Glaucoma Practice Questions

Q: Neovascular glaucoma can occur in all of the following conditions, except?

Retinopathy of prematurity. **Explanation:** Neovascular Glaucoma (NVG) is a secondary glaucoma caused by the formation of a fibrovascular membrane over the trabecular meshwork, triggered by **retinal ischemia** and the subsequent release of **VEGF** (Vascular Endothelial Growth Factor). **Why Retinopathy of Prematurity (ROP) is the correct answer:** While ROP involves retinal ischemia and neovascularization, it typically results in **tractional retinal detachment** or **cicatricial changes**. While secondary angle-closure glaucoma can occur in ROP due to forward displacement of the lens-iris diaphragm (Stage 5), it is **not** a classic cause of neovascular glaucoma. **Analysis of other options:** * **CRVO (Central Retinal Vein Occlusion):** Specifically the ischemic type, it is the most common cause of NVG. It is famously known as **"100-day glaucoma"** because NVG typically develops about 3 months after the occlusion. * **Eale’s Disease:** This is an idiopathic peripheral perivasculitis characterized by severe retinal ischemia and peripheral neovascularization, which can lead to rubeosis iridis and NVG. * **Hypertension:** While not a direct cause, systemic hypertension is a major risk factor for **Central Retinal Artery Occlusion (CRAO)** and **Diabetic Retinopathy**, both of which are potent triggers for NVG. **High-Yield Clinical Pearls for NEET-PG:** 1. **Top 3 Causes of NVG:** 1. Diabetic Retinopathy (most common overall), 2. Ischemic CRVO (most common acute cause), 3. Carotid Artery Occlusive Disease. 2. **Rubeosis Iridis:** The first sign of NVG is the appearance of new vessels at the **pupillary margin**, which then migrate toward the angle. 3. **Treatment:** The definitive management for the underlying cause is **Pan-retinal Photocoagulation (PRP)** to reduce the ischemic drive. Anti-VEGF injections are used as an adjunct.

Q: Glaucoma flecken is defined as:

Lens opacity. **Explanation:** **Glaukomflecken** (also known as Vogt’s spots) refers to multiple, small, grey-white subcapsular opacities found in the anterior lens. These represent focal areas of lens epithelial necrosis caused by a sudden, severe rise in intraocular pressure (IOP). **Why the correct answer is right:** In the setting of **Acute Angle Closure Glaucoma (AACG)**, the rapid and extreme elevation of IOP causes stagnation of the aqueous humor. This leads to localized ischemia and metabolic distress of the anterior lens epithelium, resulting in permanent necrotic spots. These opacities are pathognomonic of a **previous** attack of acute congestive glaucoma. **Why the incorrect options are wrong:** * **A. Acute uveitis:** While uveitis can cause lens changes (like posterior synechiae or complicated cataracts), Glaukomflecken is specifically a post-glaucomatous sequela. * **C. Retinal detachment:** This involves the separation of the neurosensory retina from the RPE and does not manifest as focal lens opacities. * **D. Corneal opacity:** Acute glaucoma causes corneal *edema* (due to endothelial pump failure), but Glaukomflecken is strictly a lenticular finding. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Anterior subcapsular region of the lens. * **Significance:** It serves as a "diagnostic footprint" of a past acute primary angle-closure attack. * **Triad of post-acute glaucoma:** Glaukomflecken, iris atrophy (sectoral), and a mid-dilated non-reactive pupil. * **Differential:** Do not confuse with *Vossius ring*, which is a ring of iris pigment on the anterior lens capsule following blunt trauma.

Q: Aqueous humor drains through all of the following routes except:

