Glaucoma Practice Questions

Q: Select the FALSE statement pertaining to the disease depicted in this picture. (AP PG 2016)

Commonly detected because of visual field defects. The image displays an enlarged eye with a hazy cornea, notably seen in an infant, which is indicative of **congenital glaucoma** (also known as buphthalmos). ***Commonly detected because of visual field defects*** - **Visual field defects** are difficult to detect in children and infants due to their inability to cooperate with visual field testing. - Congenital glaucoma typically presents with symptoms like **epiphora**, **photophobia**, and **blepharospasm**, which are more prominent and observable. *Commonly causes haziness of cornea (Haab striae)* - **Corneal edema** is a hallmark sign of congenital glaucoma due to elevated intraocular pressure, leading to the characteristic corneal haziness. - **Haab striae**, or tears in Descemet's membrane, are also commonly seen in congenital glaucoma due to stretching and enlargement of the globe. *Commonly causes photophobia* - **Photophobia**, an abnormal sensitivity to light, is a very frequent and important symptom in children with congenital glaucoma. - Parents often notice the child squinting or trying to avoid light. *Often due to congenital glaucoma* - The image shows a significantly enlarged globe (buphthalmos) and corneal haziness in an infant, which are classic signs of **congenital glaucoma**. - This condition results from developmental abnormalities in the **aqueous humor outflow system** that lead to elevated intraocular pressure.

Q: The normal range of intraocular pressure (in mmHg) is

10-20. ***10-20*** - The **normal range for intraocular pressure (IOP)** is generally accepted to be between **10 and 20 mmHg**. - Maintaining IOP within this range is crucial for optimal eye health, as deviations can indicate conditions like **glaucoma** or **ocular hypotony**. *15-25* - While 15 mmHg falls within the normal range, **25 mmHg is considered elevated** and potentially indicative of **ocular hypertension** or **glaucoma**. - Sustained pressures above 20-21 mmHg raise concern for **optic nerve damage**. *20-30* - Both 20 mmHg and 30 mmHg are generally considered to be at the **upper end or above the normal range** of IOP. - Pressures in this range significantly increase the **risk of developing glaucoma** and require further evaluation. *5-15* - While 5 mmHg is generally considered low, **15 mmHg is within the normal range**. - An IOP of 5 mmHg or lower for an extended period could indicate **ocular hypotony**, which can lead to various visual problems.

Q: A patient presents with eye ache and difficulty in vision after watching a movie. What will be the first line of management?

Mannitol with Pilocarpine. ***Mannitol with Pilocarpine*** - This combination is appropriate for **acute angle-closure glaucoma (AACG)**, which can be triggered by pupillary dilation (e.g., in a dark movie theater). **Mannitol** is an osmotic diuretic that rapidly reduces intraocular pressure. - **Pilocarpine** is a miotic agent that constricts the pupil, pulling the iris away from the trabecular meshwork and opening the drainage angle to facilitate aqueous humor outflow. *Mannitol with Moxifloxacin* - While mannitol helps with intraocular pressure, **Moxifloxacin is an antibiotic** used to treat bacterial infections. - There is no indication of an ocular infection in this scenario, so an antibiotic would not be the first-line treatment for sudden eye pain and vision difficulty after watching a movie. *Mannitol with Atropine* - Adding **Atropine, a cycloplegic agent**, would cause further pupillary dilation, which would worsen acute angle-closure glaucoma and increase intraocular pressure. - Atropine is contraindicated in AACG and would exacerbate the patient's condition. *Mannitol with lubricating eye drops* - While mannitol helps with intraocular pressure, **lubricating eye drops** are used for dry eyes or surface irritation, not for acute angle-closure glaucoma. - Lubricating drops do not address the underlying pathology of increased intraocular pressure due to angle closure.

Q: A one-month-old baby presents with excessive tearing (watering) and an increased corneal size. What is the most likely diagnosis?

