Glaucoma Practice Questions

Q: What is the earliest symptom of congenital glaucoma?

Photophobia. **Explanation:** Congenital glaucoma (Buphthalmos) results from developmental anomalies of the angle of the anterior chamber, leading to increased intraocular pressure (IOP). **Why Photophobia is the correct answer:** Photophobia is considered the **earliest** and most common symptom. It occurs due to corneal edema caused by elevated IOP. When the cornea swells, it causes light to scatter, irritating the rich nerve endings of the corneal epithelium. This leads to the classic triad of symptoms: **Photophobia, Lacrimation, and Blepharospasm.** While all three often appear together, photophobia is clinically recognized as the initial sign that parents notice. **Analysis of Incorrect Options:** * **Lacrimation (A) and Blepharospasm (B):** These are part of the classic triad but are usually secondary responses to the irritation caused by corneal edema and photophobia. They occur almost simultaneously but are preceded by light sensitivity. * **Diminution of vision (D):** This is a late feature. In infants, vision loss occurs much later due to optic nerve damage (cupping), corneal scarring, or secondary amblyopia. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Photophobia + Lacrimation + Blepharospasm. * **Earliest Sign:** Corneal edema (hazy cornea). * **Haab’s Striae:** Horizontal or curvilinear breaks in Descemet’s membrane due to corneal stretching. * **Buphthalmos:** "Ox-eye" appearance; occurs because the infant's sclera is distensible and stretches when IOP is >21 mmHg (usually seen if glaucoma occurs before age 3). * **Treatment of Choice:** Surgery is the primary treatment. **Goniotomy** (if the cornea is clear) or **Trabeculotomy/Trabeculectomy** (if the cornea is hazy). Medical therapy is only a temporary measure.

Q: Which type of glaucoma is associated with cataract?

Phacomorphic glaucoma. **Explanation:** **Phacomorphic glaucoma** is a type of secondary angle-closure glaucoma caused directly by an advanced cataract. As the lens becomes **intumescent** (swollen and enlarged) during the cataractous process, it pushes the iris-lens diaphragm forward. This leads to pupillary block and subsequent narrowing or closure of the anterior chamber angle, resulting in a rapid rise in intraocular pressure (IOP). **Analysis of Incorrect Options:** * **Neovascular glaucoma:** This is a secondary glaucoma caused by the growth of new vessels (neovascularization) on the iris and angle, typically triggered by retinal ischemia (e.g., Diabetic Retinopathy or CRVO), not the lens itself. * **Phacoanaphylactic glaucoma:** This is an inflammatory (uveitic) glaucoma caused by a hypersensitivity reaction to lens proteins following trauma or surgery. While lens-related, it is primarily an **immunological** response rather than a direct mechanical effect of the cataractous mass. * **Buphthalmos:** This refers to the "ox-eye" appearance (enlarged eyeball) seen in **Congenital Glaucoma** due to the distensibility of the infant sclera under high IOP. It is not associated with adult cataract formation. **High-Yield Clinical Pearls for NEET-PG:** * **Phacolytic Glaucoma:** Occurs when a **hypermature** cataract leaks soluble lens proteins through an intact capsule, which then clog the trabecular meshwork (a form of open-angle glaucoma). * **Treatment of Phacomorphic Glaucoma:** Immediate medical management to lower IOP, followed by **cataract extraction** (definitive treatment). * **Key Distinction:** Phacomorphic = Swollen lens (Angle-closure); Phacolytic = Leaking proteins (Open-angle).

Q: All are the features of an acute attack of primary narrow-angle glaucoma except?

