Glaucoma Practice Questions

Q: A 35-year-old lady, Malti, has unilateral headache, nausea, vomiting, and visual blurring. The diagnosis is:

Glaucoma. ***Glaucoma (Acute Angle-Closure)*** - The combination of **unilateral headache**, **nausea**, **vomiting**, and **visual blurring** is highly suggestive of **acute angle-closure glaucoma**. - This condition involves a sudden increase in **intraocular pressure**, which can cause a severe headache, often localized to the affected eye, and systemic symptoms due to vagal stimulation. *Posterior fossa cyst* - A posterior fossa cyst could cause headaches, nausea, and vomiting due to increased **intracranial pressure** or mass effect. - However, it typically presents with **bilateral** or generalized headache and specific neurological deficits related to cerebellar or brainstem compression, not typically unilateral visual blurring as the primary ocular symptom. *Subarachnoid hemorrhage* - A subarachnoid hemorrhage characteristically presents with a **sudden-onset**, severe "thunderclap" headache, often described as the "worst headache of my life." - While it can cause nausea and vomiting, visual blurring is not the primary or unilateral symptom, and the headache rarely gradually progresses as might be implied by "unilateral headache" without further qualification of its onset. *Cluster headache* - Cluster headaches are characterized by **severe unilateral pain**, typically around the eye or temple, accompanied by **autonomic symptoms** like tearing, nasal congestion, and ptosis on the affected side. - While visual blurring can occur, nausea and vomiting are less prominent than in acute glaucoma, and the pain is usually described as excruciating and stabbing, without the significant visual loss.

Q: Which of the following statements regarding glaucoma and its management is true?

Topiramate can cause bilateral angle closure glaucoma. ***Topiramate can cause bilateral angle closure glaucoma*** - **Topiramate**, a sulfonamide derivative, can cause acute **myopia** and **ciliary body swelling**, leading to anterior displacement of the lens-iris diaphragm and subsequent **bilateral angle closure glaucoma**. - This adverse effect typically occurs within the first few weeks of starting the drug, and prompt discontinuation can often resolve the condition. *Latanoprost is used with caution in patients of bronchial asthma* - **Latanoprost** is a **prostaglandin analog** and is generally safe for patients with bronchial asthma as it does not affect pulmonary function. - Beta-blockers, rather than latanoprost, are the class of glaucoma medications that require caution in patients with bronchial asthma due to their potential to cause **bronchospasm**. *Central scotoma is seen in open angle glaucoma* - **Central scotoma** is more characteristic of conditions affecting the **macula** or optic nerve pathologies other than typical open-angle glaucoma. - The classic visual field defect in **open-angle glaucoma** is a **paracentral scotoma** or **nasal step**, often progressing to peripheral field loss. *Methazolamide causes decrease in ocular blood flow* - **Methazolamide**, a carbonic anhydrase inhibitor (CAI), primarily acts by reducing aqueous humor production, which can **lower intraocular pressure**. - Although CAIs can cause systemic side effects, they are not known to significantly decrease **ocular blood flow**; in fact, some studies suggest they may even have a mild beneficial effect on optic nerve head blood flow.

Q: Which of the following is most likely to cause bilateral angle closure glaucoma?

Topiramate. ***Topiramate can cause bilateral angle closure glaucoma*** - **Topiramate** is known to cause a unique form of **bilateral angle closure glaucoma** due to ciliary body edema and anterior displacement of the iris-lens diaphragm, leading to acute myopia and angle closure. - This reaction typically occurs within the first few weeks of starting the drug, is **bilateral**, and is not related to angle anatomy. *Sulfonamide medications* - While some **sulfonamides** can cause acute myopia and secondary angle closure, similar to topiramate, this is a less consistently reported and less recognized association compared to topiramate. - The mechanism involves **ciliary body edema** leading to anterior displacement of the iris-lens diaphragm, but topiramate is a more classic example. *Adrenergic agonists* - **Adrenergic agonists** typically cause **mydriasis** (pupil dilation), which can precipitate acute angle closure in eyes with an already **narrow angle**. - However, they usually trigger **unilateral** angle closure and do not cause the same ciliary body edema mechanism seen with topiramate that results in bilateral involvement. *Anticholinergic drugs* - **Anticholinergic drugs** also cause **mydriasis** and can lead to **acute angle closure glaucoma** by widening the pupil and potentially blocking aqueous outflow in susceptible individuals. - Similar to adrenergic agonists, this is usually a **unilateral** event and does not involve the characteristic ciliary body edema and resultant bilateral acute myopia associated with topiramate.

Q: Which of the following is not a feature of open-angle glaucoma?

