Glaucoma Practice Questions

Q: A child presents with lid lag and an enlarged cornea with a diameter of 13 mm. Examination of the eye reveals double-contoured opacities concentric to the limbus. Which of the following is the most likely diagnosis?

Congenital Glaucoma. ***Congenital Glaucoma*** - The presence of **lagophthalmos** (incomplete eyelid closure, sometimes termed "lid lag" but distinct from thyroid-related lid lag), an **enlarged cornea** (13 mm diameter, indicative of **buphthalmos**), and **double-contoured opacities concentric to the limbus** (corresponding to **Haab's striae**) are classic signs of congenital glaucoma. - **Buphthalmos** occurs due to increased intraocular pressure in infancy, stretching the sclera and cornea, while **Haab's striae** are ruptures in Descemet's membrane resulting from this stretching. - The enlarged globe prevents complete lid closure, creating the appearance of "lid lag" (lagophthalmos). *Superficial keratitis* - This condition typically presents with **corneal inflammation** affecting the epithelial or superficial stromal layers, often causing pain, photophobia, and foreign body sensation. - It does not typically cause **corneal enlargement** or **Haab's striae**, which are characteristic of increased intraocular pressure. *Deep keratitis* - Involves inflammation deeper within the corneal stroma, potentially leading to significant vision loss and corneal scarring. - While it can cause corneal opacities, it does not typically lead to **corneal enlargement (buphthalmos)** or **Haab's striae**, which are associated with elevated intraocular pressure from birth. *Thyroid Endocrinopathy* - **Thyroid eye disease** can cause true **lid lag** (von Graefe's sign) due to sympathetic overstimulation of Muller's muscle—this is different from the lagophthalmos seen in congenital glaucoma. - However, thyroid disease does not cause **corneal enlargement** or **Haab's striae**, and is primarily an inflammatory and autoimmune condition affecting orbital tissues, not directly leading to congenital corneal changes.

Q: Krukenberg's spindle seen in patients with pigmentary glaucoma refers to deposition of pigment on

Back of cornea. ***Back of cornea*** - **Krukenberg's spindle** is a classic sign of **pigment dispersion syndrome** and subsequent pigmentary glaucoma. - It results from the deposition of **pigment granules** on the **endothelium of the central posterior cornea**, forming a **vertical spindle-shaped pattern**. - This is a pathognomonic finding that helps distinguish pigmentary glaucoma from other forms of glaucoma. *Incorrect: Trabecular meshwork* - While **pigment deposition** on the trabecular meshwork is crucial in pigmentary glaucoma, leading to **increased outflow resistance** and elevated intraocular pressure, the term **Krukenberg's spindle** specifically refers to pigment on the corneal endothelium. - Pigment on the trabecular meshwork appears as **increased pigmentation of the angle** on gonioscopy, sometimes described as **Scheie's stripe** or **Sampaolesi's line**. *Incorrect: Anterior surface of the lens* - Pigment can deposit on the **anterior lens capsule** in pigment dispersion syndrome, appearing as fine dusting. - However, this deposition is **not referred to as Krukenberg's spindle**, which is specific to the posterior corneal surface. *Incorrect: Posterior surface of iris* - In pigment dispersion syndrome, **pigment is released FROM the posterior iris** due to mechanical rubbing against zonular fibers, creating **radial transillumination defects**. - However, Krukenberg's spindle refers to where pigment is **deposited** (corneal endothelium), not where it originates from.

Q: Intumescent cataract is associated with which type of glaucoma?

Phacomorphic glaucoma. ***Phacomorphic glaucoma*** - **Intumescent cataract** refers to a mature or hypermature cataract that has absorbed water, leading to a swollen lens. - This swelling can cause the lens to push the iris forward, leading to secondary **angle closure glaucoma** due to pupillary block, which is characteristic of phacomorphic glaucoma. *Phacolytic glaucoma* - This type of glaucoma is caused by leakage of **high-molecular-weight lens proteins** from a mature or hypermature cataract into the aqueous humor, triggering a macrophagic response and obstruction of the trabecular meshwork. - It results in an **open-angle glaucoma** and anterior chamber inflammation, unlike the angle closure seen with intumescent cataracts. *Phacotopic glaucoma* - This is a rare term and not a recognized distinct category of glaucoma related to lens swelling. It may refer loosely to glaucoma associated with **lens dislocation** or subluxation. - It does not specifically describe glaucoma caused by an **intumescent cataract**. *Pseudophakic glaucoma* - This refers to glaucoma that develops in patients who have undergone **cataract surgery** and have an **intraocular lens (IOL)** implant (pseudophakia). - It can be caused by various mechanisms post-surgery, such as inflammation, steroid response, or IOL-related issues, but it is not directly associated with the presence of an intumescent natural lens.

