Glaucoma Practice Questions

Q: What is the most common symptom in buphthalmos?

Lacrimation. **Explanation:** **Buphthalmos** (Congenital Glaucoma) is characterized by an increase in intraocular pressure (IOP) in an infant’s eye, leading to the stretching of the globe. **1. Why Lacrimation is the Correct Answer:** The classic clinical triad of congenital glaucoma consists of **Lacrimation (Epiphora), Photophobia, and Blepharospasm**. Among these, **Lacrimation** is the earliest and most common presenting symptom. It occurs due to corneal epithelial edema and irritation caused by the elevated IOP. In the early stages, it is often misdiagnosed as congenital nasolacrimal duct obstruction. **2. Analysis of Incorrect Options:** * **Pain (B):** While high IOP causes discomfort, infants cannot verbalize pain. They typically present with irritability or rubbing of the eyes rather than acute pain. * **Photophobia (C):** This is a hallmark symptom and part of the classic triad, but it usually follows or accompanies lacrimation. Lacrimation remains the most frequently cited initial complaint by parents. * **Itching (D):** Itching is a characteristic feature of allergic conjunctivitis (e.g., Vernal Keratoconjunctivitis) and is not a feature of glaucoma. **3. High-Yield Clinical Pearls for NEET-PG:** * **Haab’s Striae:** Horizontal or curvilinear breaks in Descemet’s membrane due to corneal stretching. * **Buphthalmos Definition:** Enlargement of the globe (corneal diameter >12-13 mm) occurring if IOP rises before age 3. * **Treatment of Choice:** Surgery is the primary treatment. **Goniotomy** (if the cornea is clear) or **Trabeculotomy** (if the cornea is hazy) are the preferred procedures. * **B-Scan:** Useful to measure the increased axial length of the globe.

Q: Which of the following antiglaucoma medications is UNSAFE in infants?

Brimonidine. **Explanation:** The correct answer is **Brimonidine**. **Why Brimonidine is UNSAFE:** Brimonidine is a highly selective **Alpha-2 adrenergic agonist**. In infants and young children (typically under 2–3 years of age), the blood-brain barrier is immature. Brimonidine can cross this barrier and cause significant **central nervous system (CNS) depression**. This leads to life-threatening side effects, including severe somnolence, lethargy, bradycardia, hypotension, and **apnea** (respiratory depression). Consequently, it is strictly contraindicated in this age group. **Analysis of Incorrect Options:** * **A. Timolol:** A topical beta-blocker. While it must be used with caution in infants due to potential systemic absorption (risk of bradycardia or bronchospasm), it is not strictly contraindicated and is often used in pediatric glaucoma under supervision. * **C. Latanoprost:** A prostaglandin analogue. It is generally safe in children, though it is often less effective in pediatric/congenital glaucoma compared to adult open-angle glaucoma. * **D. Dorzolamide:** A topical carbonic anhydrase inhibitor. It is frequently used in children and is considered safe, though it may cause local irritation. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Congenital Glaucoma:** Surgery is the primary treatment (Goniotomy or Trabeculotomy). Medical therapy is only a temporizing measure. * **Brimonidine Warning:** Always remember the "B" in Brimonidine stands for **"Barrier"** (crosses the blood-brain barrier) and **"Baby"** (unsafe for babies). * **Systemic Absorption:** To minimize systemic side effects of any eye drop in infants, advise **punctal occlusion** for 2 minutes after instillation.

Q: What is the cause of a red, congested, painful eye with a mildly dilated, vertically oval pupil?

Acute congestive glaucoma. ### Explanation The clinical presentation of a **red, painful eye** associated with a **mildly dilated, vertically oval pupil** is a classic hallmark of **Acute Congestive Glaucoma** (Acute Angle Closure Glaucoma). #### Why Acute Congestive Glaucoma is Correct: In an acute attack, a sudden rise in intraocular pressure (IOP) causes ischemia and paralysis of the iris sphincter muscle. This results in a pupil that is mid-dilated and characteristically **vertically oval**. Other associated signs include a "steamy" or hazy cornea (due to epithelial edema), a shallow anterior chamber, and a stony-hard eyeball on palpation. #### Why Other Options are Incorrect: * **Anterior Uveitis:** While the eye is red and painful, the pupil is typically **constricted (miotic)** and may be irregular due to the formation of posterior synechiae. * **Keratoconjunctivitis:** This usually presents with discharge, itching, or a foreign body sensation. The pupil remains **normal** in size and reactive to light. * **Eale's Disease:** This is an idiopathic peripheral perivasculitis (retinal disease) characterized by recurrent vitreous hemorrhage. It presents with **painless** vision loss and does not cause a red, painful eye or pupillary changes in its early stages. #### High-Yield Clinical Pearls for NEET-PG: * **The Pupil Rule:** * Mid-dilated/Oval = Glaucoma * Constricted/Pinpoint = Uveitis * Normal = Conjunctivitis * **Symptoms:** Patients often report seeing **colored haloes** around lights (due to corneal edema) and may experience systemic symptoms like nausea and vomiting, which can lead to a misdiagnosis of an abdominal emergency. * **Immediate Management:** IV Mannitol, Acetazolamide, and topical pilocarpine (once IOP drops) are used. The definitive treatment is **Laser Peripheral Iridotomy (LPI)** for both the affected and the fellow (prophylactic) eye.

