Glaucoma Practice Questions

Q: Which of the following is true about intraocular pressure?

It increases with advancing age.. **Explanation:** **Correct Option: D (It increases with advancing age)** Intraocular pressure (IOP) tends to increase with age due to structural and functional changes in the trabecular meshwork. With advancing age, there is a reduction in the number of trabecular cells, increased accumulation of extracellular matrix material (pigment and debris), and a decrease in the facility of aqueous outflow. This makes age a significant risk factor for the development of Primary Open Angle Glaucoma (POAG). **Analysis of Incorrect Options:** * **A. It is more common in males:** This is incorrect. Most epidemiological studies suggest that there is no significant gender predilection for IOP levels, although certain types of glaucoma (like Angle Closure Glaucoma) are actually more common in females. * **B. Diurnal variation is not present in glaucomatous patients:** This is incorrect. Diurnal variation is present in everyone, but it is **exaggerated** in glaucomatous patients. While a normal eye fluctuates by 3–5 mmHg, a glaucomatous eye often shows fluctuations >8–10 mmHg. * **C. There is no change in postural variations:** This is incorrect. IOP is dynamic and changes with posture; it typically **increases** when moving from a sitting/standing position to a supine (lying down) position due to increased episcleral venous pressure. **High-Yield Clinical Pearls for NEET-PG:** * **Normal IOP Range:** 10–21 mmHg (Mean: 15.5 ± 2.5 mmHg). * **Gold Standard Measurement:** Goldmann Applanation Tonometry (GAT). It is based on the **Imbert-Fick Law**. * **Diurnal Variation:** IOP is usually highest in the early morning (around 6:00 AM) and lowest in the evening. * **Central Corneal Thickness (CCT):** A thin cornea leads to an underestimation of IOP, while a thick cornea leads to an overestimation.

Q: Painful loss of vision is seen in which of the following conditions?

Primary open-angle glaucoma. **Explanation:** The correct answer is **B. Primary open-angle glaucoma (POAG)**. This question is a classic "except" style or "negative" identification question often found in NEET-PG. **Primary open-angle glaucoma (POAG)** is characteristically a **painless, progressive, and bilateral** loss of vision. It is often called the "silent thief of sight" because patients remain asymptomatic until significant peripheral visual field loss (tunnel vision) occurs. **Analysis of Options:** * **A. Senile Cataract:** Presents as a **painless**, gradual diminution of vision due to progressive opacification of the lens. * **C. Primary Angle-Closure Glaucoma (PACG):** This is a classic cause of **sudden, painful** loss of vision. It is an ocular emergency characterized by a mid-dilated non-reacting pupil, corneal edema, and very high intraocular pressure (IOP). * **D. Anterior Uveitis:** Presents with **pain**, photophobia, redness (ciliary congestion), and blurred vision. The pain is typically due to ciliary body spasm. **Clinical Pearls for NEET-PG:** * **Painless Loss of Vision:** POAG, Senile Cataract, Diabetic Retinopathy, Retinal Detachment (usually), and Central Retinal Vein Occlusion (CRVO). * **Painful Loss of Vision:** Acute Congestive Glaucoma (PACG), Anterior Uveitis, Optic Neuritis, and Endophthalmitis. * **POAG Triad:** IOP >21 mmHg, Optic disc cupping (Vertical cup-disc ratio >0.7), and characteristic visual field defects (e.g., Bjerrum’s scotoma). * **Drug of Choice for POAG:** Prostaglandin analogues (e.g., Latanoprost).

Q: Fincham's test differentiates cataract from which of the following conditions?

