Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 91: Glaucoma is characterized by apoptosis of which of the following retinal cells?

A. Bipolar cells
B. Ganglion cells (Correct Answer)
C. Retinal pigment epithelium
D. Rods and Cones

Explanation: **Explanation:** **Glaucoma** is defined as a progressive optic neuropathy characterized by structural changes in the optic disc and corresponding visual field defects. The fundamental pathological process in glaucoma is the **apoptosis (programmed cell death) of Retinal Ganglion Cells (RGCs)**. 1. **Why Ganglion Cells are correct:** The axons of the retinal ganglion cells converge to form the **optic nerve**. In glaucoma, increased intraocular pressure (IOP) or vascular insufficiency leads to mechanical and ischemic stress at the lamina cribrosa. This triggers a cascade of events—including glutamate excitotoxicity and neurotrophic factor deprivation—that results in the selective apoptosis of RGCs. The loss of these cells leads to thinning of the Retinal Nerve Fiber Layer (RNFL) and the characteristic "cupping" of the optic disc. 2. **Why other options are incorrect:** * **Bipolar cells:** These are secondary neurons that relay signals from photoreceptors to ganglion cells. While they may undergo trans-synaptic degeneration in advanced stages, they are not the primary site of damage. * **Retinal Pigment Epithelium (RPE):** These cells support photoreceptors and are primarily involved in conditions like Age-Related Macular Degeneration (ARMD). * **Rods and Cones:** These are the primary photoreceptors. Their death is characteristic of Retinitis Pigmentosa or retinal detachment, not the primary pathology of glaucoma. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of Glaucoma:** The earliest structural change is often **RNFL thinning**, while the earliest functional change is often detected via **Short-Wavelength Automated Perimetry (SWAP)**. * **ISNT Rule:** In a healthy disc, the neuroretinal rim thickness follows the order Inferior > Superior > Nasal > Temporal. Glaucoma often causes a **breach of the ISNT rule** (Inferior and Superior thinning occurs first). * **Mechanism:** Apoptosis is the "quiet" death of cells without inflammation, distinguishing it from necrosis.

Question 92: What is the most common symptom in buphthalmos?

A. Lacrimation (Correct Answer)
B. Pain
C. Photophobia
D. Itching

Explanation: **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.

Question 93: What is the earliest field defect in primary open-angle glaucoma?

A. Reidel's scotoma
B. Scotoma in Bjerrum's field (Correct Answer)
C. Arcuate scotoma
D. Nasal spur

Explanation: 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.

Question 94: Which of the following is a steroid-induced ocular complication?

A. Glaucoma
B. Papilledema
C. Central retinal vein occlusion
D. All of the above (Correct Answer)

Explanation: **Explanation:** Corticosteroids, whether administered topically, periocularly, or systemically, can lead to several significant ocular complications. The correct answer is **All of the above** because steroids affect multiple ocular structures and physiological processes. 1. **Glaucoma (Steroid-Induced):** This is the most well-known complication. Steroids increase the resistance to aqueous outflow by causing structural changes in the trabecular meshwork (increased deposition of glycosaminoglycans and expression of the *MYOC* gene/TIGR protein). This leads to elevated Intraocular Pressure (IOP), typically occurring 2–6 weeks after starting therapy. 2. **Papilledema:** Systemic steroid use (or more commonly, steroid withdrawal) is a recognized cause of **Pseudotumor Cerebri** (Idiopathic Intracranial Hypertension). This elevation in intracranial pressure manifests clinically as bilateral optic disc swelling, or papilledema. 3. **Central Retinal Vein Occlusion (CRVO):** While not a direct pharmacological effect, steroids induce secondary risk factors for CRVO. Specifically, steroid-induced ocular hypertension/glaucoma is a major risk factor for retinal vein occlusions. Additionally, systemic steroids can contribute to a pro-thrombotic state and hypertension, further increasing the risk of CRVO. **High-Yield Clinical Pearls for NEET-PG:** * **Cataract:** Steroids classically cause **Posterior Subcapsular Cataracts (PSC)**. * **Steroid Responders:** Approximately 5–10% of the general population are "high responders" (IOP rise >15 mmHg). This risk is significantly higher in patients with Primary Open Angle Glaucoma (POAG) and their first-degree relatives. * **Drug Potency:** Topical Dexamethasone and Prednisolone have a higher propensity to raise IOP compared to "soft steroids" like **Loteprednol** or **Fluorometholone**. * **Infections:** Steroids can exacerbate viral (Herpetic dendritic ulcers) and fungal keratitis by suppressing the local immune response.

