a few weeks. Which of the following ocular conditions is commonly associated with chronic steroid use?

Open angle glaucoma. **Explanation:** **Why Open Angle Glaucoma is correct:** Chronic use of corticosteroids (especially topical, but also systemic or periocular) can lead to **Steroid-Induced Glaucoma**, which clinically mimics Primary Open Angle Glaucoma (POAG). The underlying mechanism involves the deposition of **glycosaminoglycans** and increased expression of the **MYOC (myocilin) gene** in the trabecular meshwork. This leads to physical "clogging" and increased resistance to aqueous outflow, resulting in elevated intraocular pressure (IOP). Approximately 5–10% of the population are "high responders" who develop significant IOP elevation within 2–4 weeks of therapy. **Why the other options are incorrect:** * **B. Conjunctival papillomatosis:** This is typically caused by Human Papillomavirus (HPV) infection, not steroid use. In fact, steroids may exacerbate viral infections by suppressing the local immune response. * **C. Uveitis:** Steroids are the *treatment* of choice for uveitis due to their potent anti-inflammatory properties. While steroids don't cause uveitis, they can mask its symptoms or lead to secondary complications like cataracts. **High-Yield Clinical Pearls for NEET-PG:** * **Route Risk:** Topical (drops/ointment) > Periocular injections > Systemic > Inhalational. * **Reversibility:** Unlike POAG, steroid-induced IOP elevation is usually reversible within weeks of discontinuing the drug, provided permanent damage to the meshwork hasn't occurred. * **The "Other" Steroid Side Effect:** Chronic steroid use is also strongly associated with **Posterior Subcapsular Cataract (PSC)**. * **Management:** The first step is to taper/stop the steroid or switch to "soft steroids" like **Loteprednol** or **Fluorometholone**, which have a lower risk of raising IOP.

Q: A patient presented with uveitis with raised intraocular pressure (secondary glaucoma). What drug is used?

1% atropine. **Explanation:** In cases of **uveitis with secondary glaucoma** (hypertensive uveitis), the primary goal is to control inflammation and prevent complications like synechiae. **Why 1% Atropine is the correct answer:** Atropine is a potent cycloplegic and mydriatic. It is the drug of choice here for three main reasons: 1. **Ciliary Body Rest:** It paralyzes the ciliary muscle, reducing the intense pain associated with ciliary spasm. 2. **Prevention of Synechiae:** By keeping the pupil dilated, it prevents the formation of posterior synechiae (adhesion of iris to lens). 3. **Restoration of Blood-Aqueous Barrier:** It reduces vascular permeability, thereby decreasing the inflammatory exudate. While it doesn't directly lower IOP, it addresses the underlying cause (inflammation) and prevents pupillary block, which is crucial in uveitic glaucoma. **Analysis of Incorrect Options:** * **A. 1% Pilocarpine:** This is **absolutely contraindicated**. Miotics like pilocarpine increase inflammation, promote the formation of posterior synechiae by constricting the pupil, and can worsen the breakdown of the blood-aqueous barrier. * **C & D. Timolol and Acetazolamide:** These are aqueous suppressants used to lower IOP. While they are often used as *adjuncts* in hypertensive uveitis, they do not treat the primary inflammatory process. In the context of "the drug used" for the management of the condition itself, the cycloplegic (Atropine) takes precedence. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for Uveitis:** Atropine (1%). * **Steroids:** Topical steroids are the mainstay to reduce inflammation in uveitis. * **Avoid Latanoprost:** Prostaglandin analogues are generally avoided in uveitic glaucoma as they are pro-inflammatory. * **Inverse Glaucoma:** If IOP rises after using Atropine in a patient with a narrow angle, suspect angle-closure; however, in uveitis, Atropine is protective.

Q: Hypermature morgagnian cataract most commonly leads to which type of glaucoma?

Phacolytic glaucoma. **Explanation:** **Phacolytic glaucoma** is the correct answer because it is a direct complication of a **hypermature cataract** (including the Morgagnian type). In this condition, the lens capsule becomes leaky, allowing liquefied cortical proteins to escape into the anterior chamber. These high-molecular-weight proteins are engulfed by macrophages. The resulting protein-laden macrophages, along with the free proteins themselves, clog the trabecular meshwork, leading to a sudden rise in intraocular pressure (IOP) despite an open angle. **Analysis of Incorrect Options:** * **Phacomorphic glaucoma:** This is a secondary **angle-closure** glaucoma caused by an intumescent (swollen) lens. The increased lens thickness pushes the iris forward, leading to pupillary block. While it occurs in advanced cataracts, it is associated with the *immature/intumescent* stage rather than the *hypermature/liquefied* stage. * **Phacoanaphylactic glaucoma:** This is a rare, granulomatous uveitis occurring after **trauma or surgery** where the lens capsule is ruptured. It is an autoimmune reaction to sensitized lens proteins, not a spontaneous leakage from an intact (though leaky) capsule. * **Buphthalmos:** This refers to the enlargement of the globe seen in **congenital glaucoma** due to the distensibility of the infant sclera. It is unrelated to adult cataractous changes. **Clinical Pearls for NEET-PG:** * **Key Presentation:** Sudden painful red eye, corneal edema, and "milky" aqueous with heavy flare. * **Management:** Immediate medical reduction of IOP followed by **Urgent Cataract Extraction** (ECCE/Phaco). * **Mnemonic:** Phaco**L**ytic = **L**eaky capsule + **L**iquefied cortex. Phaco**M**orphic = **M**assive lens (swollen).

