Glaucoma Practice Questions

Q: True about angle recession glaucoma, all are correct except:

Miosis is commonly seen. **Explanation:** Angle recession glaucoma is a form of **secondary open-angle glaucoma** that occurs following blunt ocular trauma. The trauma causes a longitudinal tear in the ciliary body, specifically between the circular and longitudinal muscle fibers. **Why Option A is the Correct Answer (The False Statement):** In blunt trauma severe enough to cause angle recession, the iris sphincter is often damaged, leading to **traumatic mydriasis** (dilated pupil), not miosis. The pupil is frequently irregular, sluggish, or fixed in a mid-dilated state due to sphincter tears or paralysis. **Analysis of Other Options:** * **Option B:** Blunt trauma creates a hydraulic pressure wave (Vossius ring effect) that causes various "seven rings of trauma," including **tears of the iris sphincter** and the **ciliary body** (the definition of angle recession). * **Option C:** While angle recession can be focal, the risk of developing clinical glaucoma increases significantly if the recession involves **more than 180 to 240 degrees** of the angle circumference. * **Option D:** It is classified as a **secondary open-angle glaucoma** because the angle appears "wide" or "deep" on gonioscopy, but the trabecular meshwork is dysfunctional due to scarring or an endothelial basement membrane covering (cuticularization). **Clinical Pearls for NEET-PG:** * **Gonioscopy Finding:** A characteristic **widened ciliary body band** and a deep anterior chamber. * **Bimodal Presentation:** IOP may rise immediately after trauma (due to inflammation/hyphema) or years later (due to trabecular scarring). * **Management:** It is often refractory to medical therapy. Miotics (Pilocarpine) are generally **ineffective or contraindicated** as they may reduce uveoscleral outflow, which is already compromised. Laser Trabeculoplasty (ALT/SLT) is usually unsuccessful.

Q: In buphthalmos, what is the state of the lens?

Anteroposterior flat. **Explanation:** In **Buphthalmos** (congenital glaucoma), the primary pathology is elevated intraocular pressure (IOP) occurring in an infant’s eye. Because the infant’s sclera and cornea are highly distensible, the entire globe stretches and enlarges. **Why the lens is Anteroposteriorly Flat:** As the globe expands, the **ciliary ring enlarges**. This increases the distance between the ciliary body and the lens equator, putting significant **tension on the zonules**. This centrifugal outward pull stretches the lens, causing it to become **anteroposteriorly flat**. This flattening is a compensatory mechanical response to the stretching of the globe. **Analysis of Incorrect Options:** * **B & C (Small/Large):** The lens in buphthalmos is generally of normal volume, but its *shape* is distorted. While the eye appears "large" (macrophthalmos), the lens itself does not undergo true hypertrophy or atrophy; it simply flattens due to zonular tension. * **Subluxation Risk:** It is important to note that if the stretching is extreme, the zonules may eventually snap, leading to lens subluxation (ectopia lentis), but the initial characteristic state is flattening. **High-Yield Clinical Pearls for NEET-PG:** * **Haab’s Striae:** Horizontal or curvilinear breaks in Descemet’s membrane due to corneal stretching. * **Corneal Diameter:** Suspect buphthalmos if the diameter is **>12 mm** in the first year of life. * **Axial Myopia:** The enlargement of the globe leads to significant axial myopia, though this is partially offset by the flattening of the lens. * **Treatment of Choice:** **Goniotomy** or **Trabeculotomy** (as the pathology lies in the incomplete development of the angle/Barkan’s membrane).

Q: A mild, dilated, and fixed pupil is seen in which of the following conditions?

