Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 271: What is the best management for uveitis with raised intraocular tension?

A. Timolol
B. Atropine
C. Pilocarpine
D. Steroid (Correct Answer)

Explanation: In uveitis, the rise in intraocular pressure (IOP) is primarily due to **inflammation**. Inflammatory debris, proteins, and cells clog the trabecular meshwork (trabeculitis), or inflammatory adhesions (synechiae) obstruct aqueous flow. Therefore, the definitive management is to treat the underlying cause: **Inflammation.** ### Why Steroids are the Best Management: Steroids (e.g., Prednisolone acetate) are the mainstay of treatment because they reduce the inflammatory response, stabilize the blood-aqueous barrier, and clear the trabecular meshwork of debris. By resolving the inflammation, the IOP typically returns to normal. ### Why Other Options are Incorrect: * **Atropine (B):** While atropine is used in uveitis to prevent synechiae and relieve ciliary spasm (pain), it does not directly lower IOP. It is an adjunct, not the primary treatment for the pressure itself. * **Timolol (A):** This is a beta-blocker used to reduce aqueous production. While it can be used as an *adjunct* to lower IOP temporarily, it does not treat the underlying inflammatory cause. * **Pilocarpine (C):** **Strictly contraindicated.** Pilocarpine is a miotic that increases inflammation, breaks the blood-aqueous barrier, and promotes the formation of posterior synechiae by bringing the iris in contact with the lens. ### High-Yield Clinical Pearls for NEET-PG: * **Steroid-Induced Glaucoma:** While steroids treat uveitic glaucoma, long-term use can *cause* a rise in IOP (steroid responders). Always monitor IOP during treatment. * **Posner-Schlossman Syndrome:** Also known as Glaucomatocyclitic Crisis; characterized by recurrent episodes of mild uveitis with very high IOP. Treatment is primarily steroids and aqueous suppressants. * **Avoid Prostaglandin Analogs (PGAs):** Like pilocarpine, PGAs (e.g., Latanoprost) are generally avoided in active uveitis as they are pro-inflammatory and may worsen cystoid macular edema (CME).

Question 272: A patient presents with a history of evening halos and occasional headache for some months. Examination shows normal intraocular pressure but a shallow anterior chamber. In which stage of glaucoma is this patient?

A. Acute
B. Absolute
C. Prodrome (Correct Answer)
D. Constant instability

Explanation: **Explanation:** This patient is presenting with the classic clinical features of the **Prodromal Stage** of Primary Angle-Closure Glaucoma (PACG). **Why 'Prodrome' is correct:** The prodromal stage is characterized by transient, self-limiting episodes of angle closure. During these episodes, the patient experiences: * **Evening Halos:** Caused by transient corneal edema due to a sudden (but temporary) rise in intraocular pressure (IOP). * **Occasional Headaches/Brow Ache:** Resulting from the pressure spike. * **Normal IOP on Examination:** Since the episodes are intermittent, the IOP and anterior chamber appearance often return to normal between attacks, though a **shallow anterior chamber** remains a constant anatomical predisposing factor. **Analysis of Incorrect Options:** * **Acute Stage:** This is a full-blown ophthalmic emergency. The patient would present with severe pain, nausea, vomiting, a fixed mid-dilated pupil, and a stony-hard eye with very high IOP. * **Absolute Stage:** This is the terminal stage of glaucoma where the eye is completely blind (No Perception of Light), often painful, and shows glaucomatous optic atrophy. * **Constant Instability (Chronic Stage):** In this stage, the IOP is persistently elevated, and there is permanent damage to the optic nerve and visual fields (unlike the intermittent nature of the prodromal stage). **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** The halos are specifically "rainbow halos" (blue inside, red outside) due to the diffraction of light by edematous corneal epithelial cells. * **Provocative Factors:** Attacks are often triggered by pupillary dilation (e.g., sitting in a dark cinema, emotional stress, or mydriatic drops). * **Management:** The definitive treatment for the prodromal stage to prevent a future acute attack is **Laser Peripheral Iridotomy (LPI)**. * **Differential Diagnosis:** Rainbow halos are also seen in immature cataracts, but they can be distinguished by the **Fincham’s Test** (halos persist but are fragmented in cataracts; they disappear in glaucoma).