Question 95: What is the treatment of choice for the other eye in open-angle glaucoma?

A. Trabeculectomy
B. Laser iridotomy
C. Laser trabeculoplasty (Correct Answer)
D. Peripheral iridectomy

Explanation: ### Explanation In **Primary Open-Angle Glaucoma (POAG)**, the pathology lies in increased resistance to aqueous outflow through the trabecular meshwork, despite an open anterior chamber angle. **Why Laser Trabeculoplasty is correct:** Laser Trabeculoplasty (specifically **Selective Laser Trabeculoplasty or SLT**) is increasingly considered a first-line treatment or a primary choice for the fellow eye in POAG. It works by applying laser energy to the trabecular meshwork, which stimulates cellular activity and remodeling, thereby increasing aqueous outflow and reducing Intraocular Pressure (IOP). It is preferred because it is non-invasive, has a high safety profile, and avoids the compliance issues associated with lifelong topical medications. **Why other options are incorrect:** * **Laser Iridotomy (B) and Peripheral Iridectomy (D):** These are the treatments of choice for **Angle-Closure Glaucoma**. They work by creating a bypass between the posterior and anterior chambers to relieve pupillary block. They have no role in POAG where the angle is already open. * **Trabeculectomy (A):** This is a surgical "filtering" procedure. While highly effective, it is generally reserved for cases where medical therapy and laser treatment have failed to control IOP or when the disease is advanced. It is not the initial "treatment of choice" for a stable fellow eye due to risks of infection (endophthalmitis) and cataracts. **High-Yield Clinical Pearls for NEET-PG:** * **SLT vs. ALT:** Selective Laser Trabeculoplasty (SLT) uses a YAG laser and is repeatable because it causes minimal thermal damage, whereas Argon Laser Trabeculoplasty (ALT) causes structural scarring. * **Drug of Choice (Medical):** Prostaglandin analogues (e.g., Latanoprost) are the first-line medical treatment for POAG. * **Gold Standard for Diagnosis:** Diurnal variation of IOP and visual field analysis (HFA). * **Key Distinction:** Always check the "angle" status. If the question says "Open-Angle," think Trabeculoplasty; if "Closed-Angle," think Iridotomy.

Question 96: Which of the following antiglaucoma medications is UNSAFE in infants?

A. Timolol
B. Brimonidine (Correct Answer)
C. Latanoprost
D. Dorzolamide

Explanation: **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.

Question 97: What is the cause of a red, congested, painful eye with a mildly dilated, vertically oval pupil?

A. Acute congestive glaucoma (Correct Answer)
B. Anterior uveitis
C. Keratoconjunctivitis
D. Eale's disease

Explanation: ### 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.

Question 98: Each of the following conditions may produce visual field defects similar to those seen in glaucoma, except?

A. Chronic papilledema
B. Optic disc drusen
C. Anterior ischemic optic neuropathy (AION)
D. Occipital infarction (Correct Answer)

Explanation: **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.

Question 99: What is the treatment of choice for congenital glaucoma with a corneal ulcer?

A. Trabeculotomy (Correct Answer)
B. Goniotomy
C. Miotics
D. Steroids

Explanation: **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.

Question 100: Which of the following drugs is not associated with open-angle glaucoma?

A. Betamethasone
B. Docetaxel
C. Prednisone
D. Thiazide (Correct Answer)

Explanation: **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.

Practice by Chapter

Aqueous Humor Dynamics

Practice Questions

Primary Open-Angle Glaucoma

Practice Questions

Primary Angle-Closure Glaucoma

Practice Questions

Secondary Open-Angle Glaucomas

Practice Questions

Secondary Angle-Closure Glaucomas

Practice Questions

Developmental and Congenital Glaucomas

Practice Questions

Medical Management of Glaucoma

Practice Questions

Laser Therapy in Glaucoma

Practice Questions

Glaucoma Filtration Surgery

Practice Questions

Glaucoma Drainage Devices

Practice Questions

Angle Assessment Techniques

Practice Questions

Visual Field Testing in Glaucoma

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free

Glaucoma — MCQs

Glaucoma — MCQs

On this page

Practice by Chapter

Want unlimited practice?