Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 151: True about angle recession glaucoma, all are correct except:

A. Miosis is commonly seen (Correct Answer)
B. Tears of the iris sphincter and ciliary body
C. Angle recession more than 180 degrees
D. Secondary open angle glaucoma

Explanation: **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.

Question 152: In buphthalmos, what is the state of the lens?

A. Anteroposterior flat (Correct Answer)
B. Small
C. Large
D. None of the above

Explanation: **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).

Question 153: A mild, dilated, and fixed pupil is seen in which of the following conditions?

A. Acute congestive glaucoma (Correct Answer)
B. Iridocyclitis
C. Chronic congestive glaucoma
D. Open angle glaucoma

Explanation: 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.

Question 154: Which of the following statements is not true regarding trabeculoplasty?

A. Argon laser is used.
B. The therapeutic effect is typically observed within a few weeks.
C. It is useful in inflammatory glaucoma. (Correct Answer)
D. A transient rise in intraocular pressure can be seen as a complication.

Explanation: **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.

Question 155: Which of the following procedures does not require dilatation of the pupil?

A. Laser iridotomy
B. Retinoscopy
C. Fundus examination
D. Gonioscopy (Correct Answer)

Explanation: **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.

Question 156: All of the following are true about pigmentary glaucoma except?

A. It occurs more often in young myopic men
B. Iris transillumination defects are noted
C. It is associated with Krukenberg's spindle
D. The intensity of pigment deposit in the angle is related to iris color (Correct Answer)

Explanation: **Explanation:** **Pigmentary Glaucoma (PG)** is a secondary open-angle glaucoma caused by **Pigment Dispersion Syndrome (PDS)**. The fundamental pathophysiology involves a **posterior bowing of the iris**, which causes the posterior iris pigment epithelium to rub against the lens zonules (mechanical friction), leading to pigment release. **Why Option D is the Correct Answer (The False Statement):** The intensity of pigment deposition in the trabecular meshwork is determined by the **amount of pigment released** from the iris pigment epithelium due to mechanical friction, not by the overall color of the iris (stromal pigmentation). Whether the eye is blue or brown, the pathological process depends on the anatomical configuration (concave iris) and the resulting zonular contact. **Analysis of Other Options:** * **Option A:** PG typically affects **young, Caucasian, myopic males** (20–40 years). Myopic eyes often have a deeper anterior chamber and a more concave iris configuration, predisposing them to this condition. * **Option B:** The mechanical rubbing leads to loss of pigment from the iris. This results in characteristic **radial, spoke-like iris transillumination defects** (mid-peripheral). * **Option C:** **Krukenberg’s spindle** is a classic sign where pigment deposits on the corneal endothelium in a vertical, spindle-shaped pattern due to convection currents in the aqueous humor. **High-Yield Clinical Pearls for NEET-PG:** 1. **Sampaolesi’s Line:** Pigment deposition at or anterior to Schwalbe’s line (also seen in Pseudoexfoliation syndrome). 2. **Zentmayer’s Ring (Scheie’s Line):** Pigment deposition on the posterior lens capsule near the equator. 3. **Reverse Pupillary Block:** The underlying mechanism where pressure in the anterior chamber exceeds posterior chamber pressure, pushing the iris backward. 4. **Management:** Laser Peripheral Iridotomy (LPI) can flatten the iris contour by equalizing pressure, reducing further pigment release.

Question 157: All of the following are seen in Iridocorneal endothelial syndrome except?

A. Cataract (Correct Answer)
B. Corectopia
C. Iris cysts
D. Iris atrophy

Explanation: **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.

Question 158: In which type of glaucoma are coloured haloes NOT seen?

A. Phacomorphic glaucoma
B. Pigmentary glaucoma
C. Glaucoma of epidemic dropsy
D. Steroid-induced glaucoma (Correct Answer)

Explanation: **Explanation:** The presence of **colored haloes** in glaucoma is primarily due to **corneal edema**. When the Intraocular Pressure (IOP) rises rapidly or reaches very high levels, the corneal endothelium cannot pump fluid out efficiently. This fluid accumulates in the corneal epithelium, causing it to act like a diffraction grating that splits white light into its spectral components (the "Edridge-Green" phenomenon). **Why Steroid-induced Glaucoma is the correct answer:** Steroid-induced glaucoma is a type of **secondary open-angle glaucoma**. It typically presents with a slow, insidious, and painless rise in IOP. Because the pressure rise is gradual, the corneal endothelium has time to compensate, and corneal edema does not occur. Therefore, patients remain asymptomatic until significant field loss occurs, and they **do not** see colored haloes. **Analysis of Incorrect Options:** * **Phacomorphic Glaucoma:** This is an acute secondary angle-closure glaucoma caused by a swollen (intumescent) lens. The IOP rise is sudden and severe, leading to acute corneal edema and prominent haloes. * **Pigmentary Glaucoma:** During "pigment dispersion crises" (e.g., after vigorous exercise), there is a sudden shower of pigment that blocks the trabecular meshwork, causing transient spikes in IOP and subsequent haloes. * **Glaucoma of Epidemic Dropsy:** Caused by Sanguinarine (from Argemone mexicana oil), this condition involves increased production of aqueous and dilated capillaries. It is characterized by very high IOP and marked corneal edema, making haloes a common feature. **NEET-PG High-Yield Pearls:** * **Differential Diagnosis of Haloes:** Apart from glaucoma (corneal edema), haloes are also seen in **Cataract** (due to protein clusters in the lens). * **The Fincham’s Test:** Used to differentiate glaucomatous haloes (which persist/break when a stenopeic slit is passed across the eye) from cataractous haloes (which remain intact). * **Steroid Response:** Approximately 5-10% of the population are "high responders" who develop significant IOP elevation after 4-6 weeks of topical steroid use.

Question 159: 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?

A. Acute congestive glaucoma (Correct Answer)
B. Endophthalmitis
C. Eales disease
D. Trachoma

Explanation: ### 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.

Question 160: 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?

A. Open angle glaucoma (Correct Answer)
B. Conjunctival papillomatosis
C. Uveitis
D. None of the above

Explanation: **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.

Practice by Chapter

Aqueous Humor Dynamics

Practice Questions

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

Practice Questions

Laser Therapy in Glaucoma

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Glaucoma Filtration Surgery

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Glaucoma Drainage Devices

Practice Questions

Angle Assessment Techniques

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Visual Field Testing in Glaucoma

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Glaucoma — MCQs

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