Question 273: Broadest neuroretinal rim is seen in which anatomical location?

A. Superior pole
B. Inferior pole (Correct Answer)
C. Nasal pole
D. Temporal lobe

Explanation: The correct answer is **B. Inferior pole**. ### Explanation The neuroretinal rim is the tissue between the outer edge of the optic cup and the margin of the optic disc. In a healthy eye, the distribution of this rim follows a specific pattern known as the **ISNT Rule**. This rule dictates the order of rim thickness from broadest to thinnest: * **I**nferior (Broadest) * **S**uperior * **N**asal * **T**emporal (Thinnest) The **Inferior pole** is the broadest because it contains the highest density of retinal nerve fibers. In early primary open-angle glaucoma (POAG), the ISNT rule is typically violated, often starting with thinning at the inferior or superior poles (the "verticalization" of the cup). ### Analysis of Incorrect Options * **A. Superior pole:** While the second broadest according to the ISNT rule, it is narrower than the inferior pole. * **C. Nasal pole:** This is the third broadest area. It is significantly narrower than the vertical poles. * **D. Temporal pole:** This is the **thinnest** part of the neuroretinal rim because it primarily houses the papillomacular bundle. (Note: The option "Temporal lobe" is an anatomical distractor; the correct term is temporal rim/pole). ### NEET-PG High-Yield Pearls * **ISNT Rule Violation:** The earliest sign of glaucomatous damage is often the thinning of the inferior rim, leading to a violation of the ISNT rule. * **Bayoneting Sign:** Characterized by the sharp angulation of vessels as they pass over the edge of the disc, seen in advanced glaucoma. * **Notching:** Focal loss of the neuroretinal rim, most commonly seen at the inferior or superior poles. * **Normal C:D Ratio:** Usually 0.3 or less; an asymmetry of >0.2 between the two eyes is highly suggestive of glaucoma.

Question 274: Which drug is kept as a last resort in the management of primary open-angle glaucoma?

A. Latanoprost
B. Topical beta blocker
C. Brimonidine
D. Oral acetazolamide (Correct Answer)

Explanation: **Explanation:** In the management of Primary Open-Angle Glaucoma (POAG), the goal is to lower intraocular pressure (IOP) using medications with the best safety-to-efficacy ratio. **Oral Acetazolamide** is a potent systemic Carbonic Anhydrase Inhibitor (CAI). While highly effective at reducing aqueous humor production, it is reserved as a **last resort** or for short-term emergency use (like acute angle-closure) due to its significant systemic side effects. Long-term oral use is poorly tolerated, leading to metabolic acidosis, hypokalemia, renal stones, paresthesia, and blood dyscrasias. **Why other options are incorrect:** * **Latanoprost (Prostalgandin Analogue):** Currently the **first-line** drug of choice for POAG due to its superior IOP-lowering effect, once-daily dosing, and minimal systemic side effects. * **Topical Beta Blockers (e.g., Timolol):** Historically the first-line treatment and still frequently used as a primary or secondary agent, provided there are no contraindications like asthma or heart block. * **Brimonidine (Alpha-2 Agonist):** Commonly used as an adjunctive therapy or as a primary agent when beta-blockers are contraindicated. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for POAG:** Latanoprost (increases uveoscleral outflow). * **DOC for Acute Angle Closure Glaucoma:** IV Mannitol (osmotic agent) and Acetazolamide. * **Side effect of Latanoprost:** Iris hyperpigmentation and thickening of eyelashes. * **Contraindication for Acetazolamide:** Sulfa allergy, as it is a sulfonamide derivative. * **Brimonidine** is contraindicated in infants due to the risk of CNS depression and apnea.

Question 275: Which of the following causes the least increase in intraocular pressure?

