Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 171: Triple surgery in glaucoma includes all of the following except?

A. Trabeculectomy
B. PCIOL implantation
C. Insertion of drainage device (Correct Answer)
D. Extra capsular cataract extraction

Explanation: **Explanation:** The term **"Triple Surgery"** in ophthalmology refers to a specific combined procedure designed to address both cataract and glaucoma in a single surgical sitting. The three components of this procedure are: 1. **Cataract Extraction:** This can be via Extra Capsular Cataract Extraction (ECCE), Small Incision Cataract Surgery (SICS), or Phacoemulsification. 2. **PCIOL Implantation:** Placement of a Posterior Chamber Intraocular Lens. 3. **Filtering Surgery:** Specifically, a **Trabeculectomy** (with or without antimetabolites like Mitomycin-C). **Why Option C is the correct answer:** A **Glaucoma Drainage Device (GDD)** or valve (e.g., Ahmed Glaucoma Valve) is used in refractory glaucomas where trabeculectomy has failed or is likely to fail (e.g., neovascular glaucoma). While a GDD can be combined with cataract surgery, it is **not** part of the classic definition of "Triple Surgery." **Analysis of Incorrect Options:** * **Option A (Trabeculectomy):** This is the standard "filtering" component of the triple procedure to lower intraocular pressure. * **Option B & D (PCIOL & ECCE):** These represent the cataract management portion of the procedure. Modern triple surgery usually utilizes Phacoemulsification, but ECCE remains a valid component in the classic definition. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Triple surgery is indicated in patients with significant cataract and advanced glaucoma where a single-stage procedure is preferred to avoid two separate surgeries. * **Advantage:** It prevents the post-operative IOP spikes often seen after standalone cataract surgery in glaucoma patients. * **Site:** It can be performed through a single incision (one-site) or two separate incisions (two-site). Two-site surgery is often preferred as it allows for better control of the bleb and less inflammation.

Question 172: Pilocarpine reduces intraocular pressure in persons with closed-angle glaucoma by:

A. Reducing aqueous humor secretion
B. Constricting iris sphincter muscle
C. Increasing aqueous humor outflow (Correct Answer)
D. Relaxing ciliary muscle

Explanation: **Explanation:** Pilocarpine is a direct-acting parasympathomimetic (miotic) agent. In **Primary Angle-Closure Glaucoma (PACG)**, the fundamental pathology is the mechanical obstruction of the trabecular meshwork by the peripheral iris. **Why Option C is correct:** Pilocarpine acts on the **muscarinic (M3) receptors** of the **iris sphincter muscle**, causing pupillary constriction (miosis). This contraction pulls the peripheral iris away from the trabecular meshwork, effectively "opening" the angle. By clearing this mechanical blockage, the aqueous humor can once again access the drainage channels, thereby **increasing aqueous humor outflow** and rapidly reducing intraocular pressure (IOP). **Why other options are incorrect:** * **Option A:** Aqueous secretion is reduced by Beta-blockers (Timolol), Alpha-2 agonists (Brimonidine), and Carbonic anhydrase inhibitors (Acetazolamide), not pilocarpine. * **Option B:** While pilocarpine *does* constrict the iris sphincter, this is the **mechanism**, not the physiological **result** that lowers IOP. The question asks how it reduces pressure; it does so by increasing outflow via miosis. * **Option D:** Pilocarpine actually causes **contraction** of the ciliary muscle (not relaxation). In open-angle glaucoma, this contraction pulls the scleral spur and opens the trabecular meshwork spaces. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** Pilocarpine is the drug of choice for the immediate medical management of acute angle-closure glaucoma (usually 2% concentration). * **Paradoxical Effect:** It should not be used if the IOP is very high (>40-50 mmHg) because the iris sphincter becomes ischemic and unresponsive to the drug. * **Side Effects:** Accommodative spasm (induced myopia), brow ache, and increased risk of retinal detachment. * **Contraindication:** It is contraindicated in **Uveitic Glaucoma** as it may promote the formation of posterior synechiae.

Question 173: Which of the following conditions is associated with cystoid macular edema?

A. Overuse of ocular analgesics
B. Glaucoma
C. Central Retinal Vein Occlusion (Correct Answer)
D. Topical steroid therapy

