Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 21: Severe pain in the eye with loss of vision can be a manifestation of which condition?

A. Acute angle closure glaucoma (Correct Answer)
B. Open angle glaucoma
C. Vitreous hemorrhage
D. Retinal detachment

Explanation: **Explanation:** **Acute Angle Closure Glaucoma (AACG)** is a medical emergency characterized by a sudden, severe rise in intraocular pressure (IOP), often exceeding 50–70 mmHg. This occurs due to a mechanical obstruction of the trabecular meshwork by the peripheral iris. The rapid rise in pressure stretches the corneal lamellae (causing corneal edema and halos) and stimulates the ciliary nerves, leading to **excruciating ocular pain**, headache, nausea, and vomiting. Sudden vision loss occurs due to corneal edema and ischemic damage to the optic nerve. **Why the other options are incorrect:** * **Open Angle Glaucoma:** Known as the "silent thief of sight," it is typically asymptomatic and painless until advanced stages, as IOP rises gradually. * **Vitreous Hemorrhage:** Characterized by **painless** sudden loss of vision or floaters. Pain only occurs if associated with underlying conditions like neovascular glaucoma. * **Retinal Detachment:** Typically presents with **painless** vision loss, flashes of light (photopsia), and a "curtain-like" defect in the visual field. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Mid-dilated non-reactive pupil, "steamy" (edematous) cornea, and a shallow anterior chamber. * **Gold Standard Diagnosis:** Gonioscopy (to visualize the closed angle in the fellow eye). * **Immediate Management:** IV Mannitol (osmotic diuretic) and Acetazolamide to lower IOP, followed by **Pilocarpine** (miotic) once pressure drops. * **Definitive Treatment:** Peripheral Iridotomy (usually YAG laser) for both the affected and the fellow (prophylactic) eye.

Question 22: Which of the following is NOT a symptom of angle closure glaucoma?

A. Blurring of vision
B. Coloured halos
C. Metamorphopsia (Correct Answer)
D. Headache

Explanation: ### Explanation **Angle-Closure Glaucoma (ACG)** is a medical emergency characterized by a rapid rise in intraocular pressure (IOP) due to the mechanical obstruction of the trabecular meshwork by the peripheral iris. **Why Metamorphopsia is the Correct Answer:** **Metamorphopsia** (distortion of shapes/straight lines) is a hallmark symptom of **macular pathology**, such as Age-related Macular Degeneration (ARMD) or Central Serous Chorioretinopathy (CSCR). It occurs due to the displacement of photoreceptors in the retina. It is **not** a feature of glaucoma, which primarily affects the optic nerve head and peripheral visual fields. **Analysis of Other Options:** * **Blurring of Vision:** In ACG, the sudden rise in IOP causes the corneal endothelium to fail, leading to **corneal edema**. This edema disrupts light transmission, resulting in hazy or blurred vision. * **Coloured Halos:** This is a classic symptom of ACG. Edematous corneal stroma acts as a diffraction grating, splitting white light into its spectral components (rainbow-like halos around lights). * **Headache:** The extreme elevation of IOP (often >50 mmHg) stimulates the ophthalmic division of the trigeminal nerve, causing severe ocular pain, brow ache, and frontal headache, often accompanied by nausea and vomiting. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of ACG:** Shallow anterior chamber, fixed mid-dilated pupil, and "stony hard" eye on palpation. * **Differential for Halos:** Apart from ACG, halos are seen in **immature cataracts** (due to protein water droplets) and **mucopurulent conjunctivitis** (due to mucus flakes; these disappear on blinking, whereas glaucoma halos do not). * **Immediate Management:** Systemic Acetazolamide and topical Pilocarpine (once IOP drops below 40 mmHg). The definitive treatment is **Laser Peripheral Iridotomy (LPI)**.

Question 23: 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 (IOP). What is the most likely diagnosis?