Pain and redness. ***Pain and redness*** - **Open-angle glaucoma** is typically a **painless** condition, often referred to as the "silent thief of sight", because central vision is preserved until late stages. - **Pain** and **redness** are more characteristic of **acute angle-closure glaucoma** or other inflammatory eye conditions, not the chronic, progressive nature of open-angle glaucoma. *Elevated intraocular pressure* - **Elevated intraocular pressure** (IOP) is a primary risk factor and a hallmark feature of **open-angle glaucoma**, although normal-tension glaucoma exists. - Sustained high IOP can lead to **optic nerve damage** over time. *Increased cup-to-disc ratio* - An **increased cup-to-disc ratio** on examination of the optic disc is a key diagnostic feature of **open-angle glaucoma**, indicating **optic nerve damage** and atrophy. - This enlargement of the optic cup is due to the loss of nerve fibers. *Gradual peripheral vision loss* - **Gradual peripheral vision loss** is the characteristic pattern of vision loss in **open-angle glaucoma**, often unnoticed by the patient until advanced stages. - The central vision remains relatively intact until late in the disease, making early detection challenging.

Q: Which of the following is the first visual field defect in open-angle glaucoma?

Paracentral scotoma. ***Paracentral scotoma*** - This is the **earliest visual field defect** detected in open-angle glaucoma, typically appearing in the **Bjerrum area** (10-20° from fixation). - Most commonly occurs as a **superior or inferior arcuate scotoma** in the nasal field. - Results from damage to the **retinal nerve fiber layer** around the **optic disc**, which is particularly vulnerable to elevated intraocular pressure. - These scotomas respect the **horizontal raphe** and follow the arcuate nerve fiber bundle pattern. *Ring scotoma* - A **ring scotoma** (Bjerrum scotoma) typically occurs later in the progression of glaucoma, when superior and inferior arcuate defects coalesce to form a ring-like pattern. - This represents **advanced glaucomatous damage** and is not an early finding. *Bitemporal hemianopia* - This visual field defect is characteristic of **optic chiasm compression**, commonly due to a **pituitary tumor** or other suprasellar lesions. - It is **not associated with glaucoma**, which causes damage to the optic nerve fibers within the eye, not at the chiasm. *Tunnel vision* - **Tunnel vision** represents severe, **end-stage glaucoma**, where only a small central island of vision remains. - It indicates extensive loss of peripheral visual field and is a late finding, not an early one.

Q: An 80-year-old patient complains of pain, redness, and diminished vision in the left eye. On examination, the intraocular pressure (IOP) in the right eye is 16 mmHg, while the left eye shows 50 mmHg. The left eye also exhibits deep anterior chamber flare and a white cataract. What is the most likely diagnosis?

Phacolytic glaucoma. ***Phacolytic glaucoma*** - The combination of **extremely high intraocular pressure** (50 mmHg) in the left eye, along with a **mature (white) cataract** and **deep anterior chamber flare**, is highly suggestive of phacolytic glaucoma. - This condition occurs when **lens proteins leak** from a hypermature cataract, triggering a macrophagic inflammatory response that **clogs the trabecular meshwork**, leading to an acute rise in IOP. *Central retinal artery occlusion (CRAO)* - While CRAO causes acute, profound **vision loss** in one eye, it is generally associated with a **normal or low IOP**, not the extremely high pressure seen in the left eye. - Fundoscopic examination would typically reveal a **cherry-red spot** and **pale retina**, which are not described. *Fuchs' heterochromic iridocyclitis* - This condition is characterized by **chronic, low-grade anterior uveitis** and often leads to **heterochromia** (different colored irises) and **secondary glaucoma**. - However, it typically presents with **mild IOP elevation** (if at all) and not the acute, markedly high pressure and visible white cataract with flare described here. *Malignant glaucoma* - Malignant glaucoma (also known as aqueous misdirection) presents with an **elevated IOP** and is characterized by a **shallow or flat anterior chamber**, often in the presence of a pupillary block mechanism. - The patient's left eye is described as having a **deep anterior chamber** with flare, which contradicts the typical findings of malignant glaucoma.

Q: A 60-year-old male presents with a gradual loss of peripheral vision and is diagnosed with open-angle glaucoma. Which of the following is the first line of treatment?

Prostaglandin analogs (e.g., latanoprost). ***Prostaglandin analogs (e.g., latanoprost)*** - **Prostaglandin analogs** are generally considered the **first-line treatment** for open-angle glaucoma due to their efficacy in lowering intraocular pressure (IOP) and their favorable dosing schedule (typically once daily). - They work by increasing the **outflow of aqueous humor** through the uveoscleral pathway, thereby reducing IOP. *Laser trabeculoplasty* - This procedure is often considered a **second-line treatment** or an adjunct therapy when topical medications alone are insufficient. - It works by improving the outflow of aqueous humor through the **trabecular meshwork**, but it's typically not the initial approach. *Trabeculectomy* - **Trabeculectomy** is a surgical procedure usually reserved for cases of glaucoma that **do not respond to medication or laser treatment**, or when there is advanced disease. - It creates a new drainage pathway for the aqueous humor to bypass the blocked trabecular meshwork. *Oral acetazolamide* - **Oral acetazolamide** is a carbonic anhydrase inhibitor that can effectively lower IOP, but it is typically used for **short-term management** or in acute glaucoma crises. - Its use is limited as a first-line treatment due to significant **systemic side effects**, such as metabolic acidosis, kidney stones, and paresthesias.