Disc shows glaucomatous cupping. **Explanation:** Acute Angle Closure Glaucoma (AACG) is an ophthalmic emergency characterized by a sudden, precipitous rise in intraocular pressure (IOP) due to total mechanical obstruction of the trabecular meshwork by the peripheral iris. **Why Option C is the Correct Answer:** Glaucomatous cupping is a feature of **chronic** glaucoma. It occurs due to the progressive loss of retinal nerve fiber layer (RNFL) axons over time. In an **acute** attack, the optic disc is typically **congested, edematous, and hyperemic** due to the sudden mechanical pressure. Permanent cupping does not develop instantly; it requires prolonged exposure to high IOP. **Analysis of Incorrect Options:** * **Option A:** During an acute attack, IOP typically spikes to **60–70 mmHg**, far exceeding the normal range (10–21 mmHg). This causes corneal edema and severe pain. * **Option B:** The clinical presentation includes a "ciliary flush" (redness), excruciating pain (due to trigeminal nerve stimulation), and tenderness of the globe. * **Option C:** Primary Angle Closure is a **bilateral anatomical predisposition**. The "fellow eye" almost always has a shallow anterior chamber and a narrow angle, putting it at high risk for a future attack. **Clinical Pearls for NEET-PG:** * **Classic Sign:** Vertically oval, semi-dilated, non-reactive pupil. * **Symptoms:** Halos around lights (due to corneal edema), nausea, and vomiting (often misdiagnosed as an abdominal emergency). * **Immediate Management:** IV Mannitol, Acetazolamide, and topical beta-blockers to lower IOP. * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI) for **both** the affected and the fellow eye (prophylactic).

Q: Which drug is used in refractory glaucoma?

Alpha agonist. ### Explanation **Correct Option: C (Alpha agonist)** In the context of refractory glaucoma (glaucoma that remains uncontrolled despite conventional medical or surgical therapy), **Apraclonidine** (a selective alpha-2 agonist) is the drug of choice. It is highly effective for the short-term control of intraocular pressure (IOP) spikes, particularly post-laser procedures (like iridotomy or trabeculoplasty) and in cases resistant to other medications. It works by decreasing aqueous humor production and increasing uveoscleral outflow. **Brimonidine** is another alpha-2 agonist used for long-term management due to its neuroprotective properties. **Analysis of Incorrect Options:** * **A. Systemic glucocorticoids:** These are contraindicated in glaucoma. Steroids (topical or systemic) can decrease aqueous outflow through the trabecular meshwork, leading to "steroid-induced glaucoma." * **B. ACE inhibitors:** While systemic ACE inhibitors are used for hypertension, they have no established clinical role in the primary management of refractory glaucoma. * **D. Beta blockers:** While Timolol is a first-line agent for chronic open-angle glaucoma, it is usually the first drug tried. If the glaucoma is labeled "refractory," it implies that standard treatments like beta-blockers have already failed to control the IOP. **NEET-PG High-Yield Pearls:** * **Drug of choice for post-laser IOP spikes:** Apraclonidine. * **Side effect of Apraclonidine:** High incidence of follicular conjunctivitis and "tachyphylaxis" (loss of efficacy over time), which is why it is used for short-term refractory cases. * **Brimonidine:** Can cause "granulomatous uveitis" and is contraindicated in infants due to the risk of CNS depression/apnea. * **First-line for most Glaucomas:** Prostaglandin analogues (Latanoprost) are currently preferred over Beta-blockers due to better efficacy and fewer systemic side effects.

Q: Which drug is used during a trabeculectomy procedure?

Mitomycin-C. **Explanation:** The correct answer is **Mitomycin-C (MMC)**. **1. Why Mitomycin-C is correct:** Trabeculectomy is a filtering surgery for glaucoma where a "fistula" is created to drain aqueous humor. The most common cause of surgical failure is **subconjunctival fibrosis (scarring)** at the site of the bleb. Mitomycin-C is a potent **alkylating agent** that inhibits fibroblast proliferation and DNA synthesis. When applied topically to the scleral bed during surgery (usually via a soaked sponge), it acts as an **antimetabolite** to prevent scarring, thereby maintaining the patency of the filtration site and ensuring long-term intraocular pressure (IOP) control. **2. Why the other options are incorrect:** * **Azathioprine:** An immunosuppressant used in systemic autoimmune diseases and organ transplants; it is not used topically in glaucoma surgery. * **Cetuximab:** A monoclonal antibody (EGFR inhibitor) used in treating colorectal and head/neck cancers; it has no role in ophthalmic wound healing. * **Ketorolac:** A topical NSAID used to manage post-operative inflammation and pain; while used in ophthalmology, it does not prevent the fibroblast proliferation required for trabeculectomy success. **3. High-Yield Clinical Pearls for NEET-PG:** * **5-Fluorouracil (5-FU):** Another antimetabolite used in trabeculectomy, though MMC is more potent and requires a shorter application time. * **MMC Concentration:** Typically used in concentrations of **0.02% to 0.04%**. * **Complications:** Over-use of MMC can lead to "thin-walled cystic blebs," which carry a high risk of **blebitis** and **endophthalmitis**. * **Other uses of MMC in Ophthalmology:** Pterygium surgery (to prevent recurrence) and Haze prevention after PRK (Refractive surgery).

