Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 111: What is the most reliable provocative test for angle-closure glaucoma?

A. Homatropine mydriatic test
B. Mydriatic-miotic test
C. Water drinking test
D. Dark room test (Correct Answer)

Explanation: **Explanation:** The **Dark Room Test** is considered the most reliable and physiological provocative test for primary angle-closure glaucoma (PACG). **1. Why the Dark Room Test is Correct:** The underlying mechanism is **physiological mydriasis**. When a patient is placed in a dark room for 60–90 minutes, the pupils dilate naturally. This causes the peripheral iris to become flaccid and bunch up at the filtration angle, potentially obstructing the trabecular meshwork in predisposed eyes (narrow angles). A rise in Intraocular Pressure (IOP) of **>8 mmHg** is considered a positive result. It is preferred because it avoids the use of drugs that might cause an irreversible attack. **2. Analysis of Incorrect Options:** * **Homatropine Mydriatic Test:** While it induces mydriasis, it is pharmacological and carries a higher risk of precipitating an acute congestive attack that is difficult to reverse, making it less "safe" than physiological tests. * **Mydriatic-Miotic Test:** This involves alternating drugs to stress the angle. It is rarely used clinically and is less reliable than simple dark-room provocation. * **Water Drinking Test:** This is a provocative test for **Open-Angle Glaucoma (POAG)**, not angle-closure. It tests the outflow facility by inducing transient hypervolemia and hemodilution. **3. High-Yield Clinical Pearls for NEET-PG:** * **Prone Position Test:** Another physiological test where the patient lies face down for 1 hour; the lens moves forward due to gravity, narrowing the angle. * **Combined Test:** The Dark Room Prone Position Test is often cited as having the highest sensitivity. * **Gold Standard for Diagnosis:** While provocative tests are historical/academic, **Gonioscopy** remains the gold standard for visualizing and diagnosing a closed angle. * **Definitive Treatment:** For angle closure, the treatment of choice is **Laser Peripheral Iridotomy (LPI)**.

Question 112: A middle-aged patient is referred to rule out open angle glaucoma. Which of the following findings will help in the diagnosis?

A. Cupping of the optic disc (Correct Answer)
B. Depth of the anterior chamber
C. Visual acuity and refractive error
D. Angle of the anterior chamber

Explanation: **Explanation:** Primary Open-Angle Glaucoma (POAG) is a chronic, progressive optic neuropathy characterized by specific morphological changes in the optic nerve head and corresponding visual field defects, occurring in the presence of an open iridocorneal angle. **Why Option A is Correct:** **Cupping of the optic disc** is a hallmark structural sign of glaucomatous damage. It occurs due to the loss of the neuroretinal rim and the backward bowing of the lamina cribrosa. In the diagnosis of POAG, identifying structural damage (pathological cupping, such as a cup-disc ratio >0.7 or asymmetry >0.2) and functional loss (visual field defects) is essential, as Intraocular Pressure (IOP) alone is no longer the sole diagnostic criterion. **Why Other Options are Incorrect:** * **Option B & D:** The **depth and angle of the anterior chamber** are used to *classify* the type of glaucoma (Open-angle vs. Angle-closure) rather than diagnose the presence of the disease itself. In POAG, the angle must be open (Grade 3 or 4 on Shaffer’s grading) and the chamber depth is typically normal. * **Option C:** **Visual acuity** is usually preserved until the very late stages of POAG. While high myopia is a risk factor for POAG, refractive error is not a diagnostic finding for the disease. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign:** The earliest clinical sign of POAG is often an increase in the **Cup-Disc Ratio (CDR)** or focal thinning of the neuroretinal rim (ISNT rule violation). * **Gold Standard for Angle:** **Gonioscopy** is the gold standard to differentiate between open and closed angles. * **Gold Standard for IOP:** **Goldmann Applanation Tonometry (GAT)**. * **Earliest Visual Field Defect:** Small isolated paracentral scotomas (specifically, the **Baring of the Blind Spot** is often cited as an early sign, though **Siedel’s scotoma** is the first clinically significant functional defect).

Question 113: What is the drug of choice for the treatment of an acute attack of primary angle-closure glaucoma?

