Glaucoma Practice Questions

Q: Comment on the diagnosis:

Congenital Glaucoma (Buphthalmos). ***Congenital Glaucoma (Buphthalmos)*** - The image displays enlarged, cloudy corneas and deeply set eyes, characteristic of **buphthalmos**, which is a sign of **congenital glaucoma** in infants and young children. - This condition results from elevated intraocular pressure from birth or early childhood due to developmental abnormalities of the **aqueous outflow system** leading to stretching and enlargement of the eye. - Classic triad: **Epiphora (tearing), photophobia, and blepharospasm** - Examination findings include **increased corneal diameter (>12 mm), corneal edema, and Haab's striae** *Congenital Cataract* - Would present with white pupillary reflex (leukocoria) and opacified lens, not enlarged globes - No corneal clouding or increased eye size - Does not cause buphthalmos *Retinoblastoma* - Presents with leukocoria (white pupillary reflex) - May have strabismus, but does not cause corneal enlargement or clouding - Typically unilateral in most cases *Congenital Corneal Opacity* - May present with cloudy cornea but without globe enlargement - No increased intraocular pressure or stretching of ocular tissues - Corneal size remains normal

Q: Which of the following is incorrect about a 2-yearold child presenting with watering from both eyes?

Nasolacrimal duct malformation. ***Nasolacrimal duct malformation*** - **Nasolacrimal duct malformation is NOT a feature of congenital glaucoma**, making this the incorrect statement. - While **nasolacrimal duct obstruction (NLDO)** can cause watering (epiphora) in infants, it is a separate entity from congenital glaucoma and presents differently. - In NLDO, there is watering **without photophobia, without corneal clouding, and without globe enlargement**. - The watering in **congenital glaucoma** is due to **corneal irritation and photophobia** from elevated intraocular pressure, not from nasolacrimal pathology. - There is no primary association between congenital glaucoma and nasolacrimal duct malformation. *Corneal clouding* - **Corneal clouding** is a classic sign of congenital glaucoma, caused by **corneal edema** secondary to elevated intraocular pressure. - The cloudy appearance results from breaks in **Descemet's membrane** (Haab's striae) and stromal edema. - This is a **correct statement** about congenital glaucoma. *Corneal edema* - **Corneal edema** is a direct consequence of sustained elevated intraocular pressure in congenital glaucoma. - The elevated IOP causes fluid accumulation within the corneal layers, leading to a hazy appearance. - This contributes to the photophobia and tearing seen in these patients. - This is a **correct statement** about congenital glaucoma. *Deep anterior chamber* - A **deep anterior chamber** is a hallmark feature of congenital glaucoma, NOT an incorrect finding. - In infants, elevated IOP causes the pliable eye to stretch, resulting in **buphthalmos** (enlarged globe). - As the cornea bows forward and enlarges (diameter >12mm), the **anterior chamber deepens significantly**. - This is a **correct statement** about congenital glaucoma and would be seen in this 2-year-old child.

Q: Which of the following methods of visual field testing is shown below?

Humphrey analyzer. ***Correct: Humphrey analyzer*** - The image distinctly shows a patient positioned with their head on a **chin rest** and forehead strap, looking into a large, automated machine with a **bowl-shaped perimeter** and an external monitor displaying test results, which is characteristic of a Humphrey Field Analyzer. - This **automated perimetry** device is widely used for quantitative assessment of the visual field, especially for detecting and monitoring **glaucoma** and neurologic conditions. *Incorrect: Bjerrum screen* - The Bjerrum screen is a **manual perimetry** method using a tangent screen, typically made of black felt, where targets are moved manually by the examiner. - This method is older and simpler, primarily used for detecting **central and paracentral scotomas** and would not involve a complex electronic device as pictured. *Incorrect: Goldmann perimeter* - The Goldmann perimeter is a **manual kinetic perimetry** device, characterized by a large white bowl where a light spot is moved by the examiner to map visual field boundaries. - While it uses a bowl, it is operated manually and does not feature the electronic screen and automated components seen in the image. *Incorrect: Lister's perimeter* - The term "Lister's perimeter" is not a standard or commonly recognized method of visual field testing in modern ophthalmology. - There is no widely accepted or used device by this name for perimetry.

