Glaucoma Practice Questions

Q: A 61-year-old woman comes to the emergency department because of a 2-hour history of headache, nausea, blurred vision, and pain in the left eye. She has had similar symptoms in the past. Her vital signs are within normal limits. The left eye is red and is hard on palpation. The left pupil is mid-dilated and nonreactive to light. Administration of which of the following drugs should be avoided in this patient?

Epinephrine. ***Epinephrine*** - Epinephrine is a **sympathomimetic** agent [1] that can cause **mydriasis** (pupil dilation) [1], [2] by activating alpha-1 receptors on the iris dilator muscle. - In a patient with **angle-closure glaucoma**, mydriasis can further narrow the anterior chamber angle, worsening the blockage of aqueous humor outflow and exacerbating the **intraocular pressure** (IOP) elevation [2], [3]. *Pilocarpine* - Pilocarpine is a **muscarinic agonist** that causes **miosis** (pupil constriction) and contraction of the ciliary muscle. - Miosis pulls the iris away from the trabecular meshwork, opening the anterior chamber angle and facilitating aqueous outflow, thereby **reducing IOP** [3]. *Timolol* - Timolol is a **beta-blocker** that reduces the production of aqueous humor by the ciliary body. - It is often used as a first-line treatment for glaucoma to **lower IOP** without significantly affecting pupil size. *Acetazolamide* - Acetazolamide is a **carbonic anhydrase inhibitor** that decreases aqueous humor production. - It is an effective systemic medication for rapidly **reducing IOP** in acute angle-closure glaucoma.

Q: For laser iridotomy which laser is used?

Nd YAG laser. ***Nd YAG laser*** - The **Nd:YAG laser** is the **primary laser used for laser iridotomy** due to its ability to create precise perforations in the iris. - This laser operates with a **photodisruptive mechanism**, generating plasma formation that effectively creates an opening in the iris. - It is the **treatment of choice for angle-closure glaucoma** and pupillary block. *Argon laser* - The **argon laser** was historically used for iridotomy but is now less commonly the primary choice due to its thermal effect causing more inflammation and scarring. - It is sometimes used in **sequential laser iridotomy** (argon first to thin the iris, followed by Nd:YAG to perforate) in cases where the iris is very thick or heavily pigmented. - Also used for **peripheral iridoplasty** and other thermal applications. *CO2 laser* - **CO2 lasers** are primarily used for **tissue ablation** in surgical procedures, particularly on the skin, eyelid lesions, or in general surgery. - They are **not suitable** for precise intraocular procedures like iridotomy due to their infrared wavelength (10,600 nm) and poor penetration through aqueous humor. *Excimer laser* - **Excimer lasers** are primarily used in **refractive surgery** (e.g., LASIK, PRK) to reshape the cornea. - They work by **photoablation** at 193 nm wavelength, precisely removing tissue layer by layer, and are not designed for creating an opening in the iris.

Q: Argon laser trabeculoplasty is done in:

Open angle glaucoma. ***Open angle glaucoma*** - **Argon laser trabeculoplasty (ALT)** is primarily used in **open-angle glaucoma** to improve aqueous humor outflow through the **trabecular meshwork**. - It creates **small burns** in the trabecular meshwork, increasing permeability and lowering **intraocular pressure (IOP)**. *Secondary glaucoma* - This is a broad category of glaucoma caused by other eye conditions or systemic diseases, and the specific treatment depends on the underlying etiology. - While ALT might be considered in some types of **secondary open-angle glaucoma**, it is not a primary or universal treatment for all secondary glaucomas. *Angle recession glaucoma* - This type of glaucoma occurs after blunt trauma to the eye, causing a tear in the **ciliary body** and widening of the **ciliary body band**. - ALT is generally **ineffective** in angle recession glaucoma because the damage to the trabecular meshwork is structural and not amenable to laser modification. *Angle closure glaucoma* - In **angle-closure glaucoma**, the iris blocks the drainage angle, preventing aqueous outflow. - Treatment typically involves **laser peripheral iridotomy** to create a hole in the iris, or surgical procedures, to open the angle, rather than laser trabeculoplasty.