Explanation: **Explanation:** **Cystoid Macular Edema (CME)** is the accumulation of fluid in the outer plexiform (Henle’s) and inner nuclear layers of the retina, forming characteristic fluid-filled cysts. **Why Option C is Correct:** **Central Retinal Vein Occlusion (CRVO)** is a classic cause of CME. The underlying mechanism involves venous stasis and increased intraluminal pressure, which leads to the breakdown of the **blood-retinal barrier**. This results in the leakage of fluid and plasma constituents into the extracellular space of the macula. On Fundus Fluorescein Angiography (FFA), this typically presents as a "flower-petal" appearance. **Analysis of Incorrect Options:** * **Option A (Ocular Analgesics):** There is no established clinical link between the overuse of topical analgesics and the development of CME. Overuse is more commonly associated with corneal epithelial toxicity or "ring" ulcers. * **Option B (Glaucoma):** While glaucoma itself does not cause CME, certain **prostaglandin analogues** (e.g., Latanoprost) used to treat glaucoma are known triggers for CME, especially in aphakic or pseudophakic eyes. * **Option D (Topical Steroids):** Steroids are actually used to **treat** CME by reducing inflammation and stabilizing the blood-retinal barrier. They do not cause it. **NEET-PG High-Yield Pearls:** * **Irvine-Gass Syndrome:** CME occurring after cataract surgery (peaks at 6–10 weeks). * **Drug-induced CME:** Epinephrine, Latanoprost, and Nicotinic acid. * **Gold Standard Diagnosis:** Optical Coherence Tomography (OCT) shows intraretinal cystic spaces. * **Mnemonic for CME Causes (DEPRIVED):** **D**iabetes, **E**pinephrine, **P**ars planitis, **R**etinitis pigmentosa, **I**rvine-Gass, **V**ein occlusion (CRVO), **E**2 (Prostaglandins), **D**ialysis (hypotony).

Question 174: Based on the perimetry result print-out, what is the most likely diagnosis?

A. Retinitis pigmentosa
B. Open angle glaucoma (Correct Answer)
C. Pituitary adenoma
D. Temporal lobe infarct

Explanation: ***Open angle glaucoma*** - Characteristic **arcuate scotoma** and **nasal step** pattern on perimetry, beginning with **paracentral scotomas** that respect the horizontal meridian. - Progressive **peripheral visual field loss** that spares central vision until late stages, consistent with **glaucomatous optic neuropathy**. *Retinitis pigmentosa* - Presents with **ring-shaped scotomas** or **concentric peripheral field loss** starting from the periphery and progressing inward. - Associated with **night blindness** and **tunnel vision**, showing a different perimetric pattern than glaucomatous defects. *Pituitary adenoma* - Causes **bitemporal hemianopia** due to compression of the **optic chiasm**, affecting temporal fields of both eyes. - Field defects are **symmetric** and **homonymous**, respecting the vertical meridian rather than horizontal. *Temporal lobe infarct* - Results in **homonymous superior quadrantanopia** ("pie in the sky" defect) affecting the same quadrant in both eyes. - Visual field loss is **congruous** and involves the **contralateral visual field**, not the characteristic glaucomatous pattern.

Question 175: What is the ideal treatment for subacute angle closure glaucoma?

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

Explanation: **Explanation:** **1. Why Peripheral Iridectomy (PI) is the Correct Answer:** Subacute angle closure glaucoma is characterized by recurrent, self-limiting episodes of pupillary block. The underlying pathophysiology is a **relative pupillary block**, where the iris-lens contact prevents aqueous humor from reaching the anterior chamber, causing the iris to bulge forward (iris bombé) and close the angle. **Laser Peripheral Iridotomy (LPI)** or **Surgical Peripheral Iridectomy** 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 prevents future episodes of angle closure. In modern practice, Laser PI is the gold standard, while surgical PI is reserved for cases where laser is unavailable or visualization is poor. **2. Why Other Options are Incorrect:** * **Timolol (Option A):** This is a beta-blocker that reduces aqueous production. While it helps lower Intraocular Pressure (IOP), it does not address the anatomical pupillary block, which is the root cause. * **Pilocarpine (Option B):** This is a miotic used to pull the iris away from the angle. While used as an emergency medical adjunct, it is not a definitive cure and can sometimes worsen pupillary block by increasing the iris-lens contact area. * **Trabeculectomy (Option D):** This is a filtering surgery used for chronic glaucoma when medical or laser therapy fails. It is too invasive for subacute cases where the angle is still functional between episodes. **3. Clinical Pearls for NEET-PG:** * **Prophylaxis:** Always perform PI in the **fellow eye** (contralateral eye) because the anatomical predisposition is bilateral. * **Symptoms:** Patients typically present with "haloes around lights" and transient ocular pain/blurring, often in the evenings (mydriasis-induced). * **Drug of Choice for Acute Attack:** Systemic Acetazolamide and IV Mannitol (to rapidly lower IOP) followed by topical Pilocarpine once IOP is <30 mmHg.

Question 176: Which of the following is true about intraocular pressure?

A. It is more common in males.
B. Diurnal variation is not present in glaucomatous patients.
C. There is no change in postural variations.
D. It increases with advancing age. (Correct Answer)

Explanation: **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.

Question 177: Argon Laser trabeculoplasty is used in which type of glaucoma?