Q: A 60-year-old man with primary open-angle glaucoma presents with progressive visual field loss despite maximal medical therapy. What is the next step in management?

Trabeculectomy. ***Trabeculectomy*** - This **surgical procedure** creates a new drainage pathway for aqueous humor, bypassing the clogged **trabecular meshwork**. - It is often the next step when maximal medical therapy fails to control intraocular pressure and prevent **progressive visual field loss** in open-angle glaucoma. *Cyclophotocoagulation for refractory cases* - This procedure uses **laser energy** to destroy parts of the ciliary body, reducing aqueous humor production. - It is typically reserved for **refractory glaucoma** cases that have failed other surgical interventions or in eyes with poor visual potential, which is not implied here. *Goniotomy for congenital glaucoma* - **Goniotomy** is a surgical procedure that incises the **trabecular meshwork** to improve outflow. - It is primarily used for **congenital glaucoma** in infants and young children, not in a 60-year-old man with primary open-angle glaucoma. *Laser trabeculoplasty as an adjunctive treatment* - **Laser trabeculoplasty** (either Argon or Selective) uses a laser to improve the aqueous outflow through the **trabecular meshwork**. - While it can be an initial or adjunctive treatment, the patient in this scenario is already on **maximal medical therapy** with progressive visual field loss, indicating a need for a more definitive surgical intervention.

Question 1

A 35-year-old lady, Malti, has unilateral headache, nausea, vomiting, and visual blurring. The diagnosis is:

Accepted Answer

Glaucoma

Answer

Posterior fossa cyst

Answer

Subarachnoid hemorrhage

Answer

Cluster headache

Question 2

Which of the following statements regarding glaucoma and its management is true?

Accepted Answer

Topiramate can cause bilateral angle closure glaucoma

Answer

Latanoprost is used with caution in patients of bronchial asthma

Answer

Central scotoma is seen in open angle glaucoma

Answer

Methazolamide causes decrease in ocular blood flow

Question 3

Which of the following is most likely to cause bilateral angle closure glaucoma?

Accepted Answer

Topiramate

Answer

Sulfonamide medications

Answer

Adrenergic agonists

Answer

Anticholinergic drugs

Question 4

Which of the following is not a feature of open-angle glaucoma?

Accepted Answer

Pain and redness

Answer

Elevated intraocular pressure

Answer

Increased cup-to-disc ratio

Answer

Gradual peripheral vision loss

Question 5

Which of the following is the first visual field defect in open-angle glaucoma?

Accepted Answer

Paracentral scotoma

Answer

Ring scotoma

Answer

Bitemporal hemianopia

Answer

Tunnel vision

Question 6

A 58-year-old male presents with gradual loss of peripheral vision in both eyes. On fundus examination, significant cupping of the optic disc and arcuate scotomas were noted. IOP was 28 mmHg. Based on these findings, which pathway is most likely affected in this patient’s disease?

Accepted Answer

Retinal ganglion cell apoptosis

Answer

Increased aqueous humor production

Answer

Retinal detachment

Answer

Phototransduction in rods and cones

Question 7

An 80-year-old patient complains of pain, redness, and diminished vision in the left eye. On examination, the intraocular pressure (IOP) in the right eye is 16 mmHg, while the left eye shows 50 mmHg. The left eye also exhibits deep anterior chamber flare and a white cataract. What is the most likely diagnosis?

Accepted Answer

Phacolytic glaucoma

Answer

Central retinal artery occlusion (CRAO)

Answer

Fuchs' heterochromic iridocyclitis

Answer

Malignant glaucoma

Question 8

In a 65-year-old patient with a history of narrow-angle glaucoma and an intraocular pressure of 30 mmHg despite maximal medical therapy, which surgical option is preferred for better intraocular pressure control?

Accepted Answer

Trabeculectomy with antifibrotics

Answer

Tube shunt surgery

Answer

Trabeculectomy without antifibrotics

Answer

Cyclodestructive procedure for refractory cases

Question 9

A 60-year-old male presents with a gradual loss of peripheral vision and is diagnosed with open-angle glaucoma. Which of the following is the first line of treatment?

Accepted Answer

Prostaglandin analogs (e.g., latanoprost)

Answer

Laser trabeculoplasty

Answer

Trabeculectomy

Answer

Oral acetazolamide

Question 10

A 60-year-old man with primary open-angle glaucoma presents with progressive visual field loss despite maximal medical therapy. What is the next step in management?

Accepted Answer

Trabeculectomy

Answer

Cyclophotocoagulation

Answer

Goniotomy

Answer

Laser trabeculoplasty

Glaucoma — MCQs

Glaucoma — MCQs

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