Glaucoma Practice Questions

Q: What is the primary mechanism of pathogenesis in acute angle closure glaucoma?

Outflow obstruction due to anatomical factors. ***Outflow obstruction due to anatomical factors*** - **Acute angle-closure glaucoma (AACG)** occurs due to a sudden blockage of the **trabecular meshwork**, which is the primary drainage pathway for aqueous humor. - This blockage is caused by anatomical predispositions, such as a **narrow anterior chamber angle**, relatively large lens, and **pupillary block** leading to iris bombé with peripheral iris bowing forward. - The iridocorneal angle closure prevents aqueous humor drainage, causing **rapid IOP elevation**. *Increased secretion of aqueous humor* - While increased aqueous humor production can contribute to elevated intraocular pressure, it is **not the primary mechanism** in acute angle-closure glaucoma. - This mechanism is more relevant in **open-angle glaucoma** or conditions with ciliary body overactivity. - AACG's hallmark is **outflow obstruction**, not increased production. *Decreased ciliary body function* - Decreased ciliary body function would **reduce aqueous humor production**, leading to **hypotony** (low IOP), not elevated pressure. - This is the opposite of what occurs in AACG, where IOP rises dramatically due to impaired drainage. - Ciliary body dysfunction is seen in conditions like **uveitis** or post-surgical complications. *Increased absorption of aqueous humor* - **Increased absorption** of aqueous humor would **reduce intraocular pressure**, which is the opposite of what occurs in acute angle-closure glaucoma. - The disease is characterized by a **rapid and severe rise in intraocular pressure** due to impaired outflow, not enhanced absorption. - Normal aqueous absorption occurs via trabecular and uveoscleral pathways, both of which are blocked in AACG.

Q: Recurrent anterior uveitis with increased intraocular tension is seen in which of the following conditions?

Posner-Schlossman syndrome. ***Posner-Schlossman syndrome*** - Characterized by **recurrent, unilateral, non-granulomatous anterior uveitis** associated with markedly **elevated intraocular pressure (IOP)**. - The condition is also known as **glaucomatocyclitic crisis**, highlighting the episodic inflammation and glaucoma. - Key features include **acute attacks** lasting hours to weeks with **dramatic IOP elevation** (often >40 mmHg). *Foster-Kennedy syndrome* - This syndrome is defined by ipsilateral **optic atrophy**, contralateral **papilledema**, and often **anosmia**, typically due to a frontal lobe tumor. - It does not involve anterior uveitis or primary elevated intraocular tension. - This is a neuro-ophthalmologic syndrome, not an inflammatory ocular condition. *Vogt-Koyanagi-Harada syndrome* - An autoimmune disorder affecting pigmented tissues, leading to **bilateral granulomatous panuveitis**, often with hearing loss, vitiligo, poliosis, and neurological symptoms. - While it involves uveitis, it is typically **bilateral and panuveitis**, not recurrent unilateral anterior uveitis. - IOP may be elevated but not the defining feature with dramatic episodic rises. *Fuchs heterochromic iridocyclitis* - A chronic, **unilateral, low-grade anterior uveitis** with characteristic iris heterochromia. - May have mild IOP elevation but **not recurrent episodic attacks** with marked pressure spikes. - Inflammation is typically **quiet and chronic** rather than acute and recurrent.

Q: Which of the following statements is false about phacolytic glaucoma?