Q: What are glaukomflecken?

Lens opacities associated with acute angle-closure glaucoma. ***Lens opacities associated with acute angle-closure glaucoma*** - **Glaukomflecken** are small, grey-white capsular and subcapsular lens opacities that form as a result of **ischemic necrosis** of the lens epithelium. - They are a specific sign of prior **acute angle-closure glaucoma**, caused by a sudden, severe rise in **intraocular pressure (IOP)**. *Acute uveitis due to glaucoma* - **Uveitis** is inflammation of the uvea, and while it can be associated with glaucoma (e.g., in Posner-Schlossman syndrome), **glaukomflecken** specifically refer to lens damage, not uveal inflammation. - Uveitis is typically diagnosed by observing **inflammatory cells in the anterior chamber** and different patterns of globe redness, not lens opacities. *Retinal detachment due to glaucoma* - **Retinal detachment** is a separation of the neurosensory retina from the underlying retinal pigment epithelium. - While glaucoma can cause vision loss, it does not directly cause **retinal detachment**; glaukomflecken are specifically lens findings. *Corneal opacity due to glaucoma* - **Corneal edema** can occur during an acute attack of angle-closure glaucoma due to high IOP, leading to a hazy cornea. - However, **glaukomflecken** are specific lesions found in the **lens**, not the cornea.

Q: In open-angle glaucoma, which investigation is least useful for diagnosis?

Indirect ophthalmoscopy. ***Indirect ophthalmoscopy*** - While useful for viewing the peripheral retina, **indirect ophthalmoscopy** is less effective than other methods for assessing the optic nerve head and retinal nerve fiber layer changes characteristic of open-angle glaucoma. - Its primary utility is for detecting **retinal detachment** or other peripheral retinal pathologies, which are not directly diagnostic of glaucoma. *Tonometry* - **Tonometry** measures the intraocular pressure (IOP), a primary risk factor for open-angle glaucoma, and is essential for monitoring treatment effectiveness. - Elevated IOP is a key indicator, though not always present, and normal-tension glaucoma exists. *Direct ophthalmoscopy* - **Direct ophthalmoscopy** allows for visualization of the optic nerve head, enabling detection of characteristic glaucoma changes such as **cupping** and loss of the neuroretinal rim. - This method is crucial for assessing **optic nerve damage**, a hallmark of glaucoma. *Perimetry* - **Perimetry**, or visual field testing, assesses the functional impact of glaucoma by detecting **peripheral vision loss**. - This test identifies specific patterns of visual field defects that correlate with nerve fiber layer damage and is vital for staging and monitoring disease progression.

Q: Best treatment for buphthalmos?

Goniotomy. ***Goniotomy*** - Primary surgical treatment for **congenital glaucoma** (buphthalmos) with clear cornea - Directly incises the **trabecular meshwork** to relieve the outflow obstruction at the **angle structures** - Success rate of 70-90% in appropriate cases, making it the first-line surgical intervention - Addresses the underlying pathophysiology of congenital glaucoma *Trabeculectomy* - **Filtering surgery** that creates a new drainage pathway from anterior chamber to subconjunctival space - Reserved as a **secondary procedure** when goniotomy/trabeculotomy fails in congenital glaucoma - More commonly used as primary surgery in adult-onset glaucoma - Carries higher risk of complications in infants *Cryotherapy* - **Cyclodestructive procedure** that destroys ciliary body tissue to reduce aqueous humor production - Reserved for **refractory cases** where conventional surgeries have failed - Does not address the primary anatomical obstruction in congenital glaucoma - Higher risk of complications including phthisis bulbi *Conservative* - Buphthalmos indicates **congenital glaucoma**, a surgical disease requiring prompt intervention - Medical management alone is **insufficient** due to structural trabecular meshwork abnormalities - Topical medications may serve as temporary bridge to surgery but are rarely definitive - Delayed surgical treatment risks irreversible optic nerve damage and vision loss