A. Prodromal phase of acute angle closure glaucoma (Correct Answer)
B. Acute angle closure glaucoma
C. Chronic glaucoma
D. Epidemic dropsy

Explanation: ### Explanation **1. Why Option A is Correct:** The patient is presenting with the classic **Prodromal Phase** of Acute Angle Closure Glaucoma (AACG). This stage is characterized by intermittent, self-limiting episodes of elevated intraocular pressure (IOP). * **Colored Halos:** Caused by transient **corneal edema**. When IOP rises rapidly, fluid is pushed into the corneal epithelium, acting like a prism that splits light into spectral colors (blue inside, red outside). * **Evening Symptoms:** In the evening (dim light), the pupil undergoes **physiological mydriasis**, which leads to pupillary block and crowding of the angle in predisposed eyes, triggering the attack. * **Normal IOP:** Since the episodes are transient, the IOP returns to normal between attacks, which is why the patient may have a normal reading during a clinical examination. **2. Why Other Options are Incorrect:** * **Option B (Acute AACG):** This is the "full-blown" attack. It presents with excruciating pain, nausea, vomiting, a stony-hard eye (very high IOP), and a fixed, semi-dilated pupil. It does not resolve spontaneously. * **Option C (Chronic Glaucoma):** This is usually asymptomatic ("the silent thief of sight") until advanced stages. It does not typically cause colored halos or transient blurring. * **Option D (Epidemic Dropsy):** While it causes glaucoma (due to Sanguinarine toxin), it is associated with bilateral presentation, widespread edema, and cardiac features. It is not typically intermittent or triggered by evening dimness. **3. NEET-PG High-Yield Pearls:** * **Fincham’s Test:** Used to differentiate halos of glaucoma from cataract. Glaucomatous halos remain intact when a stenopeic slit is passed across the pupil, whereas cataractous halos break into segments. * **Treatment of Choice (Prodromal):** Prophylactic **Laser Peripheral Iridotomy (LPI)** in both eyes. * **Anatomical Predisposition:** Hypermetropic eyes (small globes) with shallow anterior chambers are most at risk.

Question 24: An elderly man presents with a painful red eye. On examination, the pupil is noted to be dilated and fixed. What is the next line of investigation?

A. Tonometry (Correct Answer)
B. Visual evoked potential
C. Retinal angiogram
D. Slit lamp examination

Explanation: **Explanation:** The clinical presentation of a **painful red eye** associated with a **dilated, fixed, vertically oval pupil** is a classic hallmark of **Acute Angle-Closure Glaucoma (AACG)**. In this emergency, the sudden rise in intraocular pressure (IOP) causes iris ischemia, leading to pupillary paralysis. 1. **Why Tonometry is the correct answer:** The immediate priority in a suspected case of AACG is to confirm the diagnosis by measuring the intraocular pressure. **Tonometry** (specifically Applanation Tonometry) is the definitive investigation to document the elevated IOP, which often exceeds 40–70 mmHg in these patients. Prompt diagnosis is vital to initiate pressure-lowering treatment and prevent permanent optic nerve damage. 2. **Why other options are incorrect:** * **Visual Evoked Potential (VEP):** This is used to assess the functional integrity of the visual pathway (e.g., optic neuritis) and has no role in the acute management of a red eye. * **Retinal Angiogram (FFA):** This is used to evaluate vascular pathologies like diabetic retinopathy or macular degeneration; it is not indicated in acute glaucoma. * **Slit Lamp Examination:** While useful for seeing a shallow anterior chamber or corneal edema, it is a diagnostic tool rather than the specific investigation to confirm the *pressure* elevation. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of AACG:** Sudden ocular pain, "halos" around lights, and a stony-hard eye on palpation. * **Gold Standard for Diagnosis:** Gonioscopy (to visualize the closed angle), but **Tonometry** is the immediate next step for pressure assessment. * **Drug of Choice (Immediate):** IV Acetazolamide and topical pilocarpine (once IOP drops below 40 mmHg). * **Definitive Treatment:** Peripheral Iridotomy (Laser or Surgical).

Question 25: What is the normal diurnal variation of intraocular pressure?