Primarily caused by iris-lens contact. ***Primarily caused by iris-lens contact*** - This statement is **FALSE** because **phacolytic glaucoma** is caused by the leakage of **lens proteins** from a **hypermature cataract** into the **anterior chamber**, not by iris-lens contact. - **Iris-lens contact** is the mechanism in **pupillary block glaucoma** and **acute angle-closure glaucoma**, not in phacolytic glaucoma. - The pathophysiology involves **macrophages** engulfing leaked lens proteins and obstructing the **trabecular meshwork**. *Open angle glaucoma* - This statement is true because **phacolytic glaucoma** is definitively an **open-angle glaucoma**. - It involves obstruction of the **trabecular meshwork** by **macrophages** laden with **lens proteins**, which is an open-angle mechanism. - The angle remains anatomically open but functionally blocked. *Seen in hypermature stage of cataract* - This statement is true because **phacolytic glaucoma** develops when the **lens capsule** of a **hypermature (Morgagnian) cataract** becomes permeable. - This permeability allows **high-molecular-weight lens proteins** to leak into the **aqueous humor**. *Lens induced glaucoma* - This statement is true as **phacolytic glaucoma** is a specific type of **lens-induced glaucoma**, arising from the toxic effects of **leaked lens material**. - Other forms of **lens-induced glaucoma** include **phacomorphic glaucoma**, **lens-particle glaucoma**, and **phacoanaphylactic glaucoma**.

Q: Which of the following conditions is least likely to be associated with neovascular glaucoma?

Open angle glaucoma. ***Open angle glaucoma*** ✓ - **Open-angle glaucoma** is a primary **neurodegenerative disease** of the optic nerve, characterized by progressive loss of **retinal ganglion cells** and their axons, leading to characteristic **optic neuropathy** and visual field defects. - It does **NOT** directly cause **neovascularization** or increased VEGF production, which are the underlying mechanisms for **neovascular glaucoma**. - This is the **least likely** association among the given options. *Diabetes* - **Diabetic retinopathy** is a **major cause** of **neovascularization** due to retinal ischemia and increased production of **vascular endothelial growth factor (VEGF)**, which can lead to **neovascular glaucoma**. - **Neovascularization** on the iris (rubeosis iridis) and angle can block aqueous outflow, causing a severe, rapidly progressing form of secondary glaucoma. *CRVO (Central Retinal Vein Occlusion)* - **CRVO** leads to significant retinal ischemia and subsequent release of **VEGF**, which prompts the growth of new, fragile blood vessels. - These new vessels (neovascularization) can grow in the iris and angle, obstructing aqueous humor outflow and causing **neovascular glaucoma**. - **Ischemic CRVO** is one of the **most common causes** of neovascular glaucoma. *Eale's disease* - **Eale's disease** is an **idiopathic occlusive vasculitis** primarily affecting the **peripheral retinal veins**, leading to **retinal ischemia**. - This ischemia stimulates **neovascularization** and the production of **VEGF**, increasing the risk of **neovascular glaucoma** due to the formation of new blood vessels in the anterior chamber.

Q: Which of the following is not a risk factor for angle closure glaucoma?

Small lens. ***Correct Answer: Small lens*** - A smaller lens would lead to a **deeper anterior chamber**, reducing the likelihood of iridotrabecular contact and angle closure. - In contrast, a **large or thick lens** is a well-established risk factor for angle closure glaucoma as it pushes the iris forward, causing pupillary block. - Small lens size is **NOT a risk factor** for angle closure glaucoma. *Incorrect: Small eye* - A small eye (e.g., in **nanophthalmos**) is associated with a relatively large lens in proportion to the eye size, which can push the iris forward and narrow the angle. - This anatomical configuration makes individuals more prone to **pupillary block** and angle closure. *Incorrect: Hypermetropia* - **Hyperopic eyes** tend to be shorter with reduced axial length, which often results in a shallower anterior chamber and a relatively crowded anterior segment. - This shallow anterior chamber increases the risk of the iris occluding the **trabecular meshwork**, predisposing to angle closure. *Incorrect: Small cornea* - A small corneal diameter can be indicative of a generally smaller anterior segment, often correlating with a **shallow anterior chamber**. - A smaller cornea contributes to a more crowded anterior segment, predisposing to **angle closure glaucoma**.

Q: Laser iridotomy is done in?