Sclera. **Explanation:** Aqueous humor is produced by the ciliary body and must be drained to maintain intraocular pressure (IOP). There are two primary pathways for drainage, along with minor accessory routes. **Why Sclera is the Correct Answer:** The **Sclera** itself is a dense, fibrous protective layer and does not serve as a direct drainage route for aqueous humor. While the uveoscleral pathway involves fluid passing *through* the interstitial spaces of the ciliary muscle toward the suprachoroidal space, the fluid eventually enters the venous circulation of the choroid and sclera. However, the sclera as a tissue does not possess a drainage mechanism; it acts as a container. **Analysis of Other Options:** * **Trabecular Meshwork (Option A):** This is the **conventional (pressure-dependent) pathway**, accounting for approximately **90%** of aqueous drainage. Fluid passes through the meshwork into the Canal of Schlemm and then into episcleral veins. * **Uveoscleral Outflow (Option B):** This is the **unconventional (pressure-independent) pathway**, accounting for about **10%** of drainage. Fluid exits through the ciliary muscle into the suprachoroidal space. * **Iris (Option C):** A very small amount of aqueous humor (minor route) can be absorbed through the **iris crypts** and its anterior surface into the iris vessels. **High-Yield Clinical Pearls for NEET-PG:** * **Prostaglandin Analogs (e.g., Latanoprost):** The first-line drug in Glaucoma; they work by increasing **uveoscleral outflow**. * **Miotics (e.g., Pilocarpine):** Increase drainage through the **trabecular meshwork** by contracting the ciliary muscle. * **Goldmann Equation:** Used to determine IOP ($IOP = (F/C) + Pv$), where $F$ is aqueous formation, $C$ is facility of outflow, and $Pv$ is episcleral venous pressure.

Q: A vertically oval dilated pupil is seen in which condition?

Acute primary angle closure glaucoma. **Explanation:** In **Acute Primary Angle Closure Glaucoma (APACG)**, the sudden and severe rise in intraocular pressure (IOP) leads to ischemia and subsequent paralysis of the iris sphincter muscle. This results in a pupil that is **semi-dilated, vertically oval, and non-reactive to light**. The vertical elongation occurs because the ischemia is often most pronounced in the superior and inferior segments of the iris. **Analysis of Incorrect Options:** * **Wernicke-Korsakoff Psychosis:** This condition, caused by Thiamine (B1) deficiency, typically presents with the triad of ophthalmoplegia (most commonly lateral rectus palsy), ataxia, and confusion. It does not cause a vertically oval pupil. * **Neurosyphilis:** Classically associated with the **Argyll Robertson Pupil**, which is characterized by small, irregular pupils that demonstrate "accommodation-reflex present, but light-reflex absent" (ARP). * **Paralysis of Oculomotor Nerve (3rd Nerve Palsy):** This results in a **completely dilated (mydriatic)** and fixed pupil due to loss of parasympathetic supply, accompanied by ptosis and a "down and out" deviation of the eye. **High-Yield Clinical Pearls for NEET-PG:** * **APACG Presentation:** Sudden onset of severe pain, "halos" around lights, stony hard eye, and a shallow anterior chamber. * **Immediate Management:** Systemic Acetazolamide and topical Pilocarpine (once IOP drops below 40 mmHg to restore iris vascularity). * **Definitive Treatment:** Laser Peripheral Iridotomy (LPI) for both the affected and the fellow (prophylactic) eye. * **Festooned Pupil:** Seen in chronic iridocyclitis due to posterior synechiae.

Q: A patient presents with a history of evening halos and occasional headaches for several months. Examination reveals normal intraocular pressure but a shallow anterior chamber. In which stage of glaucoma is this patient?

Prodrome. ### Explanation This clinical scenario describes **Primary Angle-Closure Glaucoma (PACG)** in the **Prodromal Stage**. **Why "Prodrome" is correct:** The prodromal stage is characterized by transient, self-limiting episodes of increased intraocular pressure (IOP). These episodes typically occur in the evening or in low light (mydriasis causes the iris to block the angle). * **Evening Halos:** Caused by transient corneal edema due to a sudden rise in IOP. * **Headaches/Ocular Pain:** Result from the pressure spike. * **Normal IOP on Examination:** Between episodes, the IOP returns to normal, and the eye appears quiet, though the **shallow anterior chamber** remains a constant anatomical risk factor. **Why the other options are incorrect:** * **Acute Stage:** This is a medical emergency. The patient presents with sudden, severe pain, nausea, vomiting, a stony-hard eye (very high IOP), a vertically oval semi-dilated pupil, and "steamy" cornea. It does not resolve spontaneously. * **Absolute Stage:** This is the terminal stage where the eye is completely blind (No Perception of Light). The eye may be painful or painless, and the optic disc shows total glaucomatous cupping. * **Constant Instability (Chronic Stage):** Here, the angle is permanently closed by synechiae (PAS). The IOP is persistently high, and there is progressive optic nerve damage and field defects, unlike the intermittent nature of the prodromal stage. **High-Yield Clinical Pearls for NEET-PG:** * **Anatomical Predisposition:** Hypermetropic eyes, small eyeballs, and advancing age (enlarging lens) are risk factors for shallow chambers. * **Provocative Tests:** The Dark Room Test or Prone Position Test can be used to induce an attack in suspected prodromal cases. * **Definitive Treatment:** **Peripheral Iridotomy (Laser or Surgical)** is the treatment of choice to bypass the pupillary block and prevent future acute attacks.