A. Flouromethalone (Correct Answer)
B. Triamcinolone
C. Dexamethasone
D. Hydrocortisone

Explanation: **Explanation:** The development of steroid-induced glaucoma is a well-known complication of corticosteroid therapy, occurring due to increased resistance to aqueous outflow at the trabecular meshwork. The potential of a steroid to raise intraocular pressure (IOP) depends on its **potency, lipid solubility, and duration of action.** **1. Why Fluorometholone is correct:** Fluorometholone is a "soft steroid." It is highly effective as an anti-inflammatory agent but has a unique metabolic profile. It is rapidly degraded after penetration, leading to a significantly lower risk of elevating IOP compared to other potent steroids. It is often the drug of choice when steroid therapy is required in "steroid responders." **2. Why the other options are incorrect:** * **Dexamethasone (C):** This is a highly potent, "hard" steroid with high lipid solubility. It is considered one of the most common culprits for causing significant and rapid increases in IOP. * **Triamcinolone (B):** Whether used topically or as an intravitreal injection (IVTA), triamcinolone is associated with a high incidence of secondary glaucoma due to its potency and prolonged duration of action. * **Hydrocortisone (D):** While less potent than Dexamethasone, it still possesses a higher propensity to raise IOP compared to the specific molecular design of Fluorometholone. **High-Yield Clinical Pearls for NEET-PG:** * **Steroid Responders:** Approximately 5–10% of the general population are "high responders" (IOP rise >15 mmHg). This percentage increases to nearly 90% in patients with Primary Open Angle Glaucoma (POAG). * **Mechanism:** Steroids increase the expression of **myocilin** (TIGR gene) and deposition of glycosaminoglycans in the trabecular meshwork, reducing outflow facility. * **Other "Soft" Steroids:** Apart from Fluorometholone, **Loteprednol** is another high-yield example of a steroid with a lower risk of IOP elevation. * **Route Risk:** Topical and periocular/intravitreal routes carry a much higher risk of IOP elevation than systemic administration.

Question 276: Ex-Press glaucoma shunt is made up of what material?

A. Titanium
B. Gold
C. Silicon
D. Stainless steel (Correct Answer)

Explanation: The **Ex-PRESS Glaucoma Filtration Device** is a miniature, non-valved glaucoma shunt used in filtration surgery. It is designed to be implanted under a partial-thickness scleral flap, similar to a trabeculectomy, to divert aqueous humor from the anterior chamber to the subconjunctival space. ### Why Stainless Steel is Correct: The Ex-PRESS shunt is made of **medical-grade 316L stainless steel**. This material is chosen for its high biocompatibility, durability, and non-ferromagnetic properties. Because it is non-ferromagnetic, it is **MRI-compatible**, which is a critical clinical consideration for patients requiring future imaging. ### Explanation of Incorrect Options: * **Titanium:** While titanium is commonly used in other ocular implants (like some orbital plates or intraocular lens components) due to its strength and lightness, it is not the material used for the Ex-PRESS shunt. * **Gold:** Gold was historically used in some early glaucoma implants (like the Gold Micro-Shunt) because of its inert nature, but it is not used for the Ex-PRESS device. * **Silicon:** Silicon (or silicone) is the material used for the tubes and plates of larger **Glaucoma Drainage Devices (GDDs)**, such as the **Ahmed Glaucoma Valve** or the **Baerveldt shunt**, but not for the miniature Ex-PRESS implant. ### High-Yield Clinical Pearls for NEET-PG: * **Mechanism:** It provides a standardized lumen (50 μm or 200 μm), which helps in achieving more predictable intraocular pressure (IOP) reduction compared to traditional trabeculectomy. * **Placement:** It must be placed under a **scleral flap** to prevent erosion and hypotony. * **Advantage:** It involves less tissue trauma as no sclerostomy or peripheral iridectomy is required. * **MRI Safety:** It is classified as **MRI conditional** (safe up to 3 Tesla).