Q: Following injury to the right temple region, a patient complains of pain in the right eye and loss of vision. On examination, the eye movements are normal, and the pupil normally reacts to light. The affected eye shows increased intraocular pressure of 32 mmHg (normal: 10-21 mmHg), mild corneal edema, and a small hyphema visible in the anterior chamber. The diagnosis is

Traumatic glaucoma. ***Traumatic glaucoma*** - Increased **intraocular pressure (32 mmHg)** after a **temple injury** with **corneal edema** and **hyphema** are classic signs of traumatic glaucoma. - The hyphema (blood in the anterior chamber) obstructs the **trabecular meshwork**, impeding aqueous humor outflow and leading to elevated IOP. *Optic nerve atrophy* - While optic nerve atrophy can cause **vision loss**, it is a chronic condition and typically not an acute presentation following trauma unless there is direct optic nerve damage. - It would not explain the acute findings of **hyphema**, **corneal edema**, or acutely elevated **intraocular pressure**. *Sub-arachnoid haemorrhage* - A **sub-arachnoid hemorrhage** might present with headache and loss of consciousness, or **papilledema** in severe cases, but typically would not cause such specific eye findings as **hyphema** or **corneal edema** from elevated IOP. - While a blow to the head could cause this, the direct eye findings point to a local ocular issue. *Functional loss of vision* - **Functional vision loss** (or psychogenic vision loss) is a diagnosis of exclusion where no organic cause can be found. - The presence of clear organic signs such as **hyphema**, **corneal edema**, and significantly elevated **intraocular pressure** rules out a functional cause.

Q: Secondary glaucoma associated with angle recession is seen in:

Concussion injury. ***Concussion injury*** - **Concussion injuries** (blunt trauma) to the eye lead to shearing forces between the ciliary body and sclera, causing a tear in the ciliary body and trabecular meshwork. - This anatomical alteration, known as **angle recession**, impairs aqueous humor outflow over time, leading to secondary open-angle glaucoma. *Penetrating injury* - **Penetrating injuries** breach the globe and can cause direct damage to ocular structures, but angle recession leading to glaucoma is more characteristic of blunt trauma. - Such injuries often lead to other forms of glaucoma, like **pupillary block** or **phacolytic glaucoma**, depending on the extent of damage and inflammation. *Chemical injury* - **Chemical injuries** (e.g., acid or alkali burns) cause severe inflammation, tissue necrosis, and scarring within the anterior segment. - Glaucoma following chemical injury is typically due to **trabecular meshwork damage** from inflammation and scarring, or **peripheral anterior synechiae formation**, rather than angle recession. *Radiation injury* - **Radiation injury** to the eye is rare but can occur with radiation therapy for tumors, causing damage to vascular structures and contributing to neovascularization. - Glaucoma associated with radiation injury is usually secondary to **neovascularization** of the angle or **inflammatory processes**, not angle recession.

Q: Epinephrine not used in:

Aphakic glaucoma. ***Aphakic glaucoma*** - Epinephrine is **contraindicated** in aphakic eyes due to the risk of developing **cystoid macular edema (CME)**, which can significantly impair vision. - The mechanism of CME in aphakic eyes treated with epinephrine is thought to involve increased vascular permeability in the macula. *Uveitis glaucoma* - Topical epinephrine can be used in some cases of uveitic glaucoma to reduce **intraocular pressure (IOP)** by decreasing aqueous humor production and increasing uveoscleral outflow. - However, its use requires careful consideration due to the potential for exacerbating ocular inflammation in some patients. *Open angle glaucoma* - Epinephrine (and its prodrug, dipivefrin) was historically used in the treatment of **open-angle glaucoma** to lower IOP. - It acts by stimulating alpha- and beta-adrenergic receptors, leading to decreased aqueous production and increased outflow. *Neovascular glaucoma* - While traditionally not a primary treatment, epinephrine can sometimes be used as an **adjunctive therapy** in neovascular glaucoma to help lower IOP, as it reduces aqueous humor production. - The primary treatment for neovascular glaucoma involves addressing the underlying cause of **neovascularization**, usually through panretinal photocoagulation or anti-VEGF injections.