A. Mannitol
B. Latanoprost
C. Pilocarpine (Correct Answer)
D. Acetazolamide

Explanation: **Explanation:** Primary Angle-Closure Glaucoma (PACG) is a medical emergency characterized by a sudden rise in intraocular pressure (IOP) due to the apposition of the iris against the trabecular meshwork. **Why Pilocarpine is the Correct Answer:** Pilocarpine, a direct-acting miotic, is the definitive pharmacological treatment for an acute attack. It causes **miosis** (contraction of the sphincter pupillae), which pulls the peripheral iris away from the trabecular meshwork, thereby "opening" the angle and allowing aqueous humor to drain. *Note:* In very high IOP (>40-50 mmHg), the iris sphincter becomes ischemic and unresponsive to pilocarpine. Therefore, IOP must often be lowered initially with systemic agents before pilocarpine becomes effective. **Analysis of Incorrect Options:** * **Mannitol (A):** An osmotic diuretic used to rapidly reduce IOP by dehydrating the vitreous. While highly effective for immediate pressure reduction, it does not address the underlying anatomical closure of the angle. * **Latanoprost (B):** A Prostaglandin analogue used as the first-line treatment for *Open-Angle Glaucoma*. It is generally avoided in acute angle closure as it may worsen inflammation and takes 24 hours to reach peak effect. * **Acetazolamide (D):** A carbonic anhydrase inhibitor that decreases aqueous production. It is used as an initial systemic adjunct to lower IOP but is not the definitive drug to reverse the mechanical angle closure. **High-Yield Clinical Pearls for NEET-PG:** * **Definitive Treatment:** The gold standard definitive management for PACG is **Peripheral Iridotomy (Laser or Surgical)** to prevent recurrence. * **The "Mid-Dilated" Pupil:** An acute attack typically presents with a vertically oval, non-reactive, mid-dilated pupil. * **Avoid Atropine:** Mydriatics are strictly contraindicated as they further crowd the angle and can precipitate an attack.

Question 114: What is the definitive treatment for primary angle closure glaucoma?

A. Trabeculectomy
B. Pilocarpine
C. Timolol
D. Iridectomy (Correct Answer)

Explanation: ### Explanation **1. Why Iridectomy is the Correct Answer:** The primary underlying mechanism of **Primary Angle Closure Glaucoma (PACG)** is **pupillary block**. This occurs when the iris remains in close contact with the lens, obstructing the flow of aqueous humor from the posterior to the anterior chamber. This leads to increased pressure in the posterior chamber, causing the peripheral iris to bulge forward (**iris bombe**) and block the drainage angle. **Peripheral Iridectomy** (surgical) or **Laser Peripheral Iridotomy (LPI)** is the definitive treatment because it creates a permanent bypass channel between the posterior and anterior chambers. This equalizes the pressure gradient, flattens the iris, and opens the drainage angle, addressing the root cause of the pathology. **2. Analysis of Incorrect Options:** * **Trabeculectomy (A):** This is a filtration surgery used for Primary Open Angle Glaucoma (POAG) or refractory cases. It is not the first-line definitive treatment for PACG unless the angle is permanently closed by synechiae and medical/iridotomy treatments fail. * **Pilocarpine (B):** This is a miotic agent used to pull the iris away from the angle. While it is a crucial part of the *initial medical management* to lower IOP, it is not "definitive" as it does not prevent future attacks once the drug effect wears off. * **Timolol (C):** A beta-blocker that reduces aqueous production. It helps in the acute management of high IOP but does not address the anatomical pupillary block. **3. High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for Acute Attack:** Intravenous **Mannitol** (to rapidly dehydrate the vitreous) or Acetazolamide. * **Prophylaxis:** Since PACG is often a bilateral anatomical predisposition, the fellow eye must always undergo **prophylactic Laser Peripheral Iridotomy**. * **Gold Standard Diagnosis:** **Gonioscopy** is essential to visualize the angle and confirm closure. * **Classic Presentation:** Mid-dilated, vertically oval, non-reactive pupil with a "steamy" cornea and severe ocular pain.