Acute Congestive Glaucoma. **Explanation:** **Fincham’s Test** (also known as the Stenopeic Slit Test) is a clinical method used to differentiate the cause of **colored halos** around lights. Colored halos occur due to the diffraction of light, which can be caused by either lens changes (cataract) or corneal edema (acute glaucoma). 1. **Why Acute Congestive Glaucoma is Correct:** In **Acute Congestive Glaucoma**, high intraocular pressure causes **corneal edema**. When a stenopeic slit is passed across the pupil, the halos **remain intact and do not break up**. This is because the edema is uniform across the corneal surface. In contrast, in **Cataract** (specifically immature senile cataract), the halos are caused by water droplets between lens fibers. When the slit is moved, these halos **break up into segments**. 2. **Why other options are incorrect:** * **Conjunctivitis:** While "halos" may be reported due to mucus discharge on the corneal surface, they disappear immediately upon blinking or washing the eye. * **Iridocyclitis:** This typically presents with photophobia and ciliary congestion rather than colored halos. * **Open Angle Glaucoma:** This is a chronic, asymptomatic condition in early stages. Colored halos are a hallmark of sudden pressure spikes (Acute Glaucoma) or lens changes, not chronic stable elevation. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology of Halos:** Glaucomatous halos have the blue ring innermost and red ring outermost. * **Differential Diagnosis:** Always remember the "Blink Test"—if halos disappear with blinking, think conjunctivitis; if they persist, think Glaucoma or Cataract. * **Stenopeic Slit:** If halos break = Cataract; If halos persist = Glaucoma.

Q: The Van Herick test is used for measuring which of the following?

Anterior chamber depth. **Explanation:** The **Van Herick technique** is a rapid, non-contact clinical method used to estimate the **peripheral anterior chamber depth (ACD)** using a slit lamp. **Why Option B is correct:** The test involves projecting a narrow slit beam onto the cornea at a 60° angle at the limbus. The examiner compares the thickness of the corneal section (the "optic section") to the width of the dark space (the peripheral anterior chamber) between the posterior cornea and the anterior iris. By grading this ratio (e.g., Grade 4 to Grade 1), clinicians can estimate the depth of the anterior chamber and identify eyes at risk for angle closure. **Why other options are incorrect:** * **Option A (Cells and flare):** These are markers of intraocular inflammation (uveitis) and are assessed using a small, bright rectangular beam in a dark room, not the Van Herick method. * **Option C (Anterior chamber angle):** While Van Herick *infers* the state of the angle, the definitive method to visualize and measure the AC angle is **Gonioscopy** (Gold Standard). * **Option D (Anterior chamber volume):** This is a quantitative measurement usually performed using advanced imaging like Pentacam or Anterior Segment OCT, not a bedside slit-lamp test. **High-Yield Clinical Pearls for NEET-PG:** * **Grading:** * Grade 4: AC depth > corneal thickness (Wide open). * Grade 1: AC depth < 1/4 corneal thickness (High risk of closure). * Grade 0: Slit-like or closed. * **Limitation:** It only assesses the temporal and nasal periphery; it cannot detect "creeping" angle closure or synechiae. * **Gold Standard for Angle Evaluation:** Gonioscopy (using a Goldmann or Zeiss lens).

Q: A woman complains of colored haloes around lights in the evening, with nausea and vomiting. Intraocular pressure (IOP) is normal. What is the most likely diagnosis?

Prodromal stage, closed-angle glaucoma. ### Explanation **Correct Option: B. Prodromal stage, closed-angle glaucoma** The clinical triad of **colored haloes**, **evening symptoms**, and **nausea/vomiting** is classic for the prodromal (intermittent) stage of Primary Angle-Closure Glaucoma (PACG). * **Mechanism:** In the evening (dim light), physiological mydriasis (pupil dilation) occurs. This leads to increased pupillary block and peripheral iris crowding, causing a transient rise in IOP. * **Colored Haloes:** The sudden IOP rise causes transient **corneal edema**. The edematous cornea acts as a diffraction grating, splitting white light into its spectral components (Fincham’s test). * **Normal IOP:** The hallmark of the prodromal stage is that symptoms are **self-limiting**. By the time the patient reaches the clinic, the pupil has constricted (e.g., due to bright light or sleep), the angle has reopened, and the IOP has returned to normal. **Why other options are incorrect:** * **A. Incipient stage open-angle glaucoma:** POAG is typically asymptomatic ("the silent thief of sight") and does not present with acute episodes of haloes or nausea. * **C & D. Migraine/Cluster Headache:** While these cause nausea and pain, they do not cause colored haloes. Haloes are a specific sign of corneal edema or lens changes. **High-Yield Clinical Pearls for NEET-PG:** 1. **Fincham’s Test:** Used to differentiate haloes of glaucoma (corneal edema) from cataract. Glaucomatous haloes disappear when a stenopeic slit is passed across the pupil; cataractous haloes do not. 2. **Precipitating Factors:** Dim light (cinema halls), emotional stress, or mydriatic drugs. 3. **Treatment of Choice:** Peripheral Iridotomy (usually YAG Laser) is the definitive treatment to prevent a full-blown acute attack. 4. **Differential Diagnosis:** Always rule out "Early Cataract" if a patient complains of haloes without pain/nausea.