Q: Which diagnostic procedure is not done in a dilated pupil?

Gonioscopy. ***Gonioscopy*** - **Gonioscopy** is the examination of the **anterior chamber angle**, where the **iris** meets the **cornea**. - It is crucial for assessing **glaucoma** and is typically performed with a **nondilated pupil** to allow the iris to lie in its natural anatomical position, which helps visualize the angle structures accurately. *Laser interferometry* - **Laser interferometry** is used to assess **potential visual acuity** in patients with **media opacities** such as cataracts. - This procedure benefits from a **dilated pupil** as it allows more light to pass through existing clear areas of the lens, improving the measurement. *Electroretinography* - **Electroretinography (ERG)** measures the **electrical responses of the retina** to light stimulation. - **Pupil dilation** is generally performed to maximize the amount of light reaching the retina, ensuring a comprehensive assessment of retinal function. *Fundus examination* - A **fundus examination** visualizes the **retina, optic disc, macula, and retinal blood vessels**. - **Dilation of the pupil** is a standard practice for a thorough fundus examination, as it allows for a wider and more complete view of the posterior segment of the eye, facilitating detection of various retinal pathologies.

Q: Sudden painful loss of vision seen in

Angle closure glaucoma. ***Angle closure glaucoma*** - This is the **classic presentation** of sudden, painful vision loss in ophthalmology - Characterized by **acute increase in intraocular pressure** (often >40 mmHg) causing severe eye pain, headache, nausea, and vomiting - Vision loss is rapid due to damage to the **optic nerve** and corneal edema - The pain is intense and sharp due to stretching of ocular structures - **Key distinguishing feature**: Mid-dilated fixed pupil, corneal edema, shallow anterior chamber *Endophthalmitis* - Also causes **sudden painful vision loss** and is a sight-threatening emergency - Pain is severe with rapid onset of vision loss, redness, and hypopyon - **Differentiating features**: History of recent ocular surgery, trauma, or intravitreal injection; presence of hypopyon (layered pus in anterior chamber) - While both can present similarly, endophthalmitis typically has **obvious intraocular inflammation** and relevant preceding history *Acute uveitis* - Presents with **ocular pain**, **redness**, **photophobia**, and blurred vision - Vision loss is usually **gradual**, not sudden and complete - Pain is moderate, described as dull aching rather than severe acute pain - Rarely causes sudden severe vision loss unless complicated *Central retinal artery occlusion* - Causes **sudden, painless loss of vision** - this is the key distinguishing feature - Described as "curtain coming down" or sudden blackout of vision - **Absence of pain** differentiates it from acute angle-closure glaucoma - Cherry-red spot on fundoscopy is pathognomonic

Q: Commonest complication of topical corticosteroids is -

Glaucoma. ***Glaucoma*** - **Topical corticosteroids** are well-known to increase **intraocular pressure** by reducing the outflow of aqueous humor, leading to **steroid-induced glaucoma**. - This complication can result in irreversible **optic nerve damage** and vision loss if not managed properly. *Ptosis* - **Ptosis** is a drooping of the upper eyelid and is not a common complication directly associated with topical corticosteroid use. - It is more often linked to issues like **muscle weakness**, nerve damage, or age-related changes. *Proptosis* - **Proptosis** refers to the bulging of the eye and is typically associated with conditions like **Graves' ophthalmopathy** or orbital tumors. - It is not a common or direct side effect of topical corticosteroid application. *Cataract* - While **steroid-induced cataracts** (specifically **posterior subcapsular cataracts**) are a known complication of chronic systemic corticosteroid use, they are less common with topical corticosteroids and usually require prolonged, high-dose therapy. - In contrast, a rise in intraocular pressure (leading to glaucoma) can occur more acutely and with lower doses of topical corticosteroids.