Angle closure glaucoma. ***Angle closure glaucoma*** - **Laser iridotomy** creates a small hole in the iris, allowing aqueous humor to flow directly from the posterior to the anterior chamber, thus relieving pupillary block and opening the angle. - This procedure is the definitive treatment to prevent further **angle closure attacks** and is also used prophylactically in eyes at risk. *Open angle glaucoma* - This condition involves an **open angle** but impaired outflow of aqueous humor through the **trabecular meshwork**. - Laser iridotomy is not indicated as it does not address the primary outflow obstruction in the trabecular meshwork. *Pigmentary glaucoma* - This is a type of **open-angle glaucoma** caused by pigment dispersion that clogs the trabecular meshwork, leading to increased intraocular pressure. - While pigment can be released from the iris, the primary issue is the **trabecular meshwork obstruction**, which is not directly resolved by iridotomy. *None of the options* - This option is incorrect because **angle closure glaucoma** is a clear indication for laser iridotomy.

Q: Broadest neuroretinal rim is seen in -

Inferior pole. ***Inferior pole*** - The **inferior pole** of the optic disc typically has the broadest neuroretinal rim in healthy eyes. - This observation is often remembered by the "ISNT rule," where **I > S > N > T** (Inferior > Superior > Nasal > Temporal) describes the typical thickness of the neuroretinal rim. *Superior pole* - While the superior pole has a relatively thick neuroretinal rim, it is generally **thinner than the inferior rim**. - The superior rim is the second thickest based on the **ISNT rule**. *Nasal pole* - The nasal pole's neuroretinal rim is typically **thinner than both the inferior and superior poles**. - It ranks third in thickness according to the **ISNT rule**. *Temporal pole* - The temporal pole typically has the **thinnest neuroretinal rim**, making it the narrowest part of the disc. - This is due to the larger excavation of the optic cup temporally, accommodating the macular fibers.

Q: In primary open-angle glaucoma (POAG), which of the following findings is NOT typically seen?

Macular edema. ***Macular edema*** - **Macular edema** is characterized by fluid accumulation in the fovea or retina, causing blurry vision and metamorphopsia. - While it can occur in conditions like **diabetic retinopathy** or **uveitis**, it is **not a typical finding in POAG**, which primarily affects the optic nerve. *Horizontal cupping of the optic disc* - **Horizontal cupping** (or vertical elongation of the optic cup) is a common sign of **glaucomatous damage**, reflecting the loss of retinal ganglion cells. - This morphological change suggests the progression of optic nerve atrophy. *Bayoneting sign (arteriovenous crossing changes)* - The **bayoneting sign**, where blood vessels appear to dip below the optic disc margin and then sharply bend, is a feature of **advanced glaucomatous cupping**. - It indicates significant loss of optic nerve tissue and is often associated with deeply excavated optic discs. *Peripapillary atrophy* - **Peripapillary atrophy** (PPA) refers to areas of RPE and choroidal atrophy surrounding the optic disc, commonly seen in glaucoma. - While its presence and extent may correlate with **glaucoma severity**, it is a recognized clinical feature of the disease.

Q: Normal cup-to-disc ratio of the optic disc is

0.2 to 0.3. ***Correct: 0.2 to 0.3*** - The **cup-to-disc ratio (CDR)** is a crucial ophthalmological measurement for assessing optic nerve health - The **most commonly cited normal range** in standard ophthalmology textbooks (Kanski, AAO guidelines) is **0.2 to 0.3** - This represents the **typical physiological range** seen in the majority of healthy individuals - CDR up to **0.3 is considered normal**, with the average being approximately 0.3 *Incorrect: 0.3 to 0.4* - This range is at the **upper limit of normal or borderline** territory - CDR values of **0.4 or higher** are concerning and warrant close monitoring for glaucoma - Not representative of the **typical normal range** for clinical assessment *Incorrect: 0.5 to 0.6* - A CDR in this range is **highly abnormal and suspicious for glaucoma** - Indicates significant **loss of neural rim tissue** characteristic of glaucomatous optic neuropathy - Represents advanced optic nerve damage *Incorrect: 0.1 to 0.3* - While technically encompassing normal values, this range is **not the standard clinical definition** used in practice - CDR values of **0.1 are uncommonly small** and may suggest **anomalous optic disc** or measurement error - The **clinically accepted and most frequently cited normal range** starts at 0.2, making this option less precise for standard clinical assessment - In exam context, **0.2 to 0.3** is the preferred answer as it represents the **conventional teaching**

Q: A patient presents with a history of evening halos and occasional headaches for some months. His examination shows normal intraocular pressure but shallow anterior chamber. What is the most likely diagnosis?