Q: What is the treatment of choice for congenital glaucoma with a corneal ulcer?

Trabeculotomy. **Explanation:** The primary pathology in primary congenital glaucoma (buphthalmos) is **Barkan’s membrane**, a layer of embryonic tissue covering the trabecular meshwork that prevents aqueous outflow. Surgical intervention is the definitive treatment, as medical therapy is only a temporary measure. **Why Trabeculotomy is the Correct Choice:** The choice between the two main surgical procedures—Goniotomy and Trabeculotomy—depends on **corneal clarity**. * **Goniotomy** requires a clear cornea because it is an internal procedure performed under direct visualization of the angle using a goniolens. * **Trabeculotomy** is an external procedure (ab-externo) where the Schlemm’s canal is cannulated and ruptured into the anterior chamber. Since it does not require visualization through the cornea, it is the **treatment of choice when the cornea is hazy or opaque** (e.g., due to edema or a corneal ulcer). **Why Other Options are Incorrect:** * **Goniotomy:** Incorrect because a corneal ulcer causes opacification, making the internal angle structures invisible for safe surgery. * **Miotics (e.g., Pilocarpine):** These are ineffective in congenital glaucoma because the iris insertion is already high and anterior; they may even worsen the condition by increasing congestion. * **Steroids:** These have no role in treating the underlying structural defect and may paradoxically increase intraocular pressure. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Epiphora (tearing), Photophobia, and Blepharospasm. * **Haab’s Striae:** Horizontal or curvilinear breaks in Descemet’s membrane due to corneal stretching. * **Buphthalmos:** Occurs because the infant globe is distensible; usually seen if IOP rises before age 3. * **Surgery of choice (Clear Cornea):** Goniotomy. * **Surgery of choice (Hazy Cornea):** Trabeculotomy.

Q: Which of the following drugs is not associated with open-angle glaucoma?

Thiazide. **Explanation:** The correct answer is **D. Thiazide**. Thiazide diuretics are not associated with Open-Angle Glaucoma (OAG); instead, they are known to cause **secondary acute angle-closure glaucoma** due to ciliary body edema leading to forward displacement of the lens-iris diaphragm (myopic shift). **Why the other options are incorrect:** * **A & C (Betamethasone and Prednisone):** These are corticosteroids. Steroids (topical, systemic, or periocular) are the most common cause of drug-induced **Open-Angle Glaucoma**. They increase resistance to aqueous outflow by inducing biochemical changes in the trabecular meshwork (e.g., increased expression of myocilin protein and deposition of glycosaminoglycans). * **B (Docetaxel):** Taxanes like Docetaxel and Paclitaxel have been associated with increased intraocular pressure and OAG, likely due to their effect on the microtubular structures within the trabecular meshwork cells. **High-Yield Clinical Pearls for NEET-PG:** 1. **Steroid Responders:** Approximately 5–10% of the general population are "high responders" who develop significant IOP elevation after steroid use. This risk is much higher in patients with pre-existing Primary Open-Angle Glaucoma (POAG). 2. **Topical vs. Systemic:** Topical and intravitreal steroids have a much higher propensity to cause OAG than systemic steroids. 3. **Thiazides and Sulfonamides:** These drugs typically cause **bilateral acute angle-closure** and **transient myopia** rather than OAG. 4. **Anticholinergics:** Drugs like Atropine or Ipratropium can precipitate **Angle-Closure Glaucoma** in predisposed eyes (narrow angles) but do not typically cause OAG.

Q: A patient presents with a normal anterior chamber and hazy cornea in one eye, and a shallow anterior chamber and miotic pupil in the fellow eye. What is the most likely diagnosis?