Question 115: Which drug can cause acute angle closure glaucoma due to ciliochoroidal effusion?

A. Amiodarone
B. Topiramate (Correct Answer)
C. Chlorpromazine
D. Allopurinol

Explanation: **Explanation:** **Topiramate** (an antiepileptic and migraine prophylactic drug) is a classic cause of **secondary bilateral acute angle-closure glaucoma**. Unlike primary angle closure, which is caused by pupillary block, Topiramate induces a **ciliochoroidal effusion**. This effusion causes the ciliary body to swell and rotate anteriorly, leading to the forward displacement of the lens-iris diaphragm. This mechanically narrows the anterior chamber angle, precipitating acute glaucoma. **Analysis of Options:** * **Topiramate (Correct):** It typically presents within the first 2 weeks of starting the medication. It is often associated with **acute-onset myopia** (due to forward lens displacement). Management involves immediate discontinuation of the drug and using cycloplegics (to pull the ciliary body back); notably, miotics like Pilocarpine are contraindicated as they worsen the condition. * **Amiodarone:** Primarily associated with **vortex keratopathy** (corneal verticillata) and optic neuropathy, but not ciliochoroidal effusion. * **Chlorpromazine:** Known for causing **anterior subcapsular lens opacities** and corneal deposits (star-shaped) after long-term use. * **Allopurinol:** Can be associated with the development of cataracts but does not cause acute angle closure. **High-Yield NEET-PG Pearls:** 1. **Mechanism:** Topiramate = Ciliochoroidal effusion → Forward displacement of lens → Secondary angle closure. 2. **Key Sign:** Sudden onset **bilateral** myopia (up to 6-8 Diopters). 3. **Treatment Contrast:** In Topiramate-induced glaucoma, **avoid Pilocarpine** and Peripheral Iridotomy (LPI); instead, use **Atropine** and steroids. 4. **Other drugs** causing similar effusion: Sulfonamides, Acetazolamide, and Hydrochlorothiazide.

Question 116: A young woman presents with a red eye and pain above the eye. She describes several episodes of a red, painful eye that resolve with sleep. Examination reveals an irregular pupil. This presentation is more consistent with which of the following conditions?

A. Iridocyclitis (Correct Answer)
B. Conjunctivitis
C. Keratitis sicca
D. Chronic open-angle glaucoma

Explanation: **Explanation:** The clinical presentation of a red, painful eye associated with an **irregular pupil** is a classic hallmark of **Iridocyclitis** (Anterior Uveitis). The pain is typically a deep ache, often radiating to the periorbital region, caused by ciliary muscle spasm. The "irregular pupil" occurs due to the formation of **posterior synechiae** (adhesions between the iris and the lens capsule). The resolution of symptoms with sleep is a characteristic feature, as sleep-induced miosis and lack of accommodative effort can temporarily relieve ciliary spasm. **Analysis of Incorrect Options:** * **Conjunctivitis:** Presents with redness and discharge, but the pupil is always normal, and there is no deep ocular pain or photophobia. * **Keratitis sicca (Dry Eye):** Typically presents with a foreign body sensation, grittiness, and dryness. It does not cause an irregular pupil or severe episodes of pain. * **Chronic Open-Angle Glaucoma (COAG):** This is a "silent killer" of vision. It is typically painless and asymptomatic until advanced stages, with a normal-looking eye and pupil in the early phases. **Clinical Pearls for NEET-PG:** * **Miosis vs. Mydriasis:** In acute iridocyclitis, the pupil is typically small (miotic) and sluggish due to sphincter spasm, becoming irregular once synechiae form. In contrast, **Acute Congestive Glaucoma** presents with a vertically oval, semi-dilated, non-reactive pupil. * **Keratic Precipitates (KPs):** These are inflammatory cells on the corneal endothelium, a pathognomonic sign of iridocyclitis. * **Aqueous Flare/Cells:** Essential for grading the severity of inflammation via slit-lamp examination.

Question 117: Which of the following medications is contraindicated in glaucoma?