Primary angle-closure glaucoma. ***Primary angle-closure glaucoma*** - The combination of **evening halos**, **occasional headaches**, and a **shallow anterior chamber** is highly suggestive of primary angle-closure glaucoma. - While intraocular pressure might be normal at presentation, these symptoms indicate episodes of **intermittent angle closure**, leading to transient pressure spikes. *Normal-tension glaucoma* - This condition is characterized by **optic nerve damage** and vision loss despite **normal intraocular pressure**, but symptoms like halos are not typical. - The anterior chamber would typically be of normal depth. *Open-angle glaucoma* - This condition is often **asymptomatic** in its early stages and does not typically present with halos or headaches. - The anterior chamber is **open**, distinguishing it from angle-closure glaucoma. *Pigmentary glaucoma* - This type of glaucoma is caused by the release of **pigment** from the iris, which then blocks the **trabecular meshwork**. - While it can manifest with elevated intraocular pressure, it is not consistently associated with a shallow anterior chamber or episodes of halos and headaches in the same manner as angle-closure glaucoma.

Question 1

What is the primary mechanism of pathogenesis in acute angle closure glaucoma?

Accepted Answer

Outflow obstruction due to anatomical factors

Answer

Increased secretion of aqueous humor

Answer

Increased absorption of aqueous humor

Answer

Decreased ciliary body function

Question 2

Recurrent anterior uveitis with increased intraocular tension is seen in which of the following conditions?

Accepted Answer

Posner-Schlossman syndrome

Answer

Foster-Kennedy syndrome

Answer

Vogt-Koyanagi-Harada syndrome

Answer

Fuchs heterochromic iridocyclitis

Question 3

Which of the following statements is false about phacolytic glaucoma?

Accepted Answer

Primarily caused by iris-lens contact

Answer

Open angle glaucoma

Answer

Lens induced glaucoma

Answer

Seen in hypermature stage of cataract

Question 4

Which of the following conditions is least likely to be associated with neovascular glaucoma?

Accepted Answer

Open angle glaucoma

Answer

Diabetes

Answer

CRVO

Answer

Eale's disease

Question 5

Which of the following is not a risk factor for angle closure glaucoma?

Accepted Answer

Small lens

Answer

Small eye

Answer

Small cornea

Answer

Hypermetropia

Question 6

Laser iridotomy is done in?

Accepted Answer

Angle closure glaucoma

Answer

Pigmentary glaucoma

Answer

None of the options

Answer

Open angle glaucoma

Question 7

Broadest neuroretinal rim is seen in -

Accepted Answer

Inferior pole

Answer

Nasal pole

Answer

Superior pole

Answer

Temporal pole

Question 8

In primary open-angle glaucoma (POAG), which of the following findings is NOT typically seen?

Accepted Answer

Macular edema

Answer

Bayoneting sign (arteriovenous crossing changes)

Answer

Peripapillary atrophy

Answer

Horizontal cupping of the optic disc

Question 9

Normal cup-to-disc ratio of the optic disc is

Accepted Answer

0.2 to 0.3

Answer

0.5 to 0.6

Answer

0.1 to 0.3

Answer

0.3 to 0.4

Question 10

A patient presents with a history of evening halos and occasional headaches for some months. His examination shows normal intraocular pressure but shallow anterior chamber. What is the most likely diagnosis?

Accepted Answer

Primary angle-closure glaucoma

Answer

Normal-tension glaucoma

Answer

Pigmentary glaucoma

Answer

Open-angle glaucoma

Glaucoma — MCQs

Glaucoma — MCQs

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