Q: Shallow anterior chamber is seen in all of the following conditions EXCEPT:

Steroid-induced glaucoma. **Explanation:** The depth of the anterior chamber (AC) is a critical anatomical factor in differentiating types of glaucoma. **Why Steroid-induced Glaucoma is the correct answer:** Steroid-induced glaucoma is a form of **Secondary Open-Angle Glaucoma**. It occurs due to increased resistance to aqueous outflow at the level of the trabecular meshwork (caused by the accumulation of glycosaminoglycans). Because it is an open-angle pathology, the anterior chamber depth remains **normal or deep**. Therefore, it does not present with a shallow AC. **Analysis of Incorrect Options:** * **Old Age:** As age increases, the crystalline lens increases in anteroposterior thickness (phacomorphosis) and moves slightly forward, which naturally shallows the anterior chamber. * **Hypermetropia:** Hypermetropic eyes are anatomically smaller (short axial length). A relatively large lens in a small eye results in a shallow AC and a narrow drainage angle, predisposing them to angle closure. * **Angle Closure Glaucoma:** This is the classic condition associated with a shallow AC. The shallow depth facilitates iridocorneal contact, leading to pupillary block and subsequent angle closure. **High-Yield Clinical Pearls for NEET-PG:** * **Deep Anterior Chamber** is seen in: Myopia, Aphakia, Keratoconus, and Buphthalmos (Congenital Glaucoma). * **Shallow Anterior Chamber** is seen in: Hypermetropia, Malignant Glaucoma (Ciliary block), Intumescent cataract, and Spherophakia. * **Steroid Response:** Approximately 5-10% of the population are "high responders" who develop significant IOP elevation after 4-6 weeks of topical steroid use. * **Gold Standard** for measuring AC depth is Optical Pachymetry or A-scan ultrasonography; however, **Van Herick’s technique** is the common clinical screening method using a slit lamp.

Q: In Buphthalmos, all are seen except:

Small cornea. ### Explanation **Buphthalmos** (literally "ox-eye") is the clinical manifestation of **Primary Congenital Glaucoma**, occurring when intraocular pressure (IOP) is elevated before the age of 3 years. #### Why "Small Cornea" is the Correct Answer: In infants, the outer coats of the eye (sclera and cornea) are highly distensible and elastic. Persistent high IOP causes the entire globe to stretch and enlarge. Therefore, a **large cornea** (megalocornea) is a hallmark of the condition, making a "small cornea" (microcornea) clinically impossible in untreated Buphthalmos. #### Analysis of Other Options: * **Large Cornea (Megalocornea):** This is a cardinal sign. A corneal diameter >12 mm before age 1 or >13 mm at any age is diagnostic. Stretching also leads to **Haab’s striae** (horizontal breaks in Descemet’s membrane). * **Big Eyeball:** The entire globe enlarges due to the elasticity of the young sclera, leading to an increased axial length and progressive high myopia. * **Subluxated Lens:** As the eyeball and the ciliary ring enlarge, the zonules are stretched to their limit. This mechanical tension can lead to zonular dehiscence, resulting in lens subluxation. #### High-Yield Clinical Pearls for NEET-PG: 1. **Classic Triad:** Photophobia, Blepharospasm, and Lacrimation (Epiphora). 2. **Pathophysiology:** Caused by **Barkan’s Membrane**, an embryonic tissue remnant covering the trabecular meshwork due to incomplete development of the angle (Trabeculodysgenesis). 3. **Surgery of Choice:** * **Goniotomy** or **Trabeculotomy** (if the cornea is clear). * **Trabeculotomy + Trabeculectomy** (if the cornea is hazy). 4. **Genetics:** Often associated with the **CYP1B1** gene mutation.