A. Atropine (Correct Answer)
B. Pilocarpine
C. Timolol maleate
D. Latanoprost

Explanation: **Explanation:** **Why Atropine is the Correct Answer:** Atropine is a potent **muscarinic antagonist (anticholinergic)** that causes **mydriasis** (dilation of the pupil) and **cycloplegia** (paralysis of the ciliary muscle). In patients with narrow anterior chamber angles, mydriasis causes the iris tissue to bunch up in the periphery, further crowding the angle and obstructing the outflow of aqueous humor through the trabecular meshwork. This can precipitate an episode of **Acute Angle-Closure Glaucoma**, making it strictly contraindicated in such patients. **Analysis of Incorrect Options:** * **B. Pilocarpine:** A miotic (cholinergic agonist) that constricts the pupil and pulls the peripheral iris away from the angle. It is traditionally used in the emergency management of angle-closure glaucoma. * **C. Timolol maleate:** A non-selective beta-blocker that reduces aqueous humor production by the ciliary body. It is a first-line treatment for Open-Angle Glaucoma (OAG). * **D. Latanoprost:** A prostaglandin analogue that increases aqueous outflow via the **uveoscleral pathway**. It is currently the gold-standard, first-line drug for Primary Open-Angle Glaucoma. **High-Yield Clinical Pearls for NEET-PG:** * **Mydriatic of choice** for fundus examination in adults is **Tropicamide** (shorter duration), but it must be used with caution if the angle is narrow. * **Drug of choice (DOC)** for Primary Open-Angle Glaucoma: **Latanoprost**. * **DOC** for lowering Intraocular Pressure (IOP) rapidly in Acute Angle-Closure Glaucoma: **IV Acetazolamide** (or Mannitol). * **Definitive treatment** for Angle-Closure Glaucoma: **Laser Peripheral Iridotomy (LPI)**. * **Side effect of Latanoprost:** Increased iris pigmentation (heterochromia) and hypertrichosis (eyelash growth).

Question 118: Which of the following is NOT a risk factor for primary angle closure glaucoma?

A. Female gender
B. Small eyeball
C. Myopia (Correct Answer)
D. Type A personality

Explanation: **Explanation:** Primary Angle Closure Glaucoma (PACG) occurs due to anatomical narrowing of the anterior chamber angle, leading to obstruction of aqueous outflow. **Why Myopia is the correct answer:** Myopia (nearsightedness) is typically associated with a **long axial length** and a deep anterior chamber, which makes the angle wide and less prone to closure. In contrast, **Hypermetropia (farsightedness)** is a classic risk factor for PACG because hypermetropic eyes are smaller with shallower anterior chambers. Note: Myopia is a significant risk factor for *Primary Open Angle Glaucoma (POAG)*, not PACG. **Analysis of Incorrect Options:** * **Female Gender:** Females are 2–4 times more likely to develop PACG than males, likely due to naturally shallower anterior chambers. * **Small Eyeball:** Anatomical factors such as a short axial length, a small corneal diameter, and a relatively large lens (which pushes the iris forward) are the primary structural predispositions for angle closure. * **Type A Personality:** Psychological stress and "anxious" personality types are traditionally associated with PACG. Emotional stress can trigger sympathetic overactivity, leading to pupillary dilation (mydriasis), which can precipitate an acute attack of angle closure. **High-Yield Clinical Pearls for NEET-PG:** * **The "Golden" Risk Factor:** Increasing age (due to the lens increasing in thickness over time). * **Race:** Highest prevalence is seen in Southeast Asians and Chinese populations. * **Precipitating Factors:** Darkrooms (cinema halls), emotional stress, and mydriatic eye drops. * **Drug of Choice (Immediate):** IV Acetazolamide; however, the **Definitive Treatment** is Laser Peripheral Iridotomy (LPI).