Q: Vogt's triad is indicative of:

Past attack of acute angle-closure glaucoma. ***Past attack of acute-angle closure glaucoma*** - Vogt's triad refers to three specific signs observed in the eye after an episode of **acute angle-closure glaucoma**. - The triad includes **glaukomflecken** (anterior subcapsular lens opacities), **iris stromal atrophy**, and **pupil dilation or distortion**. *Vogt-Koyanagi-Harada syndrome* - This is a **multisystem inflammatory disease** primarily affecting pigmented structures, not characterized by Vogt's triad. - It involves **uveitis**, dermatological manifestations (e.g., poliosis, vitiligo), neurological symptoms (e.g., tinnitus, meningitis), and auditory symptoms. *Past attack of acute iridocyclitis* - While iridocyclitis involves **inflammation of the iris and ciliary body**, it does not typically lead to the specific triad of signs seen in Vogt's triad. - Complications of severe iridocyclitis might include synechiae or cataract, but not glaukomflecken or specific iris atrophy described by Vogt. *Past attack of herpes zoster ophthalmicus* - This condition is caused by the **reactivation of the varicella-zoster virus** in the ophthalmic division of the trigeminal nerve. - Ocular manifestations include keratitis, uveitis, and neurotrophic keratopathy, but not the specific changes of Vogt's triad.

Q: Normal intraocular pressure is typically in the range of:

10-21 mm Hg. ***10-21 mm Hg*** - This range is widely accepted as the **normal intraocular pressure (IOP)** in healthy individuals. - Maintaining IOP within this range is crucial for preventing damage to the **optic nerve** and conditions like **glaucoma**. *2.1-6 mm Hg* - This range is significantly **lower** than the normal physiological IOP. - Pressures in this range could indicate conditions like **hypotony**, which can lead to vision problems. *7-14 mm Hg* - While closer to the normal range, this range is still generally considered to be at the **lower end of normal** or slightly below. - Many individuals would fall within 10-21 mm Hg, making this a less accurate representation of the typical normal range. *16-32 mm Hg* - The upper part of this range (above 21 mm Hg) is considered **elevated IOP**, a significant risk factor for **glaucoma**. - Pressures above 21 mm Hg require closer monitoring and potentially treatment to prevent **optic nerve damage**.

Q: A 60-year-old male presents with colored halos around lights. The most probable diagnosis is

Acute angle closure glaucoma. ***Acute angle closure glaucoma*** - **Colored halos (rainbow-colored)** around lights are a classic and pathognomonic symptom of **acute angle closure glaucoma**, caused by corneal edema secondary to elevated intraocular pressure. - The edematous cornea acts as a **prism**, breaking white light into its spectral colors, producing the characteristic rainbow halos. - These colored halos can occur as **prodromal symptoms** before a full acute attack, and may be present even without severe eye pain, especially in subacute or intermittent angle closure. - The patient's age (60 years) fits the typical demographic, as angle closure glaucoma is more common in older adults, hypermetropes, and those with shallow anterior chambers. *Senile immature cataract* - Cataracts typically cause **monochromatic (white) halos** or glare around lights due to light scattering by lens opacities, not the colored/rainbow halos described. - The predominant symptoms of cataracts are **progressive blurred vision**, difficulty with night driving, and glare, rather than colored halos. - While cataracts are common at age 60, the specific symptom of colored halos does not point to this diagnosis. *Chronic open angle glaucoma* - This is typically **asymptomatic** in early stages and presents with gradual **peripheral vision loss** and optic nerve cupping. - Colored halos are not a characteristic feature of chronic open angle glaucoma, as IOP elevation is usually gradual and does not cause significant corneal edema. *Bacterial conjunctivitis* - Presents with **redness, discharge, irritation**, and foreign body sensation due to conjunctival inflammation. - Does not cause visual disturbances like colored halos, as it does not affect the cornea or cause elevated intraocular pressure.