A. 0-2 mm of Hg
B. 2-3 mm of Hg
C. 3-6 mm of Hg (Correct Answer)
D. 6-8 mm of Hg

Explanation: ### Explanation **1. Understanding the Correct Answer (C: 3-6 mm Hg)** Intraocular pressure (IOP) is not static; it fluctuates throughout a 24-hour period due to changes in aqueous humor production and drainage, as well as variations in circulating cortisol and melatonin levels. In a healthy, non-glaucomatous eye, this **diurnal variation** typically ranges between **3 to 6 mm Hg**. IOP is generally highest in the early morning hours (phasic variation) and lowest in the evening. **2. Analysis of Incorrect Options** * **Options A & B (0-3 mm Hg):** These values are too narrow. While some individuals may show very stable IOP, the physiological norm accounts for a wider range of fluctuation due to postural changes and circadian rhythms. * **Option D (6-8 mm Hg):** This range is considered suspicious. A diurnal variation exceeding **8 mm Hg** is highly suggestive of **Glaucoma**, even if the absolute IOP readings fall within the "normal" range (10-21 mm Hg) during office hours. **3. Clinical Pearls for NEET-PG** * **Gold Standard for Measurement:** The **Goldmann Applanation Tonometer (GAT)** is the gold standard for measuring IOP. * **Glaucoma Diagnosis:** In glaucomatous eyes, the diurnal fluctuation is exaggerated (often >10 mm Hg). This is why a single "normal" IOP reading in the afternoon does not rule out glaucoma. * **Diurnal Variation Recording:** To accurately capture these peaks, a **Diurnal Variation Chart (DVC)** is maintained, measuring IOP every 3-4 hours over a 24-hour period. * **Postural Influence:** IOP is typically higher in the **supine position** compared to the sitting position due to increased episcleral venous pressure.

Question 26: In closed-angle glaucoma, all of the following are true EXCEPT:

A. Iridectomy is performed.
B. Pilocarpine is used.
C. Nonsystemic manifestations occur. (Correct Answer)
D. Atropine is not used.

Explanation: In **Acute Angle-Closure Glaucoma (AACG)**, the sudden rise in intraocular pressure (IOP) is a medical emergency characterized by both ocular and significant **systemic manifestations**. ### Why Option C is the Correct Answer (The "Except") The statement "Nonsystemic manifestations occur" is false because AACG is notorious for causing **severe systemic symptoms**. Due to the oculo-visceral reflex (mediated by the Vagus nerve), patients often present with: * Nausea and vomiting. * Severe headache and prostration. * Bradycardia and sweating. These symptoms are so prominent that cases are sometimes misdiagnosed as acute abdominal or neurological emergencies. ### Explanation of Incorrect Options * **A. Iridectomy is performed:** This is true. Laser Peripheral Iridotomy (LPI) or surgical iridectomy is the definitive treatment. It creates a bypass for aqueous humor, relieving the pupillary block. * **B. Pilocarpine is used:** This is true. Pilocarpine (a miotic) is used to pull the iris away from the angle, opening the drainage pathway. Note: It is usually started once IOP has dropped below 40 mmHg, as the iris sphincter is ischemic at very high pressures. * **D. Atropine is not used:** This is true. Atropine is a **mydriatic** (dilates the pupil), which causes further crowding of the angle and can worsen or precipitate an attack of closed-angle glaucoma. It is strictly contraindicated. ### NEET-PG High-Yield Pearls * **Drug of Choice for immediate IOP reduction:** Intravenous Mannitol (osmotic diuretic) or Acetazolamide. * **Clinical Sign:** "Steamy" or "Cloudy" cornea with a vertically oval, semi-dilated, non-reacting pupil. * **Prophylaxis:** Always treat the fellow eye ("Direct Fellow Eye") with prophylactic Laser Peripheral Iridotomy, as the anatomical predisposition is bilateral.

Question 27: Inverse glaucoma is seen with which condition?