Acute congestive glaucoma. In **Acute Congestive Glaucoma** (Acute Angle Closure Glaucoma), the sudden and severe rise in intraocular pressure (IOP) leads to **ischemia of the iris sphincter muscle**. This ischemic paralysis prevents the pupil from constricting, resulting in a characteristically **vertically oval, mid-dilated, and fixed pupil**. ### Why the other options are incorrect: * **Iridocyclitis (Acute Anterior Uveitis):** This condition typically presents with a **small, constricted pupil (miosis)** due to ciliary muscle spasm and iris engorgement. If posterior synechiae form, the pupil may become irregular, but it is not mid-dilated. * **Chronic Congestive Glaucoma:** This is a late stage of angle closure where the IOP rise is more gradual or intermittent. While structural damage occurs, the acute ischemic "paralysis" of the iris seen in the acute phase is absent. * **Open Angle Glaucoma:** This is a "silent" chronic condition. The IOP rise is gradual, and the pupil remains **normal in size and reactive** to light until very advanced stages (where an Afferent Pupillary Defect may occur due to optic nerve damage). ### High-Yield Clinical Pearls for NEET-PG: * **Classic Triad of Acute Glaucoma:** Mid-dilated pupil, "steamy" (edematous) cornea, and a stony-hard eyeball on palpation. * **Pupil Shape:** In acute angle closure, the pupil is often **vertically oval** due to segmental iris ischemia. * **Management:** Immediate treatment involves systemic acetazolamide and topical pilocarpine (once IOP drops below 40 mmHg) to pull the iris away from the angle. The definitive treatment is **Laser Peripheral Iridotomy (LPI)** for both the affected and the fellow (prophylactic) eye.

Q: Which of the following statements is not true regarding trabeculoplasty?

It is useful in inflammatory glaucoma.. **Explanation:** Laser Trabeculoplasty (ALT/SLT) is a procedure used to increase aqueous outflow by applying laser energy to the trabecular meshwork. **Why Option C is the correct answer (The "Not True" statement):** Laser trabeculoplasty is **contraindicated in inflammatory (uveitic) glaucoma**. In an inflamed eye, the trabecular meshwork is often covered by inflammatory debris or peripheral anterior synechiae (PAS). Applying laser energy in this state can exacerbate intraocular inflammation, lead to further formation of synechiae, and cause a severe, refractory spike in intraocular pressure (IOP). It is also generally ineffective in pediatric and developmental glaucomas. **Analysis of Incorrect Options:** * **Option A:** **Argon Laser Trabeculoplasty (ALT)** specifically uses the blue-green argon laser to create small burns in the trabecular meshwork, causing tissue contraction that opens adjacent spaces. * **Option B:** While some immediate reduction occurs, the peak therapeutic effect of trabeculoplasty is typically realized over **4 to 6 weeks** as biological remodeling of the meshwork occurs. * **Option D:** A **transient post-operative rise in IOP** is the most common complication. To prevent this, surgeons often pre-treat the eye with alpha-2 agonists like Brimonidine or Apraclonidine. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** Open-angle glaucoma (POAG) where medical therapy is insufficient or non-compliance is a concern. * **SLT vs. ALT:** Selective Laser Trabeculoplasty (SLT) uses a frequency-doubled Nd:YAG laser. It is "selective" for pigmented cells, causes less thermal damage, and is **repeatable**, unlike ALT. * **Anatomical Requirement:** The anterior chamber angle must be open; the laser is aimed at the junction of the pigmented and non-pigmented trabecular meshwork.

Q: Which of the following procedures does not require dilatation of the pupil?

Gonioscopy. **Explanation:** The correct answer is **Gonioscopy**. **1. Why Gonioscopy is the correct answer:** Gonioscopy is the clinical technique used to visualize the anterior chamber angle. It is a fundamental step in classifying glaucoma into **Open-angle** or **Angle-closure**. Dilating the pupil (Mydriasis) causes the peripheral iris to bunch up toward the angle, which can artificially narrow or close a previously open angle. Therefore, gonioscopy must be performed in a **non-dilated state** (and often in a dark room) to accurately assess the natural state of the drainage angle and to check for "occludability." **2. Why the other options are incorrect:** * **Laser Iridotomy (A):** This procedure actually requires **Miosis** (constriction), not dilatation. Pilocarpine is used to stretch the iris tissue, making it thinner and easier for the laser to penetrate. However, since the question asks what does *not* require dilatation, and Gonioscopy is the standard "undilated" diagnostic procedure, it remains the primary choice. * **Retinoscopy (B):** While "dry" retinoscopy is possible, accurate retinoscopy (especially in children) requires **Mydriasis and Cycloplegia** to relax accommodation and allow light to enter through a larger pupillary aperture for a clearer reflex. * **Fundus Examination (C):** Although the central pole can be seen through an undilated pupil, a comprehensive evaluation of the peripheral retina and a detailed stereoscopic view of the optic disc require **Mydriasis**. **Clinical Pearls for NEET-PG:** * **Gold Standard:** Gonioscopy using a **Goldmann 3-mirror lens** or **Zeiss 4-mirror lens** is the gold standard for angle evaluation. * **Van Herick’s Technique:** A slit-lamp method to estimate angle depth *before* dilatation to prevent inducing acute angle-closure glaucoma. * **Dynamic Gonioscopy (Indentation):** Used to differentiate between appositional closure and permanent synechial closure.