Q: Which cells are affected in glaucomatous optic neuropathy?

Ganglion cells. **Explanation:** **Glaucomatous Optic Neuropathy (GON)** is characterized by progressive damage to the optic nerve, primarily involving the **Retinal Ganglion Cells (RGCs)** and their axons. 1. **Why Ganglion Cells are correct:** The pathophysiology of glaucoma involves mechanical compression (due to elevated Intraocular Pressure) and vascular ischemia at the lamina cribrosa. This leads to the **apoptosis (programmed cell death)** of Retinal Ganglion Cells. Since the axons of these RGCs converge to form the optic nerve, their loss results in the characteristic "cupping" of the optic disc and corresponding visual field defects. 2. **Why other options are incorrect:** * **Amacrine and Bipolar cells:** These are interneurons located in the inner nuclear layer of the retina. While some secondary degeneration may occur in advanced stages, they are not the primary site of injury in glaucoma. * **Rods and Cones:** These are photoreceptors located in the outermost layer of the retina. They are responsible for converting light into electrical signals. Glaucoma is a disease of the "inner retina" (output neurons), whereas diseases like Retinitis Pigmentosa primarily affect the photoreceptors. **Clinical Pearls for NEET-PG:** * **Earliest Change:** The earliest structural change in glaucoma is often the thinning of the **Retinal Nerve Fiber Layer (RNFL)**, which consists of RGC axons. * **Mechanism of Death:** RGC death in glaucoma occurs via **Apoptosis**, triggered by neurotrophin deprivation and glutamate excitotoxicity. * **Diagnostic Tool:** **Optical Coherence Tomography (OCT)** is used to quantify the loss of the Ganglion Cell Complex (GCC) and RNFL thickness for early diagnosis.

Q: A 55-year-old lady presented with sudden onset of severe eye pain and a shallow anterior chamber. What is the treatment of choice?

Intravenous mannitol & Acetazolamide. ### Explanation **Diagnosis: Acute Angle-Closure Glaucoma (AACG)** The clinical presentation of sudden onset severe eye pain associated with a shallow anterior chamber in a middle-aged female is a classic description of **Acute Angle-Closure Glaucoma**. This is a medical emergency caused by a rapid rise in intraocular pressure (IOP). **Why Option B is Correct:** The immediate goal of treatment is to **lower the IOP rapidly** to prevent permanent optic nerve damage and clear corneal edema. * **Intravenous Mannitol:** An osmotic diuretic that creates an osmotic gradient, drawing fluid out of the vitreous into the bloodstream, thereby rapidly reducing IOP. * **Acetazolamide:** A carbonic anhydrase inhibitor that reduces the production of aqueous humor. Once the pressure is controlled, the definitive treatment is a Peripheral Iridotomy (PI). **Why Other Options are Incorrect:** * **A. Atropine:** This is a strong mydriatic (dilates the pupil). In AACG, mydriasis further crowds the angle and worsens the pupillary block, potentially exacerbating the condition. It is strictly contraindicated. * **C. Atenolol:** While beta-blockers (like Timolol) are used topically in glaucoma, systemic Atenolol is a cardioselective beta-1 blocker and has no significant role in the emergency management of acute ocular hypertension. * **D. Intravenous Steroids:** These are used for inflammatory conditions (like optic neuritis or uveitis) but do not lower IOP in an acute glaucoma crisis. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for immediate IOP reduction:** IV Mannitol. * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI) – performed on both the affected and the fellow (prophylactic) eye. * **Classic Signs:** "Steamy" or hazy cornea, mid-dilated non-reactive pupil, and a "stony hard" eye on palpation. * **Risk Factors:** Hypermetropia (small eyes), advancing age, and female gender.

Q: Which beta-1 selective blocker is used in the management of glaucoma?