A. Instillation of miotics (Correct Answer)
B. Instillation of steroids
C. Instillation of mydriatics
D. All of the above

Explanation: **Explanation:** **Inverse Glaucoma** refers to a paradoxical rise in intraocular pressure (IOP) following the administration of **miotics** (like Pilocarpine). This phenomenon is classically associated with **Spherophakia** (seen in conditions like Weill-Marchesani syndrome) and **Subluxated lens**. 1. **Why Miotics are the cause:** In Spherophakia, the lens is small and spherical. When a miotic is instilled, it causes contraction of the ciliary muscle, which relaxes the zonules. This allows the already globular lens to move forward and increase its anteroposterior diameter, leading to a **pupillary block**. This pushes the iris forward, closing the angle and causing a sudden rise in IOP—the opposite of the expected effect of miotics in typical angle-closure glaucoma. 2. **Why other options are incorrect:** * **Steroids:** Steroid-induced glaucoma is a secondary open-angle glaucoma caused by increased resistance to aqueous outflow due to structural changes in the trabecular meshwork (accumulation of glycosaminoglycans). It is not "inverse." * **Mydriatics:** These typically cause pupillary block or angle crowding in predisposed eyes (primary angle-closure), which is the standard mechanism, not a paradoxical "inverse" reaction. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Inverse Glaucoma:** The definitive management is the instillation of **Mydriatics/Cycloplegics** (e.g., Atropine). These tighten the zonules, pulling the lens backward and relieving the pupillary block. * **Associated Syndrome:** Always look for **Weill-Marchesani Syndrome** (short stature, brachydactyly, and spherophakia) in questions involving inverse glaucoma. * **Contrast:** In standard Primary Angle Closure Glaucoma (PACG), miotics are used to pull the iris away from the angle; in Inverse Glaucoma, they worsen the block.

Question 28: Which one of the following procedures is most likely to increase intraocular pressure in a glaucoma patient?

A. Use of atropine
B. Decreased pressure in jugular vein
C. High dose of vitamin C (Correct Answer)
D. Dark environment

Explanation: ### Explanation The correct answer is **High dose of Vitamin C (Option C)**. This question tests the understanding of factors influencing aqueous humor dynamics and intraocular pressure (IOP). **Why High Dose Vitamin C is Correct:** Vitamin C (ascorbic acid) is an osmotic agent. When administered in **high doses**, it can lead to a transient increase in intraocular pressure. This occurs because high concentrations of ascorbic acid in the blood can alter the osmotic gradient or potentially interfere with the trabecular meshwork's outflow facility. While chronic low-dose Vitamin C is often discussed for its antioxidant properties, acute high doses are known to paradoxically elevate IOP. **Analysis of Incorrect Options:** * **A. Use of Atropine:** While atropine (a mydriatic) can precipitate acute angle-closure glaucoma in predisposed individuals with narrow angles, it does not typically increase IOP in a patient with open-angle glaucoma. In fact, in some contexts, cycloplegics can slightly increase uveoscleral outflow. * **B. Decreased pressure in jugular vein:** IOP is directly proportional to episcleral venous pressure. A **decrease** in jugular venous pressure (e.g., sitting upright) leads to a decrease in episcleral venous pressure, which subsequently **lowers** IOP. * **D. Dark environment:** Darkness causes pupillary dilation (mydriasis). Similar to atropine, this is a risk factor for angle-closure, but it is a physiological state rather than a procedure or pharmacological intervention that consistently increases IOP across all glaucoma types. **Clinical Pearls for NEET-PG:** * **Goldmann Equation:** $IOP = (F / C) + Pv$ (where $F$ = aqueous formation, $C$ = facility of outflow, $Pv$ = episcleral venous pressure). Anything increasing $Pv$ (like a tight necktie or Valsalva) increases IOP. * **Diurnal Variation:** IOP is usually highest in the early morning (around 6 AM) and lowest at night. * **Systemic Osmotics:** While high-dose Vitamin C increases IOP, other osmotics like **Mannitol** and **Glycerol** are used to *decrease* IOP by dehydrating the vitreous.

Question 29: What is the incidence of congenital glaucoma?