Acute anterior uveitis. **Explanation:** The correct answer is **Acute Anterior Uveitis**. The clinical presentation hinges on the concept of **iris bombé** and **seclusio pupillae**. In severe or recurrent uveitis, posterior synechiae (adhesions between the iris and lens) can occur. If these adhesions involve 360° of the pupil (seclusio pupillae), aqueous humor cannot flow from the posterior to the anterior chamber. This causes the peripheral iris to bulge forward (**iris bombé**), resulting in a **shallow anterior chamber** in that eye. The "hazy cornea" in the fellow eye is often due to inflammatory keratic precipitates or corneal edema. **Analysis of Incorrect Options:** * **Acute Congestive Glaucoma:** While this presents with a shallow anterior chamber and hazy cornea, it typically features a **mid-dilated, vertically oval pupil**, not a miotic one. * **Chronic Simple Glaucoma (POAG):** This is a silent, progressive disease characterized by a **normal/deep anterior chamber** and a normal-looking cornea. It does not present with acute haziness or pupillary changes. * **Endophthalmitis:** This is a devastating intraocular inflammation (usually post-surgical) presenting with severe pain, loss of vision, and hypopyon. While the cornea may be hazy, the specific combination of a shallow AC and miotic pupil in the fellow eye points more specifically to the structural sequelae of uveitis. **NEET-PG High-Yield Pearls:** * **Uveitis Pupil:** Characteristically **miotic** due to ciliary spasm and irritation. * **Glaucoma Pupil:** Characteristically **mid-dilated** due to sphincter ischemia. * **Iris Bombé:** Leads to secondary angle-closure glaucoma; the definitive treatment is **Laser Peripheral Iridotomy (LPI)**. * **Festooned Pupil:** An irregular pupil shape seen in uveitis after using mydriatics, caused by patchy posterior synechiae.

Q: Which of the following medications should not be used in a patient with acute angle-closure glaucoma associated with uveitis?

Pilocarpine. **Explanation:** In the management of glaucoma, the underlying etiology dictates the treatment. While **Pilocarpine** is a first-line miotic agent for primary acute angle-closure glaucoma (by pulling the iris away from the angle), it is **strictly contraindicated** in glaucoma secondary to **uveitis**. **Why Pilocarpine is contraindicated:** 1. **Blood-Aqueous Barrier:** Pilocarpine is a parasympathomimetic that increases inflammation by further breaking down the blood-aqueous barrier, worsening the uveitis. 2. **Posterior Synechiae:** Miosis (pupillary constriction) increases the surface area of contact between the iris and the lens, promoting the formation of posterior synechiae. This can lead to 360-degree synechiae (seclusio pupillae) and iris bombe, paradoxically worsening the angle closure. **Analysis of Incorrect Options:** * **Timolol (A):** A topical beta-blocker that reduces aqueous production. It is safe and commonly used in both primary and uveitic glaucoma. * **Atropine (C):** In uveitic glaucoma, cycloplegics like Atropine are actually indicated. They stabilize the blood-aqueous barrier, reduce pain by relieving ciliary spasm, and prevent synechiae by keeping the pupil dilated. * **Acetazolamide (D):** A systemic carbonic anhydrase inhibitor that rapidly lowers intraocular pressure by decreasing aqueous secretion. It is a standard emergency treatment for all types of acute pressure elevation. **NEET-PG High-Yield Pearls:** * **Drug of choice for Primary Acute Angle Closure:** Pilocarpine (after IOP is lowered). * **Drug of choice for Uveitic Glaucoma:** Topical steroids (to treat inflammation) and Cycloplegics (Atropine/Homatropine). * **Avoid in Uveitis:** Pilocarpine and Prostaglandin analogues (Latanoprost) as they are pro-inflammatory.

Q: A 63-year-old woman presents with a complaint of pain in her right eye. On examination, the pupil is dilated with a hazy cornea. What is the most likely diagnosis?

Acute angle closure glaucoma. **Explanation:** The clinical presentation of **Acute Angle Closure Glaucoma (AACG)** is a classic medical emergency frequently tested in NEET-PG. The diagnosis is based on the triad of sudden ocular pain, a **hazy (edematous) cornea**, and a **vertically oval, semi-dilated, non-reactive pupil**. The haziness is caused by a rapid rise in intraocular pressure (IOP) leading to corneal edema, while the pupil becomes fixed and dilated due to ischemia of the iris sphincter muscle. **Why the other options are incorrect:** * **Scleritis:** Presents with severe, boring pain and deep-seated redness, but the cornea remains clear and the pupil is normal in size and reaction. * **Anterior Uveitis:** Characterized by a **constricted (miotic) pupil** due to ciliary spasm and a clear cornea (though keratic precipitates may be seen on slit-lamp). * **Conjunctivitis:** A painless condition (or mild grittiness) with discharge. The cornea is clear, and the pupil reacts normally to light. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Hypermetropia (small eyes), shallow anterior chamber, and increasing age. * **Symptoms:** Halos around lights (due to corneal edema) and systemic symptoms like nausea/vomiting (often misdiagnosed as an abdominal issue). * **Gold Standard Diagnosis:** Gonioscopy (to visualize the closed angle). * **Immediate Management:** IV Acetazolamide and topical pilocarpine (once IOP drops). * **Definitive Treatment:** Peripheral Iridotomy (PI) – usually performed in both eyes as the fellow eye is at high risk.

