Medical Management of Glaucoma — MCQs
Anti-glaucoma drug that acts by increasing uveoscleral outflow is
What is the best drug for open-angle glaucoma?
The α2 agonist used in glaucoma is:
Pilocarpine is used in all of the following except:
Beta-blockers should be used with caution in patients with?
Cardioselective β-blocker used in glaucoma?
What condition are miotics the treatment of choice for?
A patient has been diagnosed with Primary Open Angle Glaucoma (POAG). On eliciting history, it is observed that the patient is a known case of bronchial asthma. What is the drug of choice for POAG in this patient?
Which drug is contraindicated in angle-closure glaucoma?
What is the first-line treatment for acute angle closure glaucoma?
Medical Management of Glaucoma Indian Medical PG Practice Questions and MCQs
Question 1: Anti-glaucoma drug that acts by increasing uveoscleral outflow is
- A. Dorzolamide
- B. Latanoprost (Correct Answer)
- C. Pilocarpine
- D. Timolol
Explanation: ***Latanoprost*** - **Latanoprost** is a **prostaglandin F2α analog** that effectively lowers intraocular pressure by significantly increasing **uveoscleral outflow**. - It works by remodeling the extracellular matrix in the ciliary body and sclera, which facilitates the drainage of aqueous humor through the uveoscleral pathway. *Dorzolamide* - **Dorzolamide** is a **topical carbonic anhydrase inhibitor** that reduces the production of aqueous humor, thus lowering intraocular pressure. - It does not directly affect the uveoscleral outflow pathway. *Pilocarpine* - **Pilocarpine** is a **cholinergic agonist** that primarily works by increasing the **trabecular outflow** of aqueous humor through contraction of the ciliary muscle [1]. - It does not significantly influence the uveoscleral outflow pathway. *Timolol* - **Timolol** is a **beta-adrenergic blocker** that reduces aqueous humor production by the ciliary body [1]. - Its mechanism of action involves decreasing the formation, rather than increasing the outflow, of aqueous humor [1].
Question 2: What is the best drug for open-angle glaucoma?
- A. Latanoprost (Correct Answer)
- B. Pilocarpine
- C. Physostigmine
- D. Apraclonidine
Explanation: Latanoprost - Latanoprost is a prostaglandin analog and is often considered a first-line treatment for open-angle glaucoma due to its efficacy in reducing intraocular pressure (IOP) and its once-daily dosing. - It works by increasing the outflow of aqueous humor through the uveoscleral pathway, thereby lowering IOP. Pilocarpine - Pilocarpine is a cholinergic agonist that causes miosis and ciliary muscle contraction [3], increasing the outflow of aqueous humor through the trabecular meshwork [4]. - While effective, its side effects (e.g., accommodative spasm, miosis) [1] and more frequent dosing make it generally a second-line or third-line agent for long-term management compared to prostaglandins. Physostigmine - Physostigmine is an acetylcholinesterase inhibitor that indirectly increases acetylcholine, mimicking cholinergic stimulation. - Although it can lower IOP, it is generally not used for open-angle glaucoma due to significant side effects and the availability of safer, more effective alternatives [1]. Apraclonidine - Apraclonidine is an alpha-2 adrenergic agonist [2] used primarily for short-term control of IOP, especially before or after ocular surgery, or as an adjunct therapy. - Its efficacy as a long-term monotherapy for open-angle glaucoma is limited by tachyphylaxis and potential for significant systemic side effects with chronic use.
Question 3: The α2 agonist used in glaucoma is:
- A. Brimonidine (Correct Answer)
- B. Guanabenz
- C. Guanfacine
- D. Tizanidine
Explanation: ***Correct: Brimonidine*** - **Brimonidine** is an **α2-adrenergic agonist** commonly used in the treatment of glaucoma - It works by reducing **aqueous humor production** and increasing **uveoscleral outflow**, thereby lowering intraocular pressure - Available as eye drops (0.1%, 0.15%, 0.2% concentrations) *Incorrect: Guanfacine* - **Guanfacine** is an **α2A-adrenergic agonist** primarily used to treat **attention deficit hyperactivity disorder (ADHD)** and **hypertension** - It does not have a primary role in glaucoma treatment *Incorrect: Guanabenz* - **Guanabenz** is an **α2-adrenergic agonist** that acts centrally to reduce **sympathetic outflow**, used mainly as an **antihypertensive agent** - It is not indicated for the treatment of glaucoma *Incorrect: Tizanidine* - **Tizanidine** is an **α2-adrenergic agonist** primarily used as a **muscle relaxant** to manage spasticity - It is not used for glaucoma
Question 4: Pilocarpine is used in all of the following except:
- A. Primary, Open Angle Glaucoma
- B. Acute Angle Closure Glaucoma
- C. Malignant Glaucoma (Correct Answer)
- D. Chronic Synechial Angle Closure Glaucoma
Explanation: ***Malignant Glaucoma*** - **Pilocarpine** is contraindicated in **malignant glaucoma** because it can worsen the condition by causing **ciliary body edema** and anterior displacement of the lens-iris diaphragm. - This form of glaucoma requires treatment aimed at posterior displacement of the lens-iris diaphragm, often involving **cycloplegics**, **hyperosmotic agents**, or surgical interventions. *Primary, Open Angle Glaucoma* - **Pilocarpine** is an effective **miotic agent** that increases aqueous humor outflow through the **trabecular meshwork**, thereby lowering intraocular pressure. - It can be used as a treatment for **primary open-angle glaucoma**, although it is less commonly used due to its side effects and the availability of better-tolerated medications. *Acute Angle Closure Glaucoma* - **Pilocarpine** is typically used in the management of **acute angle-closure glaucoma** after the intraocular pressure has been acutely lowered by other agents. - It works by inducing **miosis**, which pulls the iris away from the **trabecular meshwork**, opening the angle and facilitating aqueous outflow. *Chronic Synechial Angle Closure Glaucoma* - In **chronic synechial angle-closure glaucoma**, **pilocarpine** can be used to break or prevent the formation of new **peripheral anterior synechiae** by constricting the pupil. - However, its effectiveness is limited if extensive synechiae have already formed, as these physically block the outflow pathway.
