Glaucoma Practice Questions

Q: All are the features of an acute attack of primary narrow-angle glaucoma except?

Disc shows glaucomatous cupping. **Explanation:** Acute Angle Closure Glaucoma (AACG) is an ophthalmic emergency characterized by a sudden, precipitous rise in intraocular pressure (IOP) due to total mechanical obstruction of the trabecular meshwork by the peripheral iris. **Why Option C is the Correct Answer:** Glaucomatous cupping is a feature of **chronic** glaucoma. It occurs due to the progressive loss of retinal nerve fiber layer (RNFL) axons over time. In an **acute** attack, the optic disc is typically **congested, edematous, and hyperemic** due to the sudden mechanical pressure. Permanent cupping does not develop instantly; it requires prolonged exposure to high IOP. **Analysis of Incorrect Options:** * **Option A:** During an acute attack, IOP typically spikes to **60–70 mmHg**, far exceeding the normal range (10–21 mmHg). This causes corneal edema and severe pain. * **Option B:** The clinical presentation includes a "ciliary flush" (redness), excruciating pain (due to trigeminal nerve stimulation), and tenderness of the globe. * **Option C:** Primary Angle Closure is a **bilateral anatomical predisposition**. The "fellow eye" almost always has a shallow anterior chamber and a narrow angle, putting it at high risk for a future attack. **Clinical Pearls for NEET-PG:** * **Classic Sign:** Vertically oval, semi-dilated, non-reactive pupil. * **Symptoms:** Halos around lights (due to corneal edema), nausea, and vomiting (often misdiagnosed as an abdominal emergency). * **Immediate Management:** IV Mannitol, Acetazolamide, and topical beta-blockers to lower IOP. * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI) for **both** the affected and the fellow eye (prophylactic).

Q: Which drug is used in refractory glaucoma?

Alpha agonist. ### Explanation **Correct Option: C (Alpha agonist)** In the context of refractory glaucoma (glaucoma that remains uncontrolled despite conventional medical or surgical therapy), **Apraclonidine** (a selective alpha-2 agonist) is the drug of choice. It is highly effective for the short-term control of intraocular pressure (IOP) spikes, particularly post-laser procedures (like iridotomy or trabeculoplasty) and in cases resistant to other medications. It works by decreasing aqueous humor production and increasing uveoscleral outflow. **Brimonidine** is another alpha-2 agonist used for long-term management due to its neuroprotective properties. **Analysis of Incorrect Options:** * **A. Systemic glucocorticoids:** These are contraindicated in glaucoma. Steroids (topical or systemic) can decrease aqueous outflow through the trabecular meshwork, leading to "steroid-induced glaucoma." * **B. ACE inhibitors:** While systemic ACE inhibitors are used for hypertension, they have no established clinical role in the primary management of refractory glaucoma. * **D. Beta blockers:** While Timolol is a first-line agent for chronic open-angle glaucoma, it is usually the first drug tried. If the glaucoma is labeled "refractory," it implies that standard treatments like beta-blockers have already failed to control the IOP. **NEET-PG High-Yield Pearls:** * **Drug of choice for post-laser IOP spikes:** Apraclonidine. * **Side effect of Apraclonidine:** High incidence of follicular conjunctivitis and "tachyphylaxis" (loss of efficacy over time), which is why it is used for short-term refractory cases. * **Brimonidine:** Can cause "granulomatous uveitis" and is contraindicated in infants due to the risk of CNS depression/apnea. * **First-line for most Glaucomas:** Prostaglandin analogues (Latanoprost) are currently preferred over Beta-blockers due to better efficacy and fewer systemic side effects.

Q: Which drug is used during a trabeculectomy procedure?

Mitomycin-C. **Explanation:** The correct answer is **Mitomycin-C (MMC)**. **1. Why Mitomycin-C is correct:** Trabeculectomy is a filtering surgery for glaucoma where a "fistula" is created to drain aqueous humor. The most common cause of surgical failure is **subconjunctival fibrosis (scarring)** at the site of the bleb. Mitomycin-C is a potent **alkylating agent** that inhibits fibroblast proliferation and DNA synthesis. When applied topically to the scleral bed during surgery (usually via a soaked sponge), it acts as an **antimetabolite** to prevent scarring, thereby maintaining the patency of the filtration site and ensuring long-term intraocular pressure (IOP) control. **2. Why the other options are incorrect:** * **Azathioprine:** An immunosuppressant used in systemic autoimmune diseases and organ transplants; it is not used topically in glaucoma surgery. * **Cetuximab:** A monoclonal antibody (EGFR inhibitor) used in treating colorectal and head/neck cancers; it has no role in ophthalmic wound healing. * **Ketorolac:** A topical NSAID used to manage post-operative inflammation and pain; while used in ophthalmology, it does not prevent the fibroblast proliferation required for trabeculectomy success. **3. High-Yield Clinical Pearls for NEET-PG:** * **5-Fluorouracil (5-FU):** Another antimetabolite used in trabeculectomy, though MMC is more potent and requires a shorter application time. * **MMC Concentration:** Typically used in concentrations of **0.02% to 0.04%**. * **Complications:** Over-use of MMC can lead to "thin-walled cystic blebs," which carry a high risk of **blebitis** and **endophthalmitis**. * **Other uses of MMC in Ophthalmology:** Pterygium surgery (to prevent recurrence) and Haze prevention after PRK (Refractive surgery).

