Glaucoma Practice Questions

Q: What is the type of synechiae found in iris bombe?

Ring. **Explanation:** **Iris bombe** is a clinical condition that occurs due to **seclusio pupillae**, which is the formation of 360-degree posterior synechiae (adhesions between the pupillary margin and the anterior lens capsule). 1. **Why "Ring" is correct:** When synechiae form a complete circle (360°) around the pupil, it is termed **Ring Synechiae**. This creates a total obstruction to the flow of aqueous humor from the posterior chamber to the anterior chamber. The resulting pressure buildup in the posterior chamber causes the peripheral iris to bulge forward (ballooning), leading to the characteristic "bombe" appearance and secondary angle-closure glaucoma. 2. **Why other options are incorrect:** * **Total Synechiae:** Refers to the adhesion of the entire posterior surface of the iris to the lens. This results in a flat/deep anterior chamber rather than the "bombe" (ballooning) effect. * **Goniform/Filiform:** These are not standard terms used to describe the morphology of posterior synechiae in the context of iris bombe. Filiform synechiae are sometimes used to describe fine, thread-like adhesions seen in specific inflammatory conditions but do not cause iris bombe. **High-Yield Clinical Pearls for NEET-PG:** * **Sequence of events:** Iridocyclitis → Seclusio pupillae (Ring synechiae) → Iris bombe → Secondary angle-closure glaucoma. * **Festooned Pupil:** Irregularly shaped pupil seen after using mydriatics when *incomplete* posterior synechiae are present. * **Management:** The definitive treatment for iris bombe is **Laser Peripheral Iridotomy (LPI)** to bypass the pupillary block and restore aqueous flow.

Q: A 30-year-old male with a family history of glaucoma presents with headache. On examination, intraocular pressure (IOP) is 22 mmHg in the right eye and 24 mmHg in the left eye. Angles were open on gonioscopy. No visual field defects were noted. What is the true statement regarding the management of this patient?

Ocular hypertension - no intervention required. ### Explanation This patient presents with **Ocular Hypertension (OHT)**. The diagnosis is based on the triad of: 1. **Elevated IOP** (>21 mmHg). 2. **Open angles** on gonioscopy. 3. **Absence of glaucomatous damage** (normal optic disc and normal visual fields). **Why Option C is correct:** According to the **Ocular Hypertension Treatment Study (OHTS)**, the risk of progression from OHT to Primary Open-Angle Glaucoma (POAG) is only about 1% per year. Therefore, routine medical intervention is not required unless specific high-risk factors are present (e.g., central corneal thickness 30 mmHg). In this 30-year-old with borderline pressures (22/24 mmHg) and no field defects, observation is the standard of care. **Why other options are incorrect:** * **Option A:** Normal Tension Glaucoma (NTG) requires IOP to be consistently $\leq$ 21 mmHg with evidence of optic nerve damage. This patient has elevated IOP and no damage. * **Option B:** POAG requires the presence of glaucomatous optic neuropathy or visual field defects. Since the fields are normal, this diagnosis is ruled out. * **Option D:** Treatment for OHT is generally reserved for patients with IOP >28–30 mmHg or those with significant risk factors. A pressure of 24 mmHg without damage does not mandate immediate treatment. ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard for IOP:** Goldmann Applanation Tonometry (GAT). * **Pachymetry:** Essential in OHT; thin corneas are a major risk factor for progression to glaucoma. * **OHTS Criteria for Treatment:** Start treatment if IOP >24 mmHg **AND** central corneal thickness is 30 mmHg. * **Follow-up:** OHT patients require annual visual field testing and disc evaluation.

Q: Gonioscopy is used to study:

The angle of the anterior chamber. **Explanation:** **Gonioscopy** is the clinical technique used to visualize the **angle of the anterior chamber**. Under normal conditions, the iridocorneal angle cannot be seen directly because light reflected from the angle undergoes **total internal reflection** at the tear-air interface (due to the critical angle of approximately 46°). A gonioscope (a specialized contact lens) eliminates this interface, allowing the clinician to assess the drainage structures. * **Why Option C is correct:** Gonioscopy is the gold standard for differentiating between **Open-Angle Glaucoma** and **Angle-Closure Glaucoma**. It allows for the visualization of structures such as Schwalbe’s line, trabecular meshwork, scleral spur, and ciliary body band. * **Why Options A & B are incorrect:** The anterior and posterior chambers are typically evaluated using a slit-lamp biomicroscope. While the anterior chamber depth is a precursor to angle assessment, gonioscopy specifically targets the *junction* (angle) where the iris meets the cornea. * **Why Option D is incorrect:** The retina is visualized using ophthalmoscopy (direct/indirect) or fundus biomicroscopy. **High-Yield Clinical Pearls for NEET-PG:** * **Goldmann 3-mirror lens:** Used for indirect gonioscopy and peripheral retina examination. * **Koeppe lens:** A prototype for direct gonioscopy (used in pediatrics/operating rooms). * **Shaffer’s Grading:** The most common system used to grade the angle width (Grade 0 to 4). * **Van Herick Technique:** A slit-lamp method to *estimate* angle depth, but it does not replace gonioscopy. * **Dynamic Gonioscopy (Indentation):** Used to differentiate between appositional closure and permanent synechial closure.