Q: All are causes for the visual defect shown below except:

Tobacco alcohol amblyopia. ***Tobacco alcohol amblyopia*** - The image illustrates a **ring scotoma**, also known as an **annular scotoma** or **mid-peripheral scotoma**, where there is a defect in the mid-periphery of the visual field while central and far peripheral vision remain intact. - Tobacco-alcohol amblyopia typically causes a **central or centrocecal scotoma**, affecting central vision and sometimes extending to the blind spot, not a ring scotoma. *Retinitis pigmentosa* - This condition is characterized by **progressive degeneration of photoreceptors**, initially rods, leading to **night blindness** and then progressive peripheral vision loss. - It often results in a **ring scotoma** that gradually expands, causing tunnel vision as the central vision is spared initially. *High myopia* - **Pathological myopia**, or high myopia, can lead to various retinal changes, including **chorioretinal atrophy** in the mid-periphery. - These atrophic changes can manifest as a **ring scotoma** due to the loss of retinal tissue and photoreceptors in that region. *Glaucoma* - Glaucoma is characterized by **optic nerve damage** and visual field loss, typically starting in the mid-periphery. - While various types of visual field defects occur in glaucoma, a **ring scotoma** can be observed, particularly in normal tension glaucoma or advanced cases, reflecting arcuate defects or the convergence of nerve fiber layer damage.

Q: Which field defect is shown in the image below?

Roenne's nasal step. ***Roenne's nasal step*** - The image depicts a visual field defect characterized by a **step-like loss of vision along the horizontal meridian** on the nasal side. This pattern is characteristic of a Roenne's nasal step. - This defect occurs due to **glaucomatous damage to retinal nerve fibers**, specifically those running from the temporal retina that cross the midline to the nasal side, leading to an abrupt change in visual sensitivity. *Bjerrum scotoma* - A Bjerrum scotoma (also known as an arcuate scotoma) is an **arc-shaped blind spot** that typically arises from the blind spot and arcs above or below the macula before ending abruptly at the horizontal midline. - It is a common finding in glaucoma but has a distinct arcuate shape, unlike the step-like defect shown. *Seidel scotoma* - A Seidel scotoma is an **early, localized enlargement of the blind spot**, often taking on a comma or sickle shape. - While it is an early glaucomatous field defect, it does not typically present as a distinct step along the horizontal meridian as shown in the image. *Superior paracentral scotoma* - A paracentral scotoma is a **small, isolated blind spot** located close to the central vision (but not involving it). - A superior paracentral scotoma would be located in the **upper visual field**, but the image shows a defect that extends to the periphery along the nasal meridian with a distinct step, which is not characteristic of an isolated paracentral scotoma.

Q: Which of the given field defects is shown in the image given below?

Bjerrum scotoma. ***Bjerrum scotoma*** - The image shows an **arcuate scotoma** that extends from the blind spot, arching above or below the macula, and typically does not cross the horizontal meridian. This is characteristic of a Bjerrum scotoma. - This type of visual field defect is a classic sign of **early to moderate glaucoma**, resulting from damage to the retinal nerve fiber layer. *Roenne's nasal step* - Roenne's nasal step is a **depression of the nasal visual field** that respects the horizontal meridian, appearing as a sharp step in the visual field plot. - While also associated with glaucoma, it primarily involves the nasal visual field and looks distinctly different from the arcuate defect shown. *Seidel scotoma* - A Seidel scotoma is a **sickle-shaped extension of the blind spot** superiorly or inferiorly. - It is an **early indicator of glaucoma** but is typically smaller and less extensive than a full Bjerrum scotoma. *Superior paracentral scotoma* - A superior paracentral scotoma is a localized area of visual field loss **close to the central fixation point** and in the superior visual field. - While it can be an early sign of glaucoma, the image depicts an **arcuate shape extending from the blind spot**, rather than a small, isolated paracentral defect.

Q: The given fundus examination reveals presence of:

Papilledema. ***Papilledema*** - The image shows a **swollen optic disc** with blurred margins, loss of the optic cup, and retinal vessel engorgement, which are characteristic signs of papilledema. - **Papilledema** is caused by increased **intracranial pressure** transmitted to the optic nerve head, leading to axoplasmic flow stasis and optic disc edema. *Glaucoma* - **Glaucoma** typically presents with **optic disc cupping** and thinning of the neuroretinal rim due to loss of ganglion cell axons, which is opposite to the features seen in the image. - The optic disc in glaucoma often appears pale and excavated, not swollen and hyperemic as depicted. *Retinitis pigmentosa* - **Retinitis pigmentosa** is characterized by **nyctalopia**, peripheral visual field loss, and funduscopic findings like **bone-spicule pigment deposits**, attenuated retinal vessels, and waxy pallor of the optic disc. - None of these typical features of retinitis pigmentosa are visible in the provided image. *Temporal crescent* - A **temporal crescent** refers to a myopic conus or scleral crescent, which is an area of exposed sclera that appears as a white or yellowish crescent at the temporal border of the optic disc, often seen in high myopia. - The image does not show an area of exposed sclera but rather an elevated and congested optic disc.