Betaxolol. **Explanation:** **Betaxolol** is the correct answer because it is the only **selective beta-1 (β1) adrenergic receptor antagonist** available for topical ophthalmic use. ### Why Betaxolol is Correct: Most topical beta-blockers used in glaucoma are non-selective, meaning they block both β1 (heart) and β2 (lungs) receptors. Betaxolol specifically targets β1 receptors. While it is slightly less potent in lowering intraocular pressure (IOP) compared to timolol, its selectivity makes it the **safest choice for patients with underlying respiratory conditions** like asthma or Chronic Obstructive Pulmonary Disease (COPD), as it minimizes the risk of drug-induced bronchospasm. ### Why Other Options are Incorrect: * **Timolol:** The "gold standard" and most commonly used beta-blocker, but it is **non-selective** (blocks both β1 and β2). It is contraindicated in asthmatics. * **Levobunolol:** A potent **non-selective** beta-blocker with a long duration of action, often used for once-daily dosing. * **Carteolol:** A **non-selective** beta-blocker that possesses **Intrinsic Sympathomimetic Activity (ISA)**. This property may result in fewer bradycardic side effects and is theoretically less likely to adversely affect serum lipid profiles. ### High-Yield Clinical Pearls for NEET-PG: * **Mechanism of Action:** Beta-blockers reduce IOP by **decreasing the production of aqueous humor** from the ciliary body epithelium. * **Neuroprotection:** Betaxolol is often cited for having potential neuroprotective properties (via calcium channel blocking activity), which may benefit the optic nerve beyond just lowering IOP. * **Side Effects:** Always remember the systemic absorption of topical drops. Even selective blockers should be used with caution in patients with severe heart block or heart failure. * **Nasolacrimal Occlusion:** Advise patients to perform punctal occlusion after instillation to reduce systemic absorption and side effects.

Question 1

What is the earliest symptom of congenital glaucoma?

Accepted Answer

Photophobia

Answer

Lacrimation

Answer

Blepharospasm

Answer

Diminution of vision

Question 2

Which type of glaucoma is associated with cataract?

Accepted Answer

Phacomorphic glaucoma

Answer

Neovascular glaucoma

Answer

Phacoanaphylactic glaucoma

Answer

Buphthalmos

Question 3

All are the features of an acute attack of primary narrow-angle glaucoma except?

Accepted Answer

Disc shows glaucomatous cupping

Answer

Intraocular pressure is raised up to 60-70 mm of Hg

Answer

Eye is red, painful and tender

Answer

Fellow eye also shows shallow anterior chamber

Question 4

What is the standard in perimetry?

Accepted Answer

Goldman type III

Answer

Goldman type I

Answer

Goldman type II

Answer

Goldman type IV

Question 5

Which drug is used in refractory glaucoma?

Accepted Answer

Alpha agonist

Answer

Systemic glucocorticoid

Answer

ACE inhibitor

Answer

Beta blocker

Question 6

Which drug is used during a trabeculectomy procedure?

Accepted Answer

Mitomycin-C

Answer

Azathioprine

Answer

Cetuximab

Answer

Ketorolac

Question 7

Which cells are affected in glaucomatous optic neuropathy?

Accepted Answer

Ganglion cells

Answer

Amacrine cells

Answer

Bipolar cells

Answer

Rods and cones

Question 8

A 55-year-old lady presented with sudden onset of severe eye pain and a shallow anterior chamber. What is the treatment of choice?

Accepted Answer

Intravenous mannitol & Acetazolamide

Answer

Atropine

Answer

Atenolol

Answer

Intravenous steroids

Question 9

Which beta-1 selective blocker is used in the management of glaucoma?

Accepted Answer

Betaxolol

Answer

Levobunolol

Answer

Timolol

Answer

Carteolol

Question 10

In indentation tonometry, what is the relationship between scleral rigidity, intraocular pressure, and scale readings?

Accepted Answer

Lower scale readings are obtained in high intraocular pressure.

Answer

A plunger indents a hard eye more than a soft eye.

Answer

Low scleral rigidity gives a high reading of intraocular pressure.

Answer

All of the above

Glaucoma — MCQs

Glaucoma — MCQs

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