Buphthalmos. ***Buphthalmos*** - **Buphthalmos** refers to the enlargement of the eye in infants, typically caused by **congenital glaucoma**, which results in increased intraocular pressure. - The combination of **excessive tearing (epiphora)** and an **increased corneal size** (seen in the image as unusually large corneas for a one-month-old) are classic signs of buphthalmos due to elevated intraocular pressure stretching the infant's pliable sclera and cornea. *Galactosemia* - **Galactosemia** is a metabolic disorder that can cause cataracts and, in severe cases, liver damage and intellectual disability, but it does **not typically cause buphthalmos or enlarged corneas**. - While cataracts can lead to poor vision, they don't explain the excessive tearing or corneal enlargement. *Cataract* - A **cataract** is an opacity in the lens of the eye, which can cause blurry vision and a white pupil reflex (leukocoria), but **does not cause increased corneal size or excessive tearing** as primary symptoms. - While cataracts can occur in infants, they do not present with the specific combination of signs described. *Hurler syndrome* - **Hurler syndrome** is a lysosomal storage disorder (mucopolysaccharidosis type I) that can cause various ocular abnormalities, including **corneal clouding**, but typically **not corneal enlargement or buphthalmos**. - Other features include coarse facial features, skeletal abnormalities, and developmental delay, which are not mentioned in the presentation criteria.

Q: Which triad is seen after an acute attack of angle-closure glaucoma?

Vogt's triad. ***Vogt's triad*** - **Vogt's triad** refers to the classical findings seen after an acute attack of **angle-closure glaucoma**. - The triad consists of: **glaukomflecken** (anterior subcapsular lens opacities from ischemic necrosis of lens epithelium), **iris stromal atrophy** (sectoral iris atrophy in the area of ischemia), and **fixed mid-dilated pupil** (due to iris sphincter damage). - These signs indicate **ischemic damage** to the anterior segment following the acute episode of elevated intraocular pressure. *Gaucher triad* - **Gaucher triad** refers to the characteristic systemic symptoms of **Gaucher disease**, an inherited lipid storage disorder. - It involves **hepatosplenomegaly**, **bone pain**, and **thrombocytopenia**, which are unrelated to glaucoma. *Virchow triad* - The **Virchow triad** describes the three main factors contributing to **thrombus formation**: **stasis** of blood flow, **endothelial injury**, and **hypercoagulability**. - This triad is relevant to cardiovascular pathology, not the effects of angle-closure glaucoma. *Hutchinson's triad* - **Hutchinson's triad** is a set of symptoms associated with **congenital syphilis**. - It includes **interstitial keratitis**, **Hutchinson's teeth**, and **eighth nerve deafness**, which are entirely distinct from ocular hypertension.

Q: What is the earliest change in glaucoma on perimetry?

Isopter contraction + baring of blind spot. ***Isopter contraction + baring of blind spot*** - Early glaucomatous damage often manifests as an **isopter contraction**, meaning the **visual field narrows** for a given stimulus intensity. - **Baring of the blind spot** occurs when the isopter for a small target contracts inwards, leaving the physiological blind spot exposed to targets that would normally be seen. *Complete field loss* - This is indicative of **very advanced glaucoma**, representing extensive damage to the optic nerve. - It would be preceded by numerous earlier, more subtle visual field defects. *Tunnel vision defect* - **Tunnel vision** is a severe form of visual field constriction, characteristic of **advanced glaucoma** where only the central field of vision remains. - It is not the earliest change as it implies significant peripheral field loss has already occurred. *Complete vision loss* - **Complete vision loss** in an eye signifies end-stage disease, far beyond the earliest changes seen in glaucoma. - It means there is no light perception, indicating total destruction of the optic nerve fibers.

Q: Which of the following lens is used in direct gonioscopy?