Q: Gonioscopy is used for which anatomical structure?

Anterior chamber angle. **Explanation:** **Gonioscopy** is a clinical technique used to visualize the **Anterior Chamber Angle (ACA)**. Under normal conditions, the ACA cannot be seen directly through the cornea because light rays reflected from the angle undergo **total internal reflection** at the tear-air interface (due to the critical angle of approximately 46°). A goniolens eliminates this interface, allowing the clinician to evaluate the drainage structures of the eye. * **Why Option A is correct:** Gonioscopy is the gold standard for assessing the ACA to differentiate between **Open-Angle** and **Angle-Closure Glaucoma**. It allows for the identification of structures like Schwalbe’s line, trabecular meshwork, scleral spur, and ciliary body band. * **Why Options B, C, and D are incorrect:** The **Posterior Chamber** (space between the iris and lens) and the **Posterior Chamber Angle** are located behind the iris and are not visible via gonioscopy. The **Anterior Surface of the Lens** is easily visualized using a standard slit-lamp biomicroscopy without the need for a specialized goniolens. **High-Yield Clinical Pearls for NEET-PG:** 1. **Goldmann 3-Mirror Lens:** Used for both gonioscopy and viewing the central/peripheral retina. It requires a coupling fluid. 2. **Zeiss/Posner/Sussman 4-Mirror Lens:** Used for **Indentation Gonioscopy** to differentiate between appositional closure and permanent synechial closure. 3. **Shaffer’s Grading System:** The most common method used to grade the width of the angle (Grade 0 to 4). 4. **Order of structures (Posterior to Anterior):** Ciliary body band → Scleral spur → Trabecular meshwork → Schwalbe’s line (**Mnemonic: I Can See The Line** – Iris, Ciliary body, Scleral spur, Trabecular meshwork, Line of Schwalbe).

Q: Neovascular glaucoma can occur in all of the following conditions except:

Hypertension. **Explanation:** Neovascular Glaucoma (NVG) is a secondary glaucoma caused by the formation of new, fragile blood vessels (neovascularization) on the iris (rubeosis iridis) and in the iridocorneal angle. These vessels, accompanied by a fibrovascular membrane, eventually contract and pull the peripheral iris over the trabecular meshwork, leading to synechial angle closure. **Why Hypertension is the correct answer:** Hypertension is a systemic vascular condition, but it is **not a direct cause** of neovascular glaucoma. While hypertension is a major risk factor for developing CRVO or CRAO (which then cause NVG), hypertension alone does not trigger the intraocular ischemia and subsequent release of Vascular Endothelial Growth Factor (VEGF) required for neovascularization. **Analysis of other options:** * **Diabetes Mellitus:** This is the most common cause of NVG. Chronic ischemia in Proliferative Diabetic Retinopathy (PDR) triggers massive VEGF release. * **Central Retinal Vein Occlusion (CRVO):** Specifically the "Ischemic" type of CRVO is a classic cause, often referred to as **"100-day glaucoma"** because NVG typically develops within 3 months of the occlusion. * **Central Retinal Artery Occlusion (CRAO):** Although less common than in CRVO, about 1-5% of CRAO patients develop NVG due to retinal ischemia. **High-Yield Clinical Pearls for NEET-PG:** * **The Pathological Trigger:** Retinal Ischemia → VEGF release → Neovascularization of the Iris (NVI) → Neovascularization of the Angle (NVA) → NVG. * **100-Day Glaucoma:** A classic synonym for NVG following ischemic CRVO. * **Treatment Gold Standard:** Pan-retinal photocoagulation (PRP) to reduce the ischemic drive, often combined with Anti-VEGF injections. * **Other Causes:** Ocular Ischemic Syndrome (Carotid artery disease) and Eales disease.

Q: Which of the following is NOT a system for the classification of the angles of the anterior chamber?

