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: What is the earliest field defect in primary open-angle glaucoma?

Scotoma in Bjerrum's field. In Primary Open-Angle Glaucoma (POAG), visual field defects follow a characteristic sequence due to the specific anatomy of the retinal nerve fiber layer (RNFL). ### **Explanation of the Correct Answer** The earliest clinically detectable field defects in POAG are **small, isolated paracentral scotomas** located typically between 10° and 20° from fixation. These scotomas occur within **Bjerrum’s area** (the arcuate area of the field). As the disease progresses, these isolated spots coalesce to form more advanced defects. Therefore, a scotoma in Bjerrum's field is the earliest sign. ### **Analysis of Incorrect Options** * **A. Seidel’s scotoma:** This is an evolution of the paracentral scotoma. It occurs when the initial scotoma enlarges and reaches the blind spot, becoming sickle-shaped. It is a later stage than a simple paracentral scotoma. * **C. Arcuate scotoma:** Also known as a Bjerrum scotoma, this is a late-stage defect formed by the total coalescence of scotomas in the arcuate area, extending from the blind spot around the fixation point to the horizontal meridian. * **D. Nasal spur:** This is likely a distractor term. The correct term is **Roenne’s Nasal Step**, which occurs when arcuate fibers meet at the horizontal raphe, creating a step-like defect in the nasal field. ### **High-Yield Clinical Pearls for NEET-PG** * **Sequence of Defects:** Paracentral scotoma (Earliest) → Seidel’s scotoma → Arcuate/Bjerrum scotoma → Ring/Double Arcuate scotoma → Tubular vision → Total blindness. * **Isopter contraction:** While "generalized depression" of the field is technically the very first change, it is non-specific. Paracentral scotoma is the earliest *pathognomonic* defect. * **10-20 Degrees:** This is the most sensitive area (Bjerrum’s area) for early glaucomatous damage. * **Fixation:** Central vision (tubular vision) is often preserved until the end stages of glaucoma.

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: Each of the following conditions may produce visual field defects similar to those seen in glaucoma, except?

Occipital infarction. **Explanation:** The core concept in this question is distinguishing between **pre-chiasmal** (nerve fiber layer/optic nerve) and **post-chiasmal** (visual pathway) lesions. Glaucomatous field defects (like arcuate scotomas, nasal steps, and Bjerrum’s scotoma) are caused by damage to the retinal nerve fiber layer (RNFL). **Why Occipital Infarction is the Correct Answer:** Occipital lobe lesions produce **post-chiasmal** defects, typically characterized by **congruous homonymous hemianopia** with or without macular sparing. These defects respect the vertical midline and involve both eyes' visual fields in a symmetric pattern. They do not follow the arcuate distribution of the RNFL, making them distinct from glaucomatous defects. **Analysis of Incorrect Options:** * **Chronic Papilledema:** Long-standing swelling leads to axonal loss. It commonly presents with enlarged blind spots and can progress to arcuate defects and peripheral field constriction, mimicking glaucoma. * **Optic Disc Drusen:** These hyaline deposits compress the optic nerve fibers, frequently causing nerve fiber bundle defects such as arcuate scotomas and nasal steps. * **Anterior Ischemic Optic Neuropathy (AION):** This condition typically presents with an **altitudinal defect** (usually inferior), which is also a classic (though advanced) finding in glaucoma. **High-Yield Clinical Pearls for NEET-PG:** * **Glaucoma mimics:** Always rule out "Pseudo-glaucoma" (e.g., Drusen, Myopic crescents, or AION) if the Intraocular Pressure (IOP) is normal but fields are defective. * **The Vertical Midline:** Defects that respect the vertical midline are almost always neurological (post-chiasmal); glaucoma defects respect the **horizontal midline** (nasal step). * **Congruity:** The more posterior the lesion (e.g., Occipital lobe), the more identical (congruous) the field defects are in both eyes.

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.

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

What is the earliest field defect in primary open-angle glaucoma?

Accepted Answer

Scotoma in Bjerrum's field

Answer

Reidel's scotoma

Answer

Arcuate scotoma

Answer

Nasal spur

Question 4

Which of the following is a steroid-induced ocular complication?

Accepted Answer

All of the above

Answer

Glaucoma

Answer

Papilledema

Answer

Central retinal vein occlusion

Question 5

What is the treatment of choice for the other eye in open-angle glaucoma?

Accepted Answer

Laser trabeculoplasty

Answer

Trabeculectomy

Answer

Laser iridotomy

Answer

Peripheral iridectomy

Question 6

Which of the following antiglaucoma medications is UNSAFE in infants?

Accepted Answer

Brimonidine

Answer

Timolol

Answer

Latanoprost

Answer

Dorzolamide

Question 7

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 8

Each of the following conditions may produce visual field defects similar to those seen in glaucoma, except?

Accepted Answer

Occipital infarction

Answer

Chronic papilledema

Answer

Optic disc drusen

Answer

Anterior ischemic optic neuropathy (AION)

Question 9

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

Accepted Answer

Trabeculotomy

Answer

Goniotomy

Answer

Miotics

Answer

Steroids

Question 10

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

Accepted Answer

Thiazide

Answer

Betamethasone

Answer

Docetaxel

Answer

Prednisone

Glaucoma — MCQs

Glaucoma — MCQs

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