Koeppe. ***Koeppe*** - The **Koeppe lens** is designed for direct gonioscopy, providing a wide-angle view of the **anterior chamber angle**. - It is typically used with the patient in a **supine position** and requires a coupling solution to be placed directly on the cornea. *Goldmann* - The **Goldmann lens** (3-mirror lens) is used for **indirect gonioscopy** and is characterized by mirrors that reflect the image of the angle. - It is used at a **slit lamp** and provides a magnified view as the light is reflected through the mirrors. *Richardson* - The **Richardson-Shaffer lens** is another direct gonioscopy lens, similar to the Koeppe lens. - However, the question asks for "**the**" lens used in direct gonioscopy, and **Koeppe** is the most commonly recognized and frequently used direct gonioscopy lens. - Richardson-Shaffer is less commonly used in modern practice compared to Koeppe. *Zeiss* - The **Zeiss lens** (4-mirror lens) is used for **indirect gonioscopy** and allows a rapid 360-degree view of the angle. - It is commonly used with a **slit lamp** and requires minimal or no coupling fluid due to its small contact surface.

Q: A 30-year-old female presents with redness and pain in the eye. Examination revealed 38 mm of Hg on IOP, aqueous flare, and corneal precipitates. Which of the following drugs must be avoided for her?

Prostaglandin analogs. ***Prostaglandin analogs*** - **Prostaglandin analogs** are **contraindicated in anterior uveitis** because they can significantly worsen inflammation. - They increase the risk of **cystoid macular edema (CME)** in patients with intraocular inflammation. - Can exacerbate existing **uveitis** and compromise treatment outcomes. - While they effectively lower IOP in non-inflammatory conditions, their pro-inflammatory effects make them unsuitable when aqueous flare and KPs are present. *Carbonic anhydrase inhibitors* - These drugs work by decreasing **aqueous humor production** and are safe and effective for reducing **IOP** in **uveitis**. - They do not exacerbate inflammation and are commonly used in the management of **uveitic glaucoma**. - Available in topical (dorzolamide, brinzolamide) and systemic (acetazolamide) formulations. *Mannitol* - **Mannitol** is an osmotic diuretic used for acute, severe elevations in **IOP**. - It rapidly reduces **IOP** by drawing fluid out of the vitreous and is safe to use in uveitis with elevated pressure. - Its use is typically for short-term, urgent IOP control. *Beta-blockers* - **Beta-blockers** (timolol, betaxolol) reduce **IOP** by decreasing **aqueous humor production**. - They are safe and commonly used to manage **elevated IOP** in uveitic patients. - They do not exacerbate inflammation and are first-line agents for IOP control.

Q: A 61-year-old woman comes to the emergency department because of a 2-hour history of headache, nausea, blurred vision, and pain in the left eye. She has had similar symptoms in the past. Her vital signs are within normal limits. The left eye is red and is hard on palpation. The left pupil is mid-dilated and nonreactive to light. Administration of which of the following drugs should be avoided in this patient?

Epinephrine. ***Epinephrine*** - Epinephrine is a **sympathomimetic** agent [1] that can cause **mydriasis** (pupil dilation) [1], [2] by activating alpha-1 receptors on the iris dilator muscle. - In a patient with **angle-closure glaucoma**, mydriasis can further narrow the anterior chamber angle, worsening the blockage of aqueous humor outflow and exacerbating the **intraocular pressure** (IOP) elevation [2], [3]. *Pilocarpine* - Pilocarpine is a **muscarinic agonist** that causes **miosis** (pupil constriction) and contraction of the ciliary muscle. - Miosis pulls the iris away from the trabecular meshwork, opening the anterior chamber angle and facilitating aqueous outflow, thereby **reducing IOP** [3]. *Timolol* - Timolol is a **beta-blocker** that reduces the production of aqueous humor by the ciliary body. - It is often used as a first-line treatment for glaucoma to **lower IOP** without significantly affecting pupil size. *Acetazolamide* - Acetazolamide is a **carbonic anhydrase inhibitor** that decreases aqueous humor production. - It is an effective systemic medication for rapidly **reducing IOP** in acute angle-closure glaucoma.

Q: For laser iridotomy which laser is used?