Q: Pilocarpine is used in all of the following except:

Malignant Glaucoma. ***Malignant Glaucoma*** - **Pilocarpine** is contraindicated in **malignant glaucoma** because it can worsen the condition by causing **ciliary body edema** and anterior displacement of the lens-iris diaphragm. - This form of glaucoma requires treatment aimed at posterior displacement of the lens-iris diaphragm, often involving **cycloplegics**, **hyperosmotic agents**, or surgical interventions. *Primary, Open Angle Glaucoma* - **Pilocarpine** is an effective **miotic agent** that increases aqueous humor outflow through the **trabecular meshwork**, thereby lowering intraocular pressure. - It can be used as a treatment for **primary open-angle glaucoma**, although it is less commonly used due to its side effects and the availability of better-tolerated medications. *Acute Angle Closure Glaucoma* - **Pilocarpine** is typically used in the management of **acute angle-closure glaucoma** after the intraocular pressure has been acutely lowered by other agents. - It works by inducing **miosis**, which pulls the iris away from the **trabecular meshwork**, opening the angle and facilitating aqueous outflow. *Chronic Synechial Angle Closure Glaucoma* - In **chronic synechial angle-closure glaucoma**, **pilocarpine** can be used to break or prevent the formation of new **peripheral anterior synechiae** by constricting the pupil. - However, its effectiveness is limited if extensive synechiae have already formed, as these physically block the outflow pathway.

Question 1

A 61-year-old woman comes to the emergency department because of a 2-hour history of headache, nausea, blurred vision, and pain in the left eye. She has had similar symptoms in the past. Her vital signs are within normal limits. The left eye is red and is hard on palpation. The left pupil is mid-dilated and nonreactive to light. Administration of which of the following drugs should be avoided in this patient?

Accepted Answer

Epinephrine

Answer

Pilocarpine

Answer

Timolol

Answer

Acetazolamide

Question 2

For laser iridotomy which laser is used?

Accepted Answer

Nd YAG laser

Answer

Argon laser

Answer

CO2 laser

Answer

Excimer laser

Question 3

Argon laser trabeculoplasty is done in:

Accepted Answer

Open angle glaucoma

Answer

Secondary glaucoma

Answer

Angle recession glaucoma

Answer

Angle closure glaucoma

Question 4

Following injury to the right temple region, a patient complains of pain in the right eye and loss of vision. On examination, the eye movements are normal, and the pupil normally reacts to light. The affected eye shows increased intraocular pressure of 32 mmHg (normal: 10-21 mmHg), mild corneal edema, and a small hyphema visible in the anterior chamber. The diagnosis is

Accepted Answer

Traumatic glaucoma

Answer

Optic nerve atrophy

Answer

Sub-arachnoid haemorrhage

Answer

Functional loss of vision

Question 5

Secondary glaucoma associated with angle recession is seen in:

Accepted Answer

Concussion injury

Answer

Penetrating injury

Answer

Chemical injury

Answer

Radiation injury

Question 6

Epinephrine not used in:

Accepted Answer

Aphakic glaucoma

Answer

Uveitis glaucoma

Answer

Open angle glaucoma

Answer

Neovascular glaucoma

Question 7

Which diagnostic procedure is not done in a dilated pupil?

Accepted Answer

Gonioscopy

Answer

Laser interferometry

Answer

Electroretinography

Answer

Fundus examination

Question 8

Sudden painful loss of vision seen in

Accepted Answer

Angle closure glaucoma

Answer

Endophthalmitis

Answer

Acute uveitis

Answer

Central retinal artery occlusion

Question 9

Commonest complication of topical corticosteroids is -

Accepted Answer

Glaucoma

Answer

Ptosis

Answer

Proptosis

Answer

Cataract

Question 10

Pilocarpine is used in all of the following except:

Accepted Answer

Malignant Glaucoma

Answer

Primary, Open Angle Glaucoma

Answer

Acute Angle Closure Glaucoma

Answer

Chronic Synechial Angle Closure Glaucoma

Glaucoma — MCQs

Glaucoma — MCQs

On this page

Practice by Chapter

Want unlimited practice?