Q: A patient with angle-closure glaucoma is posted for laser iridotomy. Which of the following lasers is used for iridotomy?

Nd:YAG laser. ***Nd:YAG laser*** - The **Nd:YAG laser** is a **photodisruptive** laser commonly used for **laser iridotomy** due to its ability to create a small opening in the iris with minimal thermal damage. - Its short pulse duration and high peak power allow for precise tissue disruption, making it effective for creating a patent **iridectomy** to relieve pupillary block in angle-closure glaucoma. *Argon laser* - The **argon laser** is a **photocoagulative** laser that works by selectively heating and destroying pigmented tissue, often used for **trabeculasty** or retinal procedures. - While it can be used for iridotomy, the Argon laser carries a higher risk of **thermal damage** and inflammation compared to the Nd:YAG laser, making Nd:YAG the preferred choice. *Helium-Neon laser* - The **Helium-Neon laser** emits red light and is primarily used for **aiming and illumination** in ophthalmic laser systems, not for therapeutic tissue destruction. - It does not possess the power or tissue interaction properties required to perform a surgical procedure like **iridotomy**. *Krypton laser* - The **Krypton laser** is a **photocoagulative** laser, primarily used for various **retinal treatments**, particularly in conditions involving subretinal neovascularization due to its deeper penetration and less scattering by hemoglobin. - It is not suitable for iridotomy as its wavelength and tissue interaction are not optimized for creating an opening in the **iris**.

Question 1

A child presents with lid lag and an enlarged cornea with a diameter of 13 mm. Examination of the eye reveals double-contoured opacities concentric to the limbus. Which of the following is the most likely diagnosis?

Accepted Answer

Congenital Glaucoma

Answer

Superficial keratitis

Answer

Deep keratitis

Answer

Thyroid Endocrinopathy

Question 2

Krukenberg's spindle seen in patients with pigmentary glaucoma refers to deposition of pigment on

Accepted Answer

Back of cornea

Answer

Trabecular meshwork

Answer

Anterior surface of the lens

Answer

Posterior surface of iris

Question 3

Intumescent cataract is associated with which type of glaucoma?

Accepted Answer

Phacomorphic glaucoma

Answer

Phacolytic glaucoma

Answer

Phacotopic glaucoma

Answer

Pseudophakic glaucoma

Question 4

What are glaukomflecken?

Accepted Answer

Lens opacities associated with acute angle-closure glaucoma

Answer

Acute uveitis due to glaucoma

Answer

Retinal detachment due to glaucoma

Answer

Corneal opacity due to glaucoma

Question 5

In open-angle glaucoma, which investigation is least useful for diagnosis?

Accepted Answer

Indirect ophthalmoscopy

Answer

Tonometry

Answer

Direct ophthalmoscopy

Answer

Perimetry

Question 6

Best treatment for buphthalmos?

Accepted Answer

Goniotomy

Answer

Trabeculectomy

Answer

Cryotherapy

Answer

Conservative

Question 7

Vogt's triad is indicative of:

Accepted Answer

Past attack of acute angle-closure glaucoma

Answer

Past attack of acute iridocyclitis

Answer

Vogt-Koyanagi-Harada syndrome

Answer

Past attack of herpes zoster ophthalmicus

Question 8

Normal intraocular pressure is typically in the range of:

Accepted Answer

10-21 mm Hg

Answer

2.1-6 mm Hg

Answer

7-14 mm Hg

Answer

16-32 mm Hg

Question 9

A 60-year-old male presents with colored halos around lights. The most probable diagnosis is

Accepted Answer

Acute angle closure glaucoma

Answer

Senile immature cataract

Answer

Chronic open angle glaucoma

Answer

Bacterial conjunctivitis

Question 10

A patient with angle-closure glaucoma is posted for laser iridotomy. Which of the following lasers is used for iridotomy?

Accepted Answer

Nd:YAG laser

Answer

Helium-Neon laser

Answer

Argon laser

Answer

Krypton laser

Glaucoma — MCQs

Glaucoma — MCQs

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