A. 1 in 1000 births
B. 1 in 5000 births
C. 1 in 10,000 births (Correct Answer)
D. 1 in 34,000 births

Explanation: **Explanation:** Primary Congenital Glaucoma (PCG) is a rare but vision-threatening developmental defect of the trabecular meshwork and anterior chamber angle (trabeculodysgenesis) that occurs without associated ocular or systemic anomalies. **1. Why Option C is Correct:** The global incidence of Primary Congenital Glaucoma is widely accepted as **1 in 10,000 live births**. It is the most common glaucoma of infancy. While the incidence is higher in specific populations with high rates of consanguinity (e.g., 1 in 2,500 in Middle Eastern populations or 1 in 3,300 in the Andhra Pradesh region of India), the standard textbook figure for competitive exams remains 1:10,000. **2. Analysis of Incorrect Options:** * **Option A (1 in 1,000):** This overestimates the incidence significantly. Such a high frequency would make it a common pediatric condition rather than a rare developmental anomaly. * **Option B (1 in 5,000):** While closer to the incidence seen in specific high-risk ethnic groups, it does not represent the standard global average. * **Option D (1 in 34,000):** This figure is often cited for the incidence of specific rare syndromes or much rarer forms of secondary pediatric glaucoma, but it is too low for PCG. **3. NEET-PG High-Yield Pearls:** * **Genetics:** Most cases are **sporadic** (90%), but familial cases (10%) usually follow an **Autosomal Recessive** pattern. The most common gene mutation involves **CYP1B1**. * **Demographics:** It is more common in **males** (65%) and is **bilateral** in 70-80% of cases. * **Classic Triad:** Epiphora (tearing), Photophobia, and Blepharospasm. * **Clinical Signs:** **Buphthalmos** (enlarged eyeball due to high IOP before age 3), **Haab’s striae** (horizontal breaks in Descemet’s membrane), and corneal edema. * **Treatment:** Primarily **surgical**. **Goniotomy** or **Trabeculotomy** are the procedures of choice.

Question 30: What is the treatment for first-degree angle closure glaucoma?

A. Trabeculectomy
B. Pilocarpine
C. Laser iridotomy (Correct Answer)
D. Timolol

Explanation: **Explanation:** The term **"First-degree angle closure"** refers to the early stage of Primary Angle Closure (PAC), where the primary mechanism is **pupillary block**. In this state, the flow of aqueous humor from the posterior to the anterior chamber is restricted, causing the iris to bulge forward (iris bombe) and narrow the drainage angle. **Why Laser Peripheral Iridotomy (LPI) is the Correct Answer:** LPI is the definitive treatment and the gold standard for angle closure. By creating a small hole in the peripheral iris, it provides an alternative pathway for aqueous humor to bypass the pupil. This equalizes the pressure between the posterior and anterior chambers, flattens the iris, and opens the drainage angle, directly addressing the underlying anatomical cause. **Analysis of Incorrect Options:** * **A. Trabeculectomy:** This is a filtering surgery used for advanced glaucoma or when medical/laser therapy fails. It is not the first-line treatment for primary angle closure. * **B. Pilocarpine:** While used to constrict the pupil and pull the iris away from the angle, it is a temporary medical measure. It does not cure the pupillary block and can sometimes worsen it by increasing iris-lens contact. * **C. Timolol:** This is a beta-blocker that reduces aqueous production. While it helps lower intraocular pressure, it does not address the mechanical obstruction of the angle. **High-Yield Clinical Pearls for NEET-PG:** * **Prophylaxis:** LPI is also indicated in the fellow eye of a patient who has had an acute attack, as there is a 50-75% chance of an attack in the other eye within 5 years. * **Drug of Choice for Acute Attack:** Systemic **Acetazolamide** (IV/Oral) is used initially to lower pressure before performing LPI. * **Gonioscopy:** The gold standard diagnostic tool to visualize the angle and confirm closure. * **Configuration:** Always remember that a **shallow anterior chamber** and **short axial length** (hypermetropia) are major predisposing factors.

Practice by Chapter

Aqueous Humor Dynamics

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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

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Angle Assessment Techniques

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Visual Field Testing in Glaucoma

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Glaucoma — MCQs

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