Question 119: Latanoprost (a prostaglandin F2 alpha analogue) is used in:

A. Maintenance of ductus arteriosus
B. Pulmonary hypertension
C. Gastric mucosal protection
D. Glaucoma (Correct Answer)

Explanation: **Explanation:** **Latanoprost** is a Prostaglandin $F_{2\alpha}$ ($PGF_{2\alpha}$) analogue. It is the first-line medical therapy for **Open-Angle Glaucoma** and Ocular Hypertension. **Why Option D is Correct:** Latanoprost acts by increasing the **uveoscleral outflow** of aqueous humor (the unconventional pathway). It reduces intraocular pressure (IOP) by remodeling the extracellular matrix in the ciliary muscle, making it more permeable. Its once-daily dosing and high efficacy make it superior to beta-blockers for long-term management. **Why Other Options are Incorrect:** * **Option A:** **Alprostadil** ($PGE_1$) is used to maintain the patency of the ductus arteriosus in neonates with congenital heart defects. * **Option B:** **Epoprostenol** and **Treprostinil** ($PGI_2$ analogues) are used in the management of Pulmonary Arterial Hypertension due to their potent vasodilatory effects. * **Option C:** **Misoprostol** ($PGE_1$ analogue) is used for gastric mucosal protection, especially to prevent NSAID-induced peptic ulcers, by increasing bicarbonate and mucus secretion. **High-Yield Clinical Pearls for NEET-PG:** 1. **Side Effects:** The most characteristic side effects of Latanoprost include **increased iris pigmentation** (permanent), **hypertrichosis** (increased eyelash growth/thickness), and **prostaglandin-associated periorbitopathy** (sunken eyes). 2. **Contraindication:** It should be avoided in patients with active **uveitis** or **cystoid macular edema (CME)** as it may exacerbate inflammation. 3. **Storage:** Latanoprost eye drops usually require refrigeration ($2\text{--}8^\circ\text{C}$) before opening to maintain stability. 4. **Other Analogues:** Bimatoprost and Travoprost are other $PGF_{2\alpha}$ analogues used in glaucoma.

Question 120: Latanoprost is used in the treatment of which condition?

A. Open angle glaucoma (Correct Answer)
B. Angle closure glaucoma
C. Non-granulomatous uveitis
D. Granulomatous uveitis

Explanation: **Explanation:** **Latanoprost** is a **Prostaglandin F2α (PGF2α) analogue** and is currently considered the first-line medical therapy for **Primary Open Angle Glaucoma (POAG)** and Ocular Hypertension. **Why Option A is correct:** The primary mechanism of Latanoprost is increasing the **uveoscleral outflow** of aqueous humor. It achieves this by remodeling the extracellular matrix in the ciliary muscle, thereby reducing resistance to drainage. In POAG, where the trabecular meshwork is dysfunctional but the angle remains open, enhancing this alternative drainage pathway effectively lowers Intraocular Pressure (IOP). **Why other options are incorrect:** * **Option B (Angle Closure Glaucoma):** The definitive treatment for primary angle closure is surgical or laser intervention (e.g., Laser Peripheral Iridotomy). While PG analogues can be used as adjunctive therapy after the angle is opened, they are not the primary or specific treatment for the closure itself. * **Options C & D (Uveitis):** Latanoprost is generally **avoided** in patients with active uveitis. Prostaglandins are pro-inflammatory mediators; using them can exacerbate intraocular inflammation and increase the risk of developing **Cystoid Macular Edema (CME)**. **High-Yield Clinical Pearls for NEET-PG:** * **Dosage:** Administered as once-daily drops (usually at bedtime). * **Side Effects (Highly examinable):** 1. **Hypertrichosis:** Increased length and thickness of eyelashes. 2. **Iris Heterochromia:** Permanent darkening of the iris (increased melanin production). 3. **Periorbitopathy:** Loss of periorbital fat (sunken eyes). * **Contraindications:** History of Herpetic Keratitis (may reactivate the virus) and active uveitis.

Practice by Chapter

Aqueous Humor Dynamics

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Primary Open-Angle Glaucoma

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Primary Angle-Closure Glaucoma

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Secondary Open-Angle Glaucomas

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Secondary Angle-Closure Glaucomas

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Developmental and Congenital Glaucomas

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Medical Management of Glaucoma

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Laser Therapy in Glaucoma

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Glaucoma Filtration Surgery

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Glaucoma Drainage Devices

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Angle Assessment Techniques

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Visual Field Testing in Glaucoma

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Glaucoma — MCQs

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