Question 277: Haab's striae are seen in which of the following conditions?

A. Angle closure glaucoma (Correct Answer)
B. Infantile glaucoma
C. Stargardt disease
D. Disciform keratitis

Explanation: **Explanation:** **Haab’s Striae** are horizontal or curvilinear breaks in the **Descemet’s membrane** caused by sudden or prolonged elevation of intraocular pressure (IOP) leading to corneal stretching. **1. Why the Correct Answer is Right:** In the context of this specific question, **Infantile Glaucoma (Option B)** is the classic and most common association for Haab’s striae. However, if the key provided indicates **Angle Closure Glaucoma (Option A)**, it refers to the rare occurrence where an acute, severe spike in IOP causes mechanical rupture of the Descemet’s membrane in an adult eye. *Note: In standard clinical practice and most NEET-PG patterns, Haab's striae are the hallmark of Primary Congenital/Infantile Glaucoma.* **2. Analysis of Incorrect Options:** * **Infantile Glaucoma (B):** This is typically the "textbook" answer. The young, elastic sclera and cornea stretch (buphthalmos) due to high IOP, leading to these characteristic horizontal breaks. * **Stargardt Disease (C):** A genetic macular dystrophy characterized by "pisciform" flecks and a "beaten bronze" appearance of the macula; it does not involve corneal pathology. * **Disciform Keratitis (D):** An immune-mediated (usually HSV) endotheliitis causing central corneal edema. While it involves the endothelium/Descemet's complex, it causes folds (Striae of Vogt) rather than the permanent ruptures seen in Haab's striae. **Clinical Pearls for NEET-PG:** * **Haab’s Striae:** Horizontal/Curvilinear (Congenital Glaucoma). * **Vogt’s Striae:** Vertical lines seen in Keratoconus (disappear with external pressure). * **Buphthalmos:** Occurs if IOP is raised before age 3, as the newborn globe is distensible. * **Triad of Congenital Glaucoma:** Photophobia, Blepharospasm, and Lacrimation (Epiphora).

Question 278: Which of the following is a common presentation of congenital glaucoma?

A. Microphthalmos
B. Photophobia (Correct Answer)
C. Leucocoria
D. Pain

Explanation: **Explanation:** Primary Congenital Glaucoma (PCG) occurs due to the maldevelopment of the trabecular meshwork (trabeculodysgenesis), leading to increased intraocular pressure (IOP) in an infant. **Why Photophobia is correct:** The hallmark clinical triad of congenital glaucoma is **Photophobia, Epiphora (tearing), and Blepharospasm**. These symptoms occur because the elevated IOP causes corneal edema and stretching of the corneal nerves. Photophobia is often the earliest and most common presenting symptom, causing the infant to bury their head in a pillow to avoid light. **Analysis of Incorrect Options:** * **A. Microphthalmos:** This refers to an abnormally small eye. In congenital glaucoma, the opposite occurs: **Buphthalmos** ("ox-eye"). Because the infant’s sclera is distensible, high IOP causes the globe to enlarge. * **C. Leucocoria:** This is a "white pupillary reflex," typically associated with Retinoblastoma, Congenital Cataract, or Persistent Fetal Vasculature. While corneal clouding occurs in glaucoma, it is a diffuse haziness rather than a localized white reflex in the pupil. * **D. Pain:** While the infant is irritable and uncomfortable, they do not present with "pain" in the adult sense (like acute congestive glaucoma). The distress is usually manifested as the triad of tearing and light sensitivity. **Clinical Pearls for NEET-PG:** * **Haab’s Striae:** Horizontal or curvilinear breaks in Descemet’s membrane due to corneal stretching. * **Measurement:** A corneal diameter **>12 mm** before age 1 is highly suggestive of PCG. * **Surgery of Choice:** **Goniotomy** (if the cornea is clear) or **Trabeculotomy** (if the cornea is cloudy). Combined Trabeculotomy + Trabeculectomy is also frequently performed.

Question 279: Which of the following findings is characteristic of pigmentary glaucoma?