Q: Which cells are affected in glaucomatous optic neuropathy?

Ganglion cells. **Explanation:** **Glaucomatous Optic Neuropathy (GON)** is characterized by progressive damage to the optic nerve, primarily involving the **Retinal Ganglion Cells (RGCs)** and their axons. 1. **Why Ganglion Cells are correct:** The pathophysiology of glaucoma involves mechanical compression (due to elevated Intraocular Pressure) and vascular ischemia at the lamina cribrosa. This leads to the **apoptosis (programmed cell death)** of Retinal Ganglion Cells. Since the axons of these RGCs converge to form the optic nerve, their loss results in the characteristic "cupping" of the optic disc and corresponding visual field defects. 2. **Why other options are incorrect:** * **Amacrine and Bipolar cells:** These are interneurons located in the inner nuclear layer of the retina. While some secondary degeneration may occur in advanced stages, they are not the primary site of injury in glaucoma. * **Rods and Cones:** These are photoreceptors located in the outermost layer of the retina. They are responsible for converting light into electrical signals. Glaucoma is a disease of the "inner retina" (output neurons), whereas diseases like Retinitis Pigmentosa primarily affect the photoreceptors. **Clinical Pearls for NEET-PG:** * **Earliest Change:** The earliest structural change in glaucoma is often the thinning of the **Retinal Nerve Fiber Layer (RNFL)**, which consists of RGC axons. * **Mechanism of Death:** RGC death in glaucoma occurs via **Apoptosis**, triggered by neurotrophin deprivation and glutamate excitotoxicity. * **Diagnostic Tool:** **Optical Coherence Tomography (OCT)** is used to quantify the loss of the Ganglion Cell Complex (GCC) and RNFL thickness for early diagnosis.

Q: A 55-year-old lady presented with sudden onset of severe eye pain and a shallow anterior chamber. What is the treatment of choice?

Intravenous mannitol & Acetazolamide. ### Explanation **Diagnosis: Acute Angle-Closure Glaucoma (AACG)** The clinical presentation of sudden onset severe eye pain associated with a shallow anterior chamber in a middle-aged female is a classic description of **Acute Angle-Closure Glaucoma**. This is a medical emergency caused by a rapid rise in intraocular pressure (IOP). **Why Option B is Correct:** The immediate goal of treatment is to **lower the IOP rapidly** to prevent permanent optic nerve damage and clear corneal edema. * **Intravenous Mannitol:** An osmotic diuretic that creates an osmotic gradient, drawing fluid out of the vitreous into the bloodstream, thereby rapidly reducing IOP. * **Acetazolamide:** A carbonic anhydrase inhibitor that reduces the production of aqueous humor. Once the pressure is controlled, the definitive treatment is a Peripheral Iridotomy (PI). **Why Other Options are Incorrect:** * **A. Atropine:** This is a strong mydriatic (dilates the pupil). In AACG, mydriasis further crowds the angle and worsens the pupillary block, potentially exacerbating the condition. It is strictly contraindicated. * **C. Atenolol:** While beta-blockers (like Timolol) are used topically in glaucoma, systemic Atenolol is a cardioselective beta-1 blocker and has no significant role in the emergency management of acute ocular hypertension. * **D. Intravenous Steroids:** These are used for inflammatory conditions (like optic neuritis or uveitis) but do not lower IOP in an acute glaucoma crisis. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for immediate IOP reduction:** IV Mannitol. * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI) – performed on both the affected and the fellow (prophylactic) eye. * **Classic Signs:** "Steamy" or hazy cornea, mid-dilated non-reactive pupil, and a "stony hard" eye on palpation. * **Risk Factors:** Hypermetropia (small eyes), advancing age, and female gender.

Q: Which beta-1 selective blocker is used in the management of glaucoma?