Q: What is the test being performed in the image shown below?

Perkins applanation tonometry. ***Perkins applanation tonometry*** - The image shows a **handheld device** being used by an examiner to measure intraocular pressure (IOP) in a patient who is seated or reclined. - This portable nature and direct application to the cornea with a visible prism are characteristic features of the **Perkins applanation tonometer**, often used for patients who cannot be positioned at a slit lamp. *Goldmann's applanation tonometry* - This method requires the patient to be seated at a **slit lamp microscope**, and the tonometer head is attached to the slit lamp. - The image clearly shows a handheld device, **not integrated with a slit lamp**, making Goldmann's tonometry an incorrect option. *Schiotz tonometry* - Schiotz tonometry is an **indentation tonometer** that rests on the central cornea while the patient is in a supine position. - The device in the image is an applanation tonometer, which determines IOP by **flattening a small area of the cornea**, not indenting it. *Noncontact tonometry* - Noncontact tonometry, also known as the **"air puff" test**, measures IOP without direct contact with the eye. - The image clearly depicts a device with direct contact with the patient's eye, specifically the cornea, making noncontact tonometry an incorrect option.

Q: A 25 -year-old lady with past history of seeing colored haloes was watching a movie in a theater when she started having right eye pain. She started feeling nauseous and had to leave the movie midway due to vomiting. On examination she is found to have ciliary and conjunctival congestion and the pupil is vertically oval. The picture of the eye is given below. All are true about the condition shown except:

Present PL. ***Present PL (Perception of Light)*** - In **acute angle-closure glaucoma (AACG)**, visual acuity is typically severely reduced due to corneal edema and elevated intraocular pressure, but **perception of light (PL) is usually preserved** in acute presentations. - While vision may be reduced to counting fingers or hand movements, **complete loss of light perception is uncommon** unless there is severe, prolonged attack with irreversible optic nerve damage. - All other features listed (loss of iris pattern, steamy cornea, absent pupillary reactions) are **consistently present** in AACG, whereas PL can be variable but is typically **present initially**. - This makes "Present PL" the **correct answer** as it is the statement that is **NOT always/universally true** - though PL is often present, the question implies it as a definitive feature when it's actually variable. *Loss of iris pattern* - This is a **consistent finding** in AACG during an acute attack. - The iris becomes **edematous** due to elevated intraocular pressure (often >40 mmHg), which obscures the normal radial folds and crypts. - The iris appears dull, muddy, and featureless - a key diagnostic sign. *Steamy insensitive cornea* - The markedly elevated intraocular pressure causes **corneal epithelial and stromal edema**. - This produces a **hazy or "steamy" appearance** that interferes with visualization of anterior chamber structures. - Corneal sensation may be reduced due to epithelial edema and ischemia. *Absent reaction to light and accommodation* - The pupil in AACG is characteristically **fixed and mid-dilated (4-6 mm)**, often vertically oval as described. - **Complete absence of pupillary light reflex** (both direct and consensual) occurs due to iris sphincter ischemia. - **No accommodation response** due to the fixed, dilated pupil and compromised iris function.

Q: Name the test being performed in the image shown below:

Schiotz tonometry. ***Schiotz tonometry*** - The image shows a **Schiotz tonometer** being held vertically on the supine patient's eye, which is characteristic of this indentation tonometry method. - This method measures intraocular pressure (IOP) by determining the **depth of corneal indentation** caused by a known weight. *Goldmann's applanation tonometry* - This method uses a **slit lamp** and a prism to flatten a small area of the cornea. - It is considered the **gold standard** for IOP measurement but requires a specialized setup not seen here. *Perkins applanation tonometry* - This is a **portable applanation tonometer** that can be used on supine or sitting patients. - While portable, its mechanism involves flattening the cornea rather than indentation, and it looks different from the instrument in the image. *Noncontact tonometry* - This method uses a **puff of air** to flatten the cornea and does not directly touch the eye. - It is commonly used for screening but is not represented by the hand-held device seen in the image.

Question 1

Comment on the diagnosis:

Accepted Answer

Congenital Glaucoma (Buphthalmos)

Answer

Congenital Cataract

Answer

Retinoblastoma

Answer

Congenital Corneal