Q: All of the following are seen in Iridocorneal endothelial syndrome except?

Cataract. **Iridocorneal Endothelial (ICE) Syndrome** is a group of rare, typically unilateral conditions characterized by an abnormal corneal endothelial proliferation. This "hammered silver" endothelial layer migrates across the anterior chamber angle and onto the iris surface, leading to secondary angle-closure glaucoma. ### **Explanation of Options:** * **Cataract (Correct Answer):** Cataract is **not** a primary feature of ICE syndrome. While a patient may coincidentally have a cataract due to age or long-term steroid use for glaucoma, it is not part of the diagnostic triad or the underlying pathophysiology of the syndrome. * **Corectopia:** This refers to the displacement of the pupil. In ICE syndrome, the contracting basement membrane (produced by the abnormal endothelium) pulls the iris, leading to pupillary displacement. * **Iris Atrophy:** This is a hallmark of the **Progressive Iris Atrophy** variant of ICE syndrome. The mechanical stretching and ischemia caused by the migrating membrane lead to thinning and hole formation (pseudopolycoria) in the iris. * **Iris Cysts:** While less common than atrophy, "ectropion uveae" and the formation of **pedunculated iris nodules** (Cogan-Reese syndrome) are classic features. These nodules can clinically mimic iris cysts or even melanoma. ### **NEET-PG High-Yield Pearls:** 1. **The ICE Triad:** Includes **Progressive Iris Atrophy**, **Chandler Syndrome** (most common; significant corneal edema), and **Cogan-Reese Syndrome** (iris nodules). 2. **Demographics:** Typically affects **young to middle-aged women** and is almost always **unilateral**. 3. **Pathogenesis:** Linked to the **herpes simplex virus (HSV)** DNA in some studies. 4. **Clinical Sign:** "Beaten bronze" or **"Hammered silver"** appearance of the corneal endothelium on slit-lamp examination. 5. **Complication:** Severe secondary angle-closure glaucoma due to the membrane obstructing the trabecular meshwork.

Q: A 30-year-old woman presents with sudden onset of a right-sided painful red eye accompanied by nausea, vomiting, and headache. What is the most likely diagnosis?

Acute congestive glaucoma. ### Explanation **Correct Option: A. Acute congestive glaucoma** The clinical presentation of sudden onset painful red eye, headache, and systemic symptoms like nausea and vomiting is a classic "textbook" description of **Acute Congestive Glaucoma** (Acute Angle-Closure Glaucoma). * **Mechanism:** It occurs due to a sudden rise in intraocular pressure (IOP) when the drainage angle is blocked. The high IOP causes corneal edema (leading to blurred vision/halos) and stimulates the vagus nerve, resulting in nausea and vomiting. * **Demographics:** While more common in elderly hypermetropes, it can occur in younger patients with predisposing anatomical factors. **Why the other options are incorrect:** * **B. Endophthalmitis:** This is an internal inflammation of the eye, usually occurring **post-surgery** or trauma. While it presents with pain and redness, the absence of a surgical history and the presence of systemic symptoms like vomiting make it less likely than glaucoma. * **C. Eales Disease:** This is an idiopathic peripheral perivasculitis (retinal disease) characterized by **painless** vitreous hemorrhage. It does not present with acute pain or redness. * **D. Trachoma:** A chronic keratoconjunctivitis caused by *Chlamydia trachomatis*. It presents with follicular hypertrophy and scarring over a long period, not as an acute, painful emergency with systemic symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Gonioscopy (to visualize the closed angle). * **Immediate Management:** IV Mannitol (osmotic diuretic) and Acetazolamide to rapidly lower IOP. * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI) – performed in both the affected and the fellow (prophylactic) eye. * **Classic Sign:** A vertically oval, semi-dilated, non-reacting pupil with a "steamy" or "cloudy" cornea.

Q: A patient on long-term steroid therapy develops certain ocular symptoms over a few weeks. Which of the following ocular conditions is commonly associated with chronic steroid use?