Q: Which topical drug can cause Heterochromia Iridis?

Latanoprost. **Explanation:** **Latanoprost** is a Prostaglandin Analogue (PGA) used as a first-line treatment for Open-Angle Glaucoma. It causes **Heterochromia Iridis** (specifically hyperpigmentation) by increasing the production of melanin within the stromal melanocytes of the iris. It is important to note that this occurs due to increased melanogenesis, not an increase in the number of melanocytes (no hyperplasia). This change is usually permanent and most noticeable in individuals with hazel or multicolored eyes. **Analysis of Incorrect Options:** * **Timolol (Option A):** A non-selective beta-blocker. Its primary side effects are systemic (bradycardia, bronchospasm) and local (stinging, dry eye), but it does not affect iris pigmentation. * **Olopatadine (Option B):** An antihistamine and mast cell stabilizer used for allergic conjunctivitis. It has no role in glaucoma management or iris color changes. * **Brimonidine (Option C):** An alpha-2 agonist. Common side effects include follicular conjunctivitis and lethargy (especially in children), but it does not cause heterochromia. **High-Yield Clinical Pearls for NEET-PG:** 1. **PGA Side Effects (Mnemonic: "3 L's"):** **L**ashes (Hypertrichosis/lengthening), **L**ids (Pigmentation of periorbital skin), and **L**iris (Heterochromia). 2. **Prostaglandin-Associated Periorbitopathy (PAP):** PGAs can cause deepening of the upper eyelid sulcus and fat atrophy. 3. **Contraindication:** PGAs should be avoided in **Uveitic Glaucoma** as they are pro-inflammatory and can exacerbate cystoid macular edema (CME).

Question 1

Glaucoma is characterized by apoptosis of which of the following retinal cells?

Accepted Answer

Ganglion cells

Answer

Bipolar cells

Answer

Retinal pigment epithelium

Answer

Rods and Cones

Question 2

What is the most common symptom in buphthalmos?

Accepted Answer

Lacrimation

Answer

Pain

Answer

Photophobia

Answer

Itching

Question 3

Which of the following antiglaucoma medications is UNSAFE in infants?

Accepted Answer

Brimonidine

Answer

Timolol

Answer

Latanoprost

Answer

Dorzolamide

Question 4

What is the cause of a red, congested, painful eye with a mildly dilated, vertically oval pupil?

Accepted Answer

Acute congestive glaucoma

Answer

Anterior uveitis

Answer

Keratoconjunctivitis

Answer

Eale's disease

Question 5

What is the treatment of choice for congenital glaucoma with a corneal ulcer?

Accepted Answer

Trabeculotomy

Answer

Goniotomy

Answer

Miotics

Answer

Steroids

Question 6

Which of the following drugs is not associated with open-angle glaucoma?

Accepted Answer

Thiazide

Answer

Betamethasone

Answer

Docetaxel

Answer

Prednisone

Question 7

A patient presents with a normal anterior chamber and hazy cornea in one eye, and a shallow anterior chamber and miotic pupil in the fellow eye. What is the most likely diagnosis?

Accepted Answer

Acute anterior uveitis

Answer

Endophthalmitis

Answer

Acute congestive glaucoma

Answer

Chronic simple glaucoma

Question 8

Which of the following medications should not be used in a patient with acute angle-closure glaucoma associated with uveitis?

Accepted Answer

Pilocarpine

Answer

Timolol

Answer

Atropine

Answer

Acetazolamide

Question 9

A 63-year-old woman presents with a complaint of pain in her right eye. On examination, the pupil is dilated with a hazy cornea. What is the most likely diagnosis?

Accepted Answer

Acute angle closure glaucoma

Answer

Scleritis

Answer

Anterior uveitis

Answer

Conjunctivitis

Question 10

Which topical drug can cause Heterochromia Iridis?

Accepted Answer

Latanoprost

Answer

Timolol

Answer

Olopatadine

Answer

Brimonidine

Glaucoma — MCQs

Glaucoma — MCQs

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