Sun Classification. The correct answer is **Sun Classification** because it is not a system used for grading the anterior chamber angle; rather, it is used to grade **anterior chamber cells** in uveitis (Standardization of Uveitis Nomenclature). ### Explanation of Options: * **Shaffer’s System:** The most commonly used classification in clinical practice. It grades the angle based on the **degree of openness** (from 0° to 45°) and the visibility of anatomical structures. Grade 0 is closed, while Grade 4 is wide open. * **Spaeth Classification:** A highly detailed system that assesses three parameters: the **level of iris insertion**, the **width of the angle** (in degrees), and the **configuration of the peripheral iris** (e.g., steep, regular, or concave). * **RPC (Redmond Smith, Scheie, and van Beuningen) Classification:** These are historical or specialized systems used to describe angle anatomy. The **Scheie system** is particularly high-yield, as it grades the angle based on the structures visible (Grade IV is closed, which is the opposite of Shaffer’s). ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard:** Gonioscopy remains the gold standard for angle evaluation. * **Shaffer vs. Scheie:** Remember that in **Shaffer**, Grade 4 is wide open. In **Scheie**, Grade IV is "closed" (no structures visible). * **SUN Criteria:** Always associate "SUN" with **Uveitis** grading (cells and flare), not Glaucoma. * **Van Herick Technique:** This is a slit-lamp method to *estimate* angle depth without a gonioscopy lens, comparing the peripheral corneal thickness to the depth of the peripheral anterior chamber.

Q: The Worth 4 dot test is performed to assess:

Binocular vision function. ### Explanation The **Worth 4 Dot Test (W4DT)** is a clinical test used to assess **Binocular Single Vision (BSV)**, specifically to detect suppression, diplopia, and the presence of fusion. **Why the correct answer is right:** The test utilizes the principle of **dissociation** through color filters. The patient wears red-green goggles (Red over the right eye, Green over the left) and views four lights: one red, two green, and one white. * **Normal BSV:** The patient sees four dots (the white dot is fused by both eyes). * **Suppression:** If the patient sees only two red dots, the left eye is suppressed; if they see three green dots, the right eye is suppressed. * **Diplopia:** If the patient sees five dots, it indicates a lack of fusion (strabismus). **Why the incorrect options are wrong:** * **A. Color vision deficiency:** This is assessed using **Ishihara charts**, Hardy-Rand-Rittler (HRR) plates, or the Farnsworth-Munsell 100 hue test. * **B. Visual acuity:** This measures the clarity of vision, typically using the **Snellen chart** (distance) or Jaeger chart (near). * **D. Ocular alignment:** While W4DT can indicate a misalignment (diplopia), the primary tools for measuring alignment are the **Cover-Uncover test**, Hirschberg corneal reflex test, and Prism Cover Test. **High-Yield Clinical Pearls for NEET-PG:** * **Anomalous Retinal Correspondence (ARC):** A patient with a manifest squint who sees 4 dots on W4DT has ARC (harmonious). * **Testing Distance:** It is performed at both 6 meters (assesses central fusion) and 33 cm (assesses peripheral fusion). * **Suppression Scotoma:** W4DT is highly sensitive for detecting a central suppression scotoma, commonly seen in **Monofixation Syndrome**.

Q: All of the following are causes of neovascular glaucoma except?

Central serous retinopathy. **Explanation:** Neovascular Glaucoma (NVG) is a secondary glaucoma caused by the formation of new vessels (neovascularization) on the iris (**rubeosis iridis**) and in the iridocorneal angle. This process is driven by **vascular endothelial growth factor (VEGF)**, which is released in response to chronic **retinal ischemia**. **Why Central Serous Retinopathy (CSR) is the correct answer:** CSR is characterized by the accumulation of subretinal fluid due to a leak in the retinal pigment epithelium. Unlike the other options, CSR is **not an ischemic condition**. Since there is no retinal hypoxia, there is no stimulus for VEGF production, making it a non-cause of NVG. **Analysis of Incorrect Options:** * **Diabetic Retinopathy:** Specifically Proliferative Diabetic Retinopathy (PDR), it is the most common cause of NVG. Extensive capillary non-perfusion leads to massive VEGF release. * **Central Retinal Vein Occlusion (CRVO):** Ischemic CRVO is the second most common cause. It is classically associated with **"100-day glaucoma"** (NVG typically appearing 3 months after the vascular event). * **Intraocular Tumors:** Tumors like Retinoblastoma (in children) or Uveal Melanoma (in adults) can cause NVG by inducing ischemia through mass effect or by secreting angiogenic factors. **Clinical Pearls for NEET-PG:** * **The "Big Three" causes of NVG:** 1. Diabetic Retinopathy, 2. Ischemic CRVO, 3. Carotid Artery Occlusive Disease. * **Pathogenesis:** VEGF → Rubeosis Iridis → Fibrovascular membrane contracts → Ectropion uveae and Synechial angle closure. * **Management:** Pan-retinal photocoagulation (PRP) is the gold standard to reduce the ischemic drive; Anti-VEGF injections are used as an adjunct.