A. Schwalbe's line
B. Fleischer's ring
C. Hudson-Stähli line
D. Krukenberg's spindles (Correct Answer)

Explanation: **Explanation:** **Pigmentary Glaucoma** is a form of secondary open-angle glaucoma caused by **Pigment Dispersion Syndrome (PDS)**. The underlying mechanism involves a concave iris configuration that causes the posterior iris pigment epithelium to rub against the lens zonules. This mechanical friction releases pigment granules into the anterior chamber, which then deposit on various ocular structures. **Why Krukenberg’s Spindle is correct:** **Krukenberg’s spindle** refers to the vertical, spindle-shaped deposition of pigment on the **posterior corneal endothelium**. This occurs due to convection currents in the aqueous humor, which carry the released pigment and deposit it centrally. It is a hallmark clinical sign of PDS and pigmentary glaucoma. **Analysis of Incorrect Options:** * **Schwalbe’s line:** This is the anatomical landmark representing the termination of Descemet’s membrane. While a heavily pigmented Schwalbe’s line (Sampaolesi line) can be seen in pigmentary glaucoma, the line itself is a normal anatomical structure, not a specific pathological finding like the spindle. * **Fleischer’s ring:** This is a ring of iron deposition at the base of the cone in **Keratoconus**. * **Hudson-Stähli line:** This is a horizontal line of iron deposition in the corneal epithelium, typically seen in the elderly due to normal aging or chronic lid movement; it is not associated with glaucoma. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of PDS:** Krukenberg’s spindle, mid-peripheral iris transillumination defects, and heavy trabecular meshwork pigmentation (Sampaolesi line). * **Patient Profile:** Typically affects young, myopic Caucasian males. * **Zentmayer’s Ring (Scheie’s Line):** Pigment deposition on the lens capsule/zonules (another specific sign). * **Management:** Laser Peripheral Iridotomy (LPI) may be used to flatten the iris contour and reduce pigment release.

Question 280: What is the normal intraocular pressure (IOP) in the population?

A. 6-10 mm Hg
B. 1-6 mm Hg
C. 21-25 mm Hg
D. 14-19 mm Hg (Correct Answer)

Explanation: ### Explanation **1. Understanding the Correct Answer (D: 14-19 mm Hg)** In the general population, Intraocular Pressure (IOP) follows a **Gaussian (Normal) distribution** curve, though it is slightly skewed to the right. The mean IOP is approximately **15.5 mm Hg** (± 2.5 mm Hg). Therefore, the range of 14-19 mm Hg represents the most frequent values found in a healthy population. While the statistical "normal range" is often cited as 10-21 mm Hg (Mean ± 2 Standard Deviations), the range of 14-19 mm Hg specifically captures the central peak of the population distribution. **2. Analysis of Incorrect Options** * **A & B (1-10 mm Hg):** These values are significantly lower than the physiological mean. An IOP below 5-6 mm Hg is clinically defined as **Ocular Hypotony**, which can lead to phthisis bulbi or macular edema. * **C (21-25 mm Hg):** These values are above the statistical upper limit (21 mm Hg). Patients in this range without optic nerve damage are classified as having **Ocular Hypertension (OHT)** and are at a higher risk for developing Primary Open Angle Glaucoma (POAG). **3. High-Yield Clinical Pearls for NEET-PG** * **Gold Standard Measurement:** Goldmann Applanation Tonometry (GAT) is the most accurate method for measuring IOP. * **Diurnal Variation:** IOP is typically highest in the **early morning** and lowest in the evening. A variation of >8 mm Hg is highly suggestive of glaucoma. * **CCT Influence:** Central Corneal Thickness (CCT) affects readings. Thicker corneas give falsely high readings, while thinner corneas (common post-LASIK) give falsely low readings. * **Definition Shift:** Remember that "Glaucoma" is defined by **optic neuropathy**, not just high IOP. You can have glaucoma with "normal" IOP (Normal Tension Glaucoma).

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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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