Question 5: Beta-blockers should be used with caution in patients with?
- A. Hypertension
- B. CHF
- C. Conduction defect (Correct Answer)
- D. Glaucoma
Explanation: ***Conduction defect*** - Beta-blockers **slow heart rate** and **decrease AV nodal conduction**, which can worsen pre-existing conduction defects like **AV block** or **sick sinus syndrome**. - Their use can lead to **symptomatic bradycardia** or complete heart block in susceptible individuals. - This represents a **strong relative contraindication** requiring significant caution. *Hypertension* - Beta-blockers are a **first-line treatment for hypertension**, effectively lowering blood pressure by reducing cardiac output and renin release. - They are generally **well-tolerated** and beneficial in most hypertensive patients. *Glaucoma* - Topical beta-blockers, such as **timolol**, are a common treatment for open-angle glaucoma as they **reduce aqueous humor production**, thereby lowering intraocular pressure. - Systemic use of beta-blockers does not typically worsen glaucoma and may even offer some benefit. *CHF* - While certain beta-blockers (**carvedilol, metoprolol succinate, bisoprolol**) are now proven beneficial in **chronic heart failure with reduced ejection fraction (HFrEF)**, they do require careful use. - They must be **initiated at low doses and carefully titrated** to avoid acute decompensation, and are **contraindicated in acute decompensated heart failure**. - However, **conduction defects** represent a **stronger contraindication** where beta-blockers can cause life-threatening bradycardia or complete heart block, making it the best answer for conditions requiring the most caution.
Question 6: Cardioselective β-blocker used in glaucoma?
- A. Timolol
- B. Betaxolol (Correct Answer)
- C. Acebutalol
- D. Carvedilol
Explanation: ***Betaxolol*** - **Betaxolol** is a **cardioselective β1-adrenergic receptor blocker** that reduces aqueous humor production, making it suitable for glaucoma patients, especially those with pulmonary disease. - Its **selectivity for β1 receptors** minimizes systemic side effects on the lungs (bronchoconstriction) compared to non-selective β-blockers. *Timolol* - **Timolol** is a **non-selective β-blocker** commonly used in glaucoma to reduce intraocular pressure. - It blocks both **β1 and β2 receptors**, which can lead to systemic side effects like bronchoconstriction and bradycardia, making it less suitable for patients with **asthma or COPD**. *Acebutalol* - **Acebutalol** is a **cardioselective β1-blocker** with **intrinsic sympathomimetic activity (ISA)**, primarily used for hypertension and arrhythmias. - While cardioselective, it is **not commonly formulated or indicated for topical ocular use** in glaucoma. *Carvedilol* - **Carvedilol** is a **non-selective β-blocker** with **alpha-1 adrenergic blocking activity**, primarily used for heart failure and hypertension. - It is **not used for glaucoma** as it is not formulated for topical ophthalmic application and its systemic effects are not ideal for this purpose.
Question 7: What condition are miotics the treatment of choice for?
- A. Angle closure glaucoma
- B. Open-angle glaucoma (Correct Answer)
- C. Buphthalmos
- D. Sympathetic ophthalmia
Explanation: ***Open-angle glaucoma*** - Miotics, such as **pilocarpine**, are a classical treatment option for **primary open-angle glaucoma (POAG)**. - They work by **contracting the ciliary muscle**, which opens up the **trabecular meshwork** and increases aqueous humor outflow. - This results in **reduction of intraocular pressure (IOP)**, the primary goal in glaucoma management. - Though less commonly used today due to side effects (brow ache, miosis affecting vision), they remain effective and are particularly useful in patients who cannot tolerate other medications. *Angle closure glaucoma* - Miotics are **contraindicated in acute angle-closure glaucoma** as they can worsen pupillary block during the acute attack. - The initial treatment involves **IOP-lowering agents, systemic medications, and laser iridotomy**, not miotics. - Miotics may have a limited role in chronic angle closure after definitive treatment, but they are NOT the treatment of choice. *Buphthalmos* - This refers to **enlargement of the eyeball** in infants due to congenital glaucoma. - Management primarily involves **surgical intervention** (goniotomy, trabeculotomy) to address the developmental anomalies of the drainage angle. - Medical management alone, including miotics, is insufficient. *Sympathetic ophthalmia* - A rare **bilateral granulomatous panuveitis** following penetrating trauma or surgery to one eye. - Treated with **corticosteroids and immunosuppressive agents**. - Miotics have no role in managing this inflammatory condition.