Open angle glaucoma. **Explanation:** **Why Open Angle Glaucoma is correct:** Chronic use of corticosteroids (especially topical, but also systemic or periocular) can lead to **Steroid-Induced Glaucoma**, which clinically mimics Primary Open Angle Glaucoma (POAG). The underlying mechanism involves the deposition of **glycosaminoglycans** and increased expression of the **MYOC (myocilin) gene** in the trabecular meshwork. This leads to physical "clogging" and increased resistance to aqueous outflow, resulting in elevated intraocular pressure (IOP). Approximately 5–10% of the population are "high responders" who develop significant IOP elevation within 2–4 weeks of therapy. **Why the other options are incorrect:** * **B. Conjunctival papillomatosis:** This is typically caused by Human Papillomavirus (HPV) infection, not steroid use. In fact, steroids may exacerbate viral infections by suppressing the local immune response. * **C. Uveitis:** Steroids are the *treatment* of choice for uveitis due to their potent anti-inflammatory properties. While steroids don't cause uveitis, they can mask its symptoms or lead to secondary complications like cataracts. **High-Yield Clinical Pearls for NEET-PG:** * **Route Risk:** Topical (drops/ointment) > Periocular injections > Systemic > Inhalational. * **Reversibility:** Unlike POAG, steroid-induced IOP elevation is usually reversible within weeks of discontinuing the drug, provided permanent damage to the meshwork hasn't occurred. * **The "Other" Steroid Side Effect:** Chronic steroid use is also strongly associated with **Posterior Subcapsular Cataract (PSC)**. * **Management:** The first step is to taper/stop the steroid or switch to "soft steroids" like **Loteprednol** or **Fluorometholone**, which have a lower risk of raising IOP.

Question 1

True about angle recession glaucoma, all are correct except:

Accepted Answer

Miosis is commonly seen

Answer

Tears of the iris sphincter and ciliary body

Answer

Angle recession more than 180 degrees

Answer

Secondary open angle glaucoma

Question 2

In buphthalmos, what is the state of the lens?

Accepted Answer

Anteroposterior flat

Answer

Small

Answer

Large

Answer

None of the above

Question 3

A mild, dilated, and fixed pupil is seen in which of the following conditions?

Accepted Answer

Acute congestive glaucoma

Answer

Iridocyclitis

Answer

Chronic congestive glaucoma

Answer

Open angle glaucoma

Question 4

Which of the following statements is not true regarding trabeculoplasty?

Accepted Answer

It is useful in inflammatory glaucoma.

Answer

Argon laser is used.

Answer

The therapeutic effect is typically observed within a few weeks.

Answer

A transient rise in intraocular pressure can be seen as a complication.

Question 5

Which of the following procedures does not require dilatation of the pupil?

Accepted Answer

Gonioscopy

Answer

Laser iridotomy

Answer

Retinoscopy

Answer

Fundus examination

Question 6

All of the following are true about pigmentary glaucoma except?

Accepted Answer

The intensity of pigment deposit in the angle is related to iris color

Answer

It occurs more often in young myopic men

Answer

Iris transillumination defects are noted

Answer

It is associated with Krukenberg's spindle

Question 7

All of the following are seen in Iridocorneal endothelial syndrome except?

Accepted Answer

Cataract

Answer

Corectopia

Answer

Iris cysts

Answer

Iris atrophy

Question 8

In which type of glaucoma are coloured haloes NOT seen?

Accepted Answer

Steroid-induced glaucoma

Answer

Phacomorphic glaucoma

Answer

Pigmentary glaucoma

Answer

Glaucoma of epidemic dropsy

Question 9

A 30-year-old woman presents with sudden onset of a right-sided painful red eye accompanied by nausea, vomiting, and headache. What is the most likely diagnosis?

Accepted Answer

Acute congestive glaucoma

Answer

Endophthalmitis

Answer

Eales disease

Answer

Trachoma

Question 10

A patient on long-term steroid therapy develops certain ocular symptoms over a few weeks. Which of the following ocular conditions is commonly associated with chronic steroid use?

Accepted Answer

Open angle glaucoma

Answer

Conjunctival papillomatosis

Answer

Uveitis

Answer

None of the above

Glaucoma — MCQs

Glaucoma — MCQs

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