Betaxolol. **Explanation:** **Betaxolol** is the correct answer because it is the only **selective beta-1 (β1) adrenergic receptor antagonist** available for topical ophthalmic use. ### Why Betaxolol is Correct: Most topical beta-blockers used in glaucoma are non-selective, meaning they block both β1 (heart) and β2 (lungs) receptors. Betaxolol specifically targets β1 receptors. While it is slightly less potent in lowering intraocular pressure (IOP) compared to timolol, its selectivity makes it the **safest choice for patients with underlying respiratory conditions** like asthma or Chronic Obstructive Pulmonary Disease (COPD), as it minimizes the risk of drug-induced bronchospasm. ### Why Other Options are Incorrect: * **Timolol:** The "gold standard" and most commonly used beta-blocker, but it is **non-selective** (blocks both β1 and β2). It is contraindicated in asthmatics. * **Levobunolol:** A potent **non-selective** beta-blocker with a long duration of action, often used for once-daily dosing. * **Carteolol:** A **non-selective** beta-blocker that possesses **Intrinsic Sympathomimetic Activity (ISA)**. This property may result in fewer bradycardic side effects and is theoretically less likely to adversely affect serum lipid profiles. ### High-Yield Clinical Pearls for NEET-PG: * **Mechanism of Action:** Beta-blockers reduce IOP by **decreasing the production of aqueous humor** from the ciliary body epithelium. * **Neuroprotection:** Betaxolol is often cited for having potential neuroprotective properties (via calcium channel blocking activity), which may benefit the optic nerve beyond just lowering IOP. * **Side Effects:** Always remember the systemic absorption of topical drops. Even selective blockers should be used with caution in patients with severe heart block or heart failure. * **Nasolacrimal Occlusion:** Advise patients to perform punctal occlusion after instillation to reduce systemic absorption and side effects.

Q: Haab's striae are seen in which of the following conditions?

Buphthalmos. **Explanation:** **Haab’s striae** are horizontal or curvilinear breaks in the **Descemet’s membrane** caused by sudden stretching of the cornea due to increased intraocular pressure (IOP). 1. **Why Buphthalmos is correct:** Buphthalmos (Congenital Glaucoma) occurs when elevated IOP causes the infant’s elastic sclera and cornea to enlarge. As the cornea stretches, the rigid Descemet’s membrane cannot keep pace and ruptures, resulting in Haab’s striae. These are typically **horizontal** (when central) or **concentric** with the limbus (when peripheral). 2. **Why other options are incorrect:** * **Keratoglobus:** Characterized by generalized thinning and protrusion of the entire cornea, but it does not typically present with Haab’s striae. * **Trachoma:** Leads to Arlt’s line (conjunctival scarring) and Herbert’s pits (limbal scarring), not Descemet’s breaks. * **Keratoconus:** Features **Vogt’s striae**, which are fine, **vertical** stress lines in the deep stroma/Descemet’s membrane that disappear upon applying pressure to the globe. **High-Yield Clinical Pearls for NEET-PG:** * **Haab’s Striae vs. Vogt’s Striae:** Remember **H**aab’s are **H**orizontal (Buphthalmos); **V**ogt’s are **V**ertical (Keratoconus). * **Triad of Congenital Glaucoma:** Photophobia, Blepharospasm, and Lacrimation (Epiphora). * **Corneal Diameter:** In Buphthalmos, the diameter is usually >12 mm before age 1. * **Management:** The primary treatment for Buphthalmos is surgical (Goniotomy or Trabeculotomy).

Question 1

All are the features of an acute attack of primary narrow-angle glaucoma except?

Accepted Answer

Disc shows glaucomatous cupping

Answer

Intraocular pressure is raised up to 60-70 mm of Hg

Answer

Eye is red, painful and tender

Answer

Fellow eye also shows shallow anterior chamber

Question 2

What is the standard in perimetry?

Accepted Answer

Goldman type III

Answer

Goldman type I

Answer

Goldman type II

Answer

Goldman type IV

Question 3

Which drug is used in refractory glaucoma?

Accepted Answer

Alpha agonist

Answer

Systemic glucocorticoid

Answer

ACE inhibitor

Answer

Beta blocker

Question 4

Which drug is used during a trabeculectomy procedure?

Accepted Answer

Mitomycin-C

Answer

Azathioprine

Answer

Cetuximab

Answer

Ketorolac

Question 5

Which cells are affected in glaucomatous optic neuropathy?

Accepted Answer

Ganglion cells

Answer

Amacrine cells

Answer

Bipolar cells

Answer

Rods and cones

Question 6

A 55-year-old lady presented with sudden onset of severe eye pain and a shallow anterior chamber. What is the treatment of choice?

Accepted Answer

Intravenous mannitol & Acetazolamide

Answer

Atropine

Answer

Atenolol

Answer

Intravenous steroids

Question 7

Which beta-1 selective blocker is used in the management of glaucoma?

Accepted Answer

Betaxolol

Answer

Levobunolol

Answer

Timolol

Answer

Carteolol

Question 8

In indentation tonometry, what is the relationship between scleral rigidity, intraocular pressure, and scale readings?

Accepted Answer

Lower scale readings are obtained in high intraocular pressure.

Answer

A plunger indents a hard eye more than a soft eye.

Answer

Low scleral rigidity gives a high reading of intraocular pressure.

Answer

All of the above

Question 9

Haab's striae are seen in which of the following conditions?

Accepted Answer

Buphthalmos

Answer

Keratoglobus

Answer

Trachoma

Answer

Keratoconus

Question 10

Malignant glaucoma is characterized by which of the following?

Accepted Answer

Misdirected aqueous flow

Answer

Anterior chamber is normal

Answer

Pilocarpine is the drug of choice

Answer

Management is medical only

Glaucoma — MCQs

Glaucoma — MCQs

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