Q: A 25-year-old young adult presented with painless red eye and an intraocular pressure of 60 mmHg. What is the most likely diagnosis?

Glaucomatocyclitic crisis. **Explanation:** The correct answer is **Glaucomatocyclitic crisis**, also known as **Posner-Schlossman Syndrome (PSS)**. **Why it is correct:** PSS typically presents in young adults (20–50 years) as recurrent, unilateral episodes of markedly elevated intraocular pressure (often 40–60 mmHg) with disproportionately mild symptoms. The hallmark is a **"painless red eye"** (or very mild discomfort/blurring) despite the massive IOP spike. Clinical findings include mild ciliary congestion, a few fine "stellate" keratic precipitates (KPs) on the endothelium, and an open angle on gonioscopy. The pressure rise is due to acute trabeculitis. **Why other options are incorrect:** * **Chronic papilledema:** This involves optic disc swelling due to increased intracranial pressure. It does not cause elevated intraocular pressure or a red eye. * **Acute angle closure glaucoma (AACG):** While IOP is very high, AACG is a medical emergency characterized by **severe pain**, nausea, vomiting, a hazy cornea, and a shallow anterior chamber. It rarely occurs in a 25-year-old unless there is a predisposing anatomical factor (e.g., nanophthalmos). * **Acute anterior uveitis:** While this causes a red eye, the IOP is typically **low or normal** due to ciliary body hyposecretion. If the IOP is high (hypertensive uveitis), it is usually accompanied by significant pain and photophobia, unlike the "painless" presentation of PSS. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of PSS:** Unilateral high IOP + Open angles + Fine stellate KPs. * **Treatment:** Medical management with topical steroids (to control inflammation) and aqueous suppressants (to lower IOP). Miotics (Pilocarpine) are avoided. * **Prognosis:** Excellent, as the episodes are self-limiting, though long-term monitoring is required for permanent glaucomatous damage.

Question 1

What is the type of synechiae found in iris bombe?

Accepted Answer

Ring

Answer

Total

Answer

Goniform

Answer

Filiform

Question 2

A 30-year-old male with a family history of glaucoma presents with headache. On examination, intraocular pressure (IOP) is 22 mmHg in the right eye and 24 mmHg in the left eye. Angles were open on gonioscopy. No visual field defects were noted. What is the true statement regarding the management of this patient?

Accepted Answer

Ocular hypertension - no intervention required

Answer

Normal tension glaucoma to be treated

Answer

Primary open-angle glaucoma to be treated

Answer

Ocular hypertension to be treated

Question 3

Gonioscopy is used to study:

Accepted Answer

The angle of the anterior chamber

Answer

Anterior chamber

Answer

Posterior chamber

Answer

Retina

Question 4

Gonioscopy is used for which anatomical structure?

Accepted Answer

Anterior chamber angle

Answer

Posterior chamber angle

Answer

Anterior surface of the lens

Answer

Posterior chamber

Question 5

Neovascular glaucoma can occur in all of the following conditions except:

Accepted Answer

Hypertension

Answer

Diabetes mellitus

Answer

Central retinal artery occlusion (CRAO)

Answer

Central retinal vein occlusion (CRVO)

Question 6

Which of the following is NOT a system for the classification of the angles of the anterior chamber?

Accepted Answer

Sun Classification

Answer

Spaeth

Answer

RPC classification

Answer

Shaffer's system

Question 7

The Worth 4 dot test is performed to assess:

Accepted Answer

Binocular vision function

Answer

Color vision deficiency

Answer

Visual acuity

Answer

Ocular alignment

Question 8

All of the following are causes of neovascular glaucoma except?

Accepted Answer

Central serous retinopathy

Answer

Diabetic retinopathy

Answer

Intraocular tumour

Answer

Central retinal vein occlusion

Question 9

All of the following are true statements with respect to angle closure glaucoma EXCEPT:

Accepted Answer

Vogt's triad is indicative of an acute active attack of angle closure glaucoma

Answer

Does not cause ocular pain at evening/night

Answer

Bullous keratopathy and shallow anterior chamber may be seen

Answer

Intravenous Mannitol is the drug of choice for angle closure glaucoma

Question 10

A 25-year-old young adult presented with painless red eye and an intraocular pressure of 60 mmHg. What is the most likely diagnosis?

Accepted Answer

Glaucomatocyclitic crisis

Answer

Chronic papilledema

Answer

Acute angle closure glaucoma

Answer

Acute anterior uveitis

Glaucoma — MCQs

Glaucoma — MCQs

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