Question 8: A patient has been diagnosed with Primary Open Angle Glaucoma (POAG). On eliciting history, it is observed that the patient is a known case of bronchial asthma. What is the drug of choice for POAG in this patient?
- A. Gemeprost
- B. Alprostadil
- C. Latanoprost (Correct Answer)
- D. Carboprost
Explanation: ***Latanoprost*** - **Latanoprost** is a **prostaglandin analog** and is considered a **first-line drug of choice** for POAG due to its excellent efficacy and tolerability profile, especially in patients with **bronchial asthma**. - It works by increasing the **uveoscleral outflow** of aqueous humor, thus lowering **intraocular pressure** without causing systemic effects like bronchoconstriction. *Gemeprost* - **Gemeprost** is a **prostaglandin E1 analog** primarily used for **cervical ripening** and **abortion**, not for glaucoma treatment. - It has no role in managing **intraocular pressure** and would be an inappropriate choice for POAG. *Alprostadil* - **Alprostadil** is another **prostaglandin E1 analog** used for **erectile dysfunction** and maintaining **patency of the ductus arteriosus** in neonates. - It does not lower **intraocular pressure** and is not indicated for the treatment of glaucoma. *Carboprost* - **Carboprost** is a **prostaglandin F2α analog** mainly used to **manage postpartum hemorrhage** due to its potent uterotonic effects. - While it is a prostaglandin, it is not used in the treatment of glaucoma and has significant systemic side effects.
Question 9: Which drug is contraindicated in angle-closure glaucoma?
- A. Atropine (Correct Answer)
- B. Pilocarpine
- C. Timolol
- D. Dorzolamide
Explanation: ***Atropine*** - **Atropine** is an **anticholinergic** agent that causes **mydriasis** (pupil dilation) by blocking muscarinic receptors in the iris sphincter muscle. - In angle-closure glaucoma, pupillary dilation can narrow the **anterior chamber angle**, preventing aqueous humor outflow and acutely increasing **intraocular pressure**. *Pilocarpine* - **Pilocarpine** is a **muscarinic agonist** that causes **miosis** (pupil constriction) and contraction of the ciliary muscle, widening the anterior chamber angle. - This action facilitates **aqueous humor outflow**, making it a treatment for, not contraindicated in, angle-closure glaucoma. *Timolol* - **Timolol** is a **beta-blocker** that reduces aqueous humor production, thereby lowering intraocular pressure. - It does not significantly affect pupil size or the anterior chamber angle, making it a safe and effective treatment for various forms of glaucoma, including open-angle. *Dorzolamide* - **Dorzolamide** is a **carbonic anhydrase inhibitor** that reduces aqueous humor production. - Like timolol, it primarily acts to lower intraocular pressure without affecting pupil size or the anterior chamber angle, making it suitable for glaucoma treatment.
Question 10: What is the first-line treatment for acute angle closure glaucoma?
- A. Pilocarpine
- B. Beta blocker eyedrops
- C. IV mannitol
- D. Acetazolamide (Correct Answer)
Explanation: **Acetazolamide** - **Acetazolamide** (oral or intravenous) is a carbonic anhydrase inhibitor that rapidly reduces intraocular pressure by decreasing aqueous humor production, making it the **first-line medical treatment** for acute angle-closure glaucoma. - While other agents are used, acetazolamide provides the quickest and most significant initial reduction in **intraocular pressure (IOP)**, which is crucial in preventing permanent vision loss. *IV mannitol* - **Intravenous mannitol** is an osmotic diuretic used to draw fluid from the vitreous humor to lower **IOP** significantly, but it is typically reserved for cases where **acetazolamide** alone is insufficient or for very high **IOPs**. - It is often considered a second-line or adjunctive agent rather than the initial first-line treatment. *Pilocarpine* - **Pilocarpine** is a miotic agent that constricts the pupil, which helps to pull the iris away from the trabecular meshwork and open the angle. - However, it should only be administered *after* the **intraocular pressure** has been significantly lowered (e.g., with acetazolamide), as it can worsen angle closure in an inflamed eye with very high **IOP**. *Beta blocker eyedrops* - **Topical beta-blockers** (e.g., timolol) reduce **IOP** by decreasing aqueous humor production and are a common treatment for various types of glaucoma. - While useful in acute angle-closure glaucoma, they act more slowly than **acetazolamide** and are typically used as an adjunct rather than the sole initial first-line treatment.
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