Q: Which of the following is a new drug approved for the treatment of glaucoma?

Netarsudil. **Explanation:** **Netarsudil (Option A)** is the correct answer. It represents a novel class of glaucoma medications known as **Rho-kinase (ROCK) inhibitors**. Unlike traditional drugs that primarily reduce aqueous production or increase uveoscleral outflow, Netarsudil works by increasing aqueous outflow through the **trabecular meshwork** (the primary physiological pathway). It achieves this by inhibiting the Rho-kinase enzyme, which reduces cellular stiffness and relaxes the trabecular meshwork fibers. Additionally, it lowers episcleral venous pressure and reduces aqueous production. **Analysis of Incorrect Options:** * **Semaglutide (Option B):** A GLP-1 receptor agonist used in the management of Type 2 Diabetes Mellitus and obesity. * **Etelcalcetide (Option C):** A calcimimetic agent used to treat secondary hyperparathyroidism in patients with chronic kidney disease on dialysis. * **Plecanatide (Option D):** A guanylate cyclase-C agonist used for the treatment of chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C). **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Netarsudil is unique because it targets the "diseased" trabecular meshwork directly. * **Fixed-Dose Combination:** *Rocklatan* is a recently approved combination of Netarsudil and Latanoprost. * **Common Side Effect:** The most characteristic side effect of Netarsudil is **conjunctival hyperemia** (redness) and **conjunctival hemorrhages** (petechiae). * **Corneal Verticillata:** Netarsudil can cause vortex keratopathy (whorl-like deposits), similar to Amiodarone or Fabry disease.

Question 1

Which of the following drugs is not used in the management of acute angle-closure glaucoma?

Accepted Answer

Clozapine

Answer

Pilocarpine

Answer

Fluphenazine

Answer

Duloxetine

Question 2

Neovascular glaucoma can occur in all of the following conditions, except?

Accepted Answer

Retinopathy of prematurity

Answer

Central Retinal Vein Occlusion (CRVO)

Answer

Eale's disease

Answer

Hypertension

Question 3

Glaucoma flecken is defined as:

Accepted Answer

Lens opacity

Answer

Acute uveitis

Answer

Retinal detachment

Answer

Corneal opacity

Question 4

Aqueous humor drains through all of the following routes except:

Accepted Answer

Sclera

Answer

Trabecular meshwork

Answer

Uveoscleral outflow

Answer

Iris

Question 5

A vertically oval dilated pupil is seen in which condition?

Accepted Answer

Acute primary angle closure glaucoma

Answer

Wernicke's Korsakoff psychosis

Answer

Neurosyphilis

Answer

Paralysis of oculomotor nerve

Question 6

Which of the following is considered primary glaucoma?

Accepted Answer

Juvenile glaucoma

Answer

Steroid-induced glaucoma

Answer

Pigmentary glaucoma

Answer

All of the above

Question 7

Field defects in chronic simple glaucoma includes all EXCEPT:

Accepted Answer

Paracentral scotoma

Answer

Arcuate scotoma

Answer

Seidel scotoma

Question 8

A patient presents with a history of evening halos and occasional headaches for several months. Examination reveals normal intraocular pressure but a shallow anterior chamber. In which stage of glaucoma is this patient?

Accepted Answer

Prodrome

Answer

Acute

Answer

Absolute

Answer

Constant instability

Question 9

A patient complains of seeing colored halos around lights in the evening and blurring of vision for the past few days, with normal intraocular pressure. What is the most likely diagnosis?

Accepted Answer

Prodromal phase of acute angle closure glaucoma

Answer

Acute angle closure glaucoma

Answer

Chronic glaucoma

Answer

Epidemic dropsy

Question 10

Which of the following is a new drug approved for the treatment of glaucoma?

Accepted Answer

Netarsudil

Answer

Semaglutide

Answer

Etelcalcetide

Answer

Plecanatide

Glaucoma — MCQs

Glaucoma — MCQs

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