A. Open angle glaucoma (Correct Answer)
B. Angle closure glaucoma
C. Buphthalmos
D. None of the above

Explanation: **Explanation:** **Argon Laser Trabeculoplasty (ALT)** is a procedure designed to lower intraocular pressure (IOP) by increasing aqueous outflow through the trabecular meshwork. 1. **Why Open Angle Glaucoma (OAG) is correct:** In OAG, the drainage angle is anatomically open, but there is resistance to aqueous outflow within the trabecular meshwork [1]. During ALT, laser burns are applied to the **junction of the pigmented and non-pigmented trabecular meshwork**. This causes mechanical tightening of the tissue, which "opens up" the adjacent untreated pores of the sieve-like meshwork, facilitating better drainage. It is primarily indicated for Primary Open Angle Glaucoma (POAG) when medical therapy is insufficient or poorly tolerated. 2. **Why other options are incorrect:** * **Angle Closure Glaucoma:** The primary pathology is a physically blocked angle (apposition of the iris to the cornea), where the iris reaches the back of the cornea and obliterates the filtration angle [1]. Laser cannot reach the trabecular meshwork if the angle is closed. The treatment of choice here is **Laser Peripheral Iridotomy (LPI)**. * **Buphthalmos (Congenital Glaucoma):** This is caused by a structural defect (Barkan’s membrane) covering the angle. Laser is ineffective; the definitive treatment is surgical (**Goniotomy or Trabeculotomy**). **High-Yield Clinical Pearls for NEET-PG:** * **Site of Laser:** Anterior part of the pigmented trabecular meshwork. * **Mechanism:** Mechanical stretching of the trabecular lamellae. * **Selective Laser Trabeculoplasty (SLT):** A newer alternative to ALT that uses a YAG laser to target only pigmented cells, causing less thermal damage and allowing for repeat procedures. * **Contraindication:** ALT is ineffective in secondary glaucomas like inflammatory or neovascular glaucoma where the meshwork is covered by membranes.

Question 178: Painful loss of vision is seen in which of the following conditions?

A. Senile cataract
B. Primary open-angle glaucoma (Correct Answer)
C. Primary angle-closure glaucoma
D. Anterior uveitis

Explanation: **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).

Question 179: What is the treatment of malignant glaucoma?

A. Pilocarpine
B. Cyclocryotherapy
C. Vitreous aspiration (Correct Answer)
D. Trabeculectomy

Explanation: ### Explanation **Malignant Glaucoma (Ciliary Block Glaucoma)** is a rare but serious complication, typically occurring after intraocular surgery in patients with narrow-angle glaucoma. The underlying mechanism is the **misdirection of aqueous humor** into the vitreous cavity, which pushes the lens-iris diaphragm forward, causing a shallow anterior chamber and high intraocular pressure (IOP). **Why Vitreous Aspiration is Correct:** The definitive management aims to break the ciliary block and relocate the trapped aqueous. **Vitreous aspiration** (or pars plana vitrectomy) directly removes the fluid/vitreous from the posterior segment, allowing the lens-iris diaphragm to move back to its normal position, thereby deepening the anterior chamber and lowering IOP. **Analysis of Incorrect Options:** * **Pilocarpine (A):** This is **contraindicated**. As a miotic, it causes forward movement of the lens-iris diaphragm and increases ciliary body congestion, worsening the ciliary block. * **Cyclocryotherapy (B):** This is a destructive procedure used for refractory end-stage glaucoma to reduce aqueous production; it does not address the anatomical misdirection in malignant glaucoma. * **Trabeculectomy (D):** This is a filtration surgery. In malignant glaucoma, the anterior chamber is flat; performing a trabeculectomy without relieving the posterior pressure will fail and may lead to further complications like suprachoroidal hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Medical Management (Initial):** Atropine (1% drops) is the drug of choice. It acts as a **cycloplegic**, relaxing the ciliary muscle and pulling the lens-iris diaphragm backward. * **Laser Treatment:** Nd:YAG laser capsulotomy or hyaloidotomy can be used to break the block in pseudophakic/aphakic eyes. * **Classic Presentation:** A shallow anterior chamber and high IOP following surgery (like trabeculectomy or cataract extraction) where a patent peripheral iridectomy is already present.

Question 180: Fincham's test differentiates cataract from which of the following conditions?

A. Conjunctivitis
B. Iridocyclitis
C. Open angle Glaucoma
D. Acute Congestive Glaucoma (Correct Answer)

Explanation: **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.

Practice by Chapter

Aqueous Humor Dynamics

Practice Questions

Primary Open-Angle Glaucoma

Practice Questions

Primary Angle-Closure Glaucoma

Practice Questions

Secondary Open-Angle Glaucomas

Practice Questions

Secondary Angle-Closure Glaucomas

Practice Questions

Developmental and Congenital Glaucomas

Practice Questions

Medical Management of Glaucoma

Practice Questions

Laser Therapy in Glaucoma

Practice Questions

Glaucoma Filtration Surgery

Practice Questions

Glaucoma Drainage Devices

Practice Questions

Angle Assessment Techniques

Practice Questions

Visual Field Testing in Glaucoma

Practice Questions

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Glaucoma — MCQs

Glaucoma — MCQs

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