Q: Increased intraocular tension is seen in all except?

Phthisis bulbi. **Explanation:** The question asks for the condition where intraocular pressure (IOP) is **not** increased. **1. Why Phthisis Bulbi is the correct answer:** Phthisis bulbi represents the "end-stage" of a severely damaged eye. It is characterized by atrophy of the ciliary body, leading to a cessation or significant reduction in aqueous humor production. This results in **ocular hypotony** (very low IOP), a shrunken globe, and disorganized intraocular structures. Therefore, it is the only condition among the options where IOP is decreased rather than increased. **2. Analysis of Incorrect Options:** * **Epidemic Dropsy:** Caused by ingestion of Argemone mexicana oil (sanguinarine toxin). It leads to **Glaucoma** due to increased permeability of the uveal capillaries and increased production of aqueous humor. * **Branch Retinal Vein Occlusion (BRVO):** While not a direct cause of high IOP itself, BRVO is strongly associated with **pre-existing Primary Open Angle Glaucoma (POAG)**. Furthermore, ischemic variants can lead to neovascular glaucoma (NVG) due to iris neovascularization. * **Malignant Melanoma:** Intraocular tumors can cause secondary glaucoma through various mechanisms, including direct invasion of the angle, displacement of the iris-lens diaphragm anteriorly, or pigment dispersion (melanomalytic glaucoma). **Clinical Pearls for NEET-PG:** * **Hypotony definition:** IOP < 5 mmHg. * **Epidemic Dropsy:** Look for keywords like "Sanguinarine," "dilated uveal capillaries," and "normal angle" (it is a form of open-angle glaucoma). * **Neovascular Glaucoma (NVG):** Often follows Central Retinal Vein Occlusion (CRVO) rather than BRVO (the "100-day glaucoma"). * **Phthisis Bulbi:** Characterized by a "squared-off" globe due to the pull of extraocular muscles on a soft eye.

Question 1

Which of the following statements is not true regarding trabeculoplasty?

Accepted Answer

It is useful in inflammatory glaucoma.

Answer

Argon laser is used.

Answer

The therapeutic effect is typically observed within a few weeks.

Answer

A transient rise in intraocular pressure can be seen as a complication.

Question 2

Which of the following procedures does not require dilatation of the pupil?

Accepted Answer

Gonioscopy

Answer

Laser iridotomy

Answer

Retinoscopy

Answer

Fundus examination

Question 3

All of the following are true about pigmentary glaucoma except?

Accepted Answer

The intensity of pigment deposit in the angle is related to iris color

Answer

It occurs more often in young myopic men

Answer

Iris transillumination defects are noted

Answer

It is associated with Krukenberg's spindle

Question 4

All of the following are seen in Iridocorneal endothelial syndrome except?

Accepted Answer

Cataract

Answer

Corectopia

Answer

Iris cysts

Answer

Iris atrophy

Question 5

In which type of glaucoma are coloured haloes NOT seen?

Accepted Answer

Steroid-induced glaucoma

Answer

Phacomorphic glaucoma

Answer

Pigmentary glaucoma

Answer

Glaucoma of epidemic dropsy

Question 6

A 30-year-old woman presents with sudden onset of a right-sided painful red eye accompanied by nausea, vomiting, and headache. What is the most likely diagnosis?

Accepted Answer

Acute congestive glaucoma

Answer

Endophthalmitis

Answer

Eales disease

Answer

Trachoma

Question 7

A patient on long-term steroid therapy develops certain ocular symptoms over a few weeks. Which of the following ocular conditions is commonly associated with chronic steroid use?

Accepted Answer

Open angle glaucoma

Answer

Conjunctival papillomatosis

Answer

Uveitis

Answer

None of the above

Question 8

A patient presented with uveitis with raised intraocular pressure (secondary glaucoma). What drug is used?

Accepted Answer

1% atropine

Answer

1% pilocarpine

Answer

Timolol

Answer

Acetazolamide

Question 9

Hypermature morgagnian cataract most commonly leads to which type of glaucoma?

Accepted Answer

Phacolytic glaucoma

Answer

Phacomorphic glaucoma

Answer

Phacoanaphylactic glaucoma

Answer

Buphthalmos

Question 10

Increased intraocular tension is seen in all except?

Accepted Answer

Phthisis bulbi

Answer

Epidemic dropsy

Answer

Branch retinal vein occlusion

Answer

Malignant melanoma

Glaucoma — MCQs

Glaucoma — MCQs

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