Q: A patient has developed acute congestive glaucoma in their right eye. What prophylactic measure should be taken in the fellow eye?

Laser iridotomy. **Explanation:** **1. Why Laser Iridotomy is Correct:** Acute congestive glaucoma (Primary Angle Closure Glaucoma - PACG) is fundamentally an anatomical disease. If a patient experiences an attack in one eye, there is a **40-80% chance** of a similar attack occurring in the fellow eye within 5–10 years because the anatomical predisposition (shallow anterior chamber, narrow angles) is bilateral. Prophylactic **Laser Peripheral Iridotomy (LPI)** is the gold standard. It creates a small opening in the iris, bypassing pupillary block and allowing aqueous humor to flow freely from the posterior to the anterior chamber, thereby deepening the angle and preventing an acute attack. **2. Why Other Options are Incorrect:** * **Topical Steroids:** These are used to reduce inflammation *during* an acute attack but do not address the underlying anatomical narrow angle. In fact, long-term steroid use can cause secondary open-angle glaucoma. * **Peripheral Iridectomy:** While this achieves the same goal as LPI, it is a **surgical** procedure. In modern practice, non-invasive laser (LPI) is always preferred over surgical iridectomy unless the laser cannot be performed (e.g., due to a cloudy cornea). * **Antibiotics:** Glaucoma is a pressure-related mechanical/vascular issue, not an infectious one. Antibiotics have no role in its management. **3. High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (Medical):** IV Mannitol or Acetazolamide to rapidly lower IOP. * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI). * **The "Fellow Eye":** In PACG, the fellow eye is always considered an "eye at risk." * **Provocative Test:** The Dark Room Prone Position Test is used to diagnose inducible angle closure. * **Classic Presentation:** Mid-dilated, vertically oval, non-reactive pupil with "steamy" corneal edema and halos around lights.

Question 1

Which of the following is true about intraocular pressure?

Accepted Answer

It increases with advancing age.

Answer

It is more common in males.

Answer

Diurnal variation is not present in glaucomatous patients.

Answer

There is no change in postural variations.

Question 2

Painful loss of vision is seen in which of the following conditions?

Accepted Answer

Primary open-angle glaucoma

Answer

Senile cataract

Answer

Primary angle-closure glaucoma

Answer

Anterior uveitis

Question 3

What is the treatment of malignant glaucoma?

Accepted Answer

Vitreous aspiration

Answer

Pilocarpine

Answer

Cyclocryotherapy

Answer

Trabeculectomy

Question 4

Fincham's test differentiates cataract from which of the following conditions?

Accepted Answer

Acute Congestive Glaucoma

Answer

Conjunctivitis

Answer

Iridocyclitis

Answer

Open angle Glaucoma

Question 5

The Van Herick test is used for measuring which of the following?

Accepted Answer

Anterior chamber depth

Answer

Cells and flare

Answer

Anterior chamber angle

Answer

Anterior chamber volume

Question 6

A woman complains of colored haloes around lights in the evening, with nausea and vomiting. Intraocular pressure (IOP) is normal. What is the most likely diagnosis?

Accepted Answer

Prodromal stage, closed-angle glaucoma

Answer

Incipient stage open-angle glaucoma

Answer

Migraine

Answer

Cluster headache

Question 7

Shallow anterior chamber is seen in all of the following conditions EXCEPT:

Accepted Answer

Steroid-induced glaucoma

Answer

Old age

Answer

Hypermetropia

Answer

Angle closure glaucoma

Question 8

Pain in absolute glaucoma is best relieved by:

Accepted Answer

Retrobulbar injection of alcohol

Answer

Analgesics

Answer

Trabeculectomy

Answer

Miotics

Question 9

In Buphthalmos, all are seen except:

Accepted Answer

Small cornea

Answer

Subluxated lens

Answer

Large cornea

Answer

Big eyeball

Question 10

A patient has developed acute congestive glaucoma in their right eye. What prophylactic measure should be taken in the fellow eye?

Accepted Answer

Laser iridotomy

Answer

Topical steroids

Answer

Peripheral iridectomy

Answer

Antibiotics

Glaucoma — MCQs

Glaucoma — MCQs

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