Nd YAG laser. ***Nd YAG laser*** - The **Nd:YAG laser** is the **primary laser used for laser iridotomy** due to its ability to create precise perforations in the iris. - This laser operates with a **photodisruptive mechanism**, generating plasma formation that effectively creates an opening in the iris. - It is the **treatment of choice for angle-closure glaucoma** and pupillary block. *Argon laser* - The **argon laser** was historically used for iridotomy but is now less commonly the primary choice due to its thermal effect causing more inflammation and scarring. - It is sometimes used in **sequential laser iridotomy** (argon first to thin the iris, followed by Nd:YAG to perforate) in cases where the iris is very thick or heavily pigmented. - Also used for **peripheral iridoplasty** and other thermal applications. *CO2 laser* - **CO2 lasers** are primarily used for **tissue ablation** in surgical procedures, particularly on the skin, eyelid lesions, or in general surgery. - They are **not suitable** for precise intraocular procedures like iridotomy due to their infrared wavelength (10,600 nm) and poor penetration through aqueous humor. *Excimer laser* - **Excimer lasers** are primarily used in **refractive surgery** (e.g., LASIK, PRK) to reshape the cornea. - They work by **photoablation** at 193 nm wavelength, precisely removing tissue layer by layer, and are not designed for creating an opening in the iris.

Question 1

Select the FALSE statement pertaining to the disease depicted in this picture. (AP PG 2016)

Accepted Answer

Commonly detected because of visual field defects

Answer

Commonly causes haziness of cornea (Haab striae)

Answer

Commonly causes photophobia

Answer

Often due to congenital glaucoma

Question 2

The normal range of intraocular pressure (in mmHg) is

Accepted Answer

10-20

Answer

15-25

Answer

20-30

Answer

5-15

Question 3

A patient presents with eye ache and difficulty in vision after watching a movie. What will be the first line of management?

Accepted Answer

Mannitol with Pilocarpine

Answer

Mannitol with Moxifloxacin

Answer

Mannitol with Atropine

Answer

Mannitol with lubricating eye drops

Question 4

A one-month-old baby presents with excessive tearing (watering) and an increased corneal size. What is the most likely diagnosis?

Accepted Answer

Buphthalmos

Answer

Galactosemia

Answer

Cataract

Answer

Hurler syndrome

Question 5

Which triad is seen after an acute attack of angle-closure glaucoma?

Accepted Answer

Vogt's triad

Answer

Gaucher triad

Answer

Virchow triad

Answer

Hutchinson's triad

Question 6

What is the earliest change in glaucoma on perimetry?

Accepted Answer

Isopter contraction + baring of blind spot

Answer

Complete field loss

Answer

Tunnel vision defect

Answer

Complete vision loss

Question 7

Which of the following lens is used in direct gonioscopy?

Accepted Answer

Koeppe

Answer

Goldmann

Answer

Richardson

Answer

Zeiss

Question 8

A 30-year-old female presents with redness and pain in the eye. Examination revealed 38 mm of Hg on IOP, aqueous flare, and corneal precipitates. Which of the following drugs must be avoided for her?

Accepted Answer

Prostaglandin analogs

Answer

Carbonic anhydrase inhibitors

Answer

Mannitol

Answer

Beta-blockers

Question 9

A 61-year-old woman comes to the emergency department because of a 2-hour history of headache, nausea, blurred vision, and pain in the left eye. She has had similar symptoms in the past. Her vital signs are within normal limits. The left eye is red and is hard on palpation. The left pupil is mid-dilated and nonreactive to light. Administration of which of the following drugs should be avoided in this patient?

Accepted Answer

Epinephrine

Answer

Pilocarpine

Answer

Timolol

Answer

Acetazolamide

Question 10

For laser iridotomy which laser is used?

Accepted Answer

Nd YAG laser

Answer

Argon laser

Answer

CO2 laser

Answer

Excimer laser

Glaucoma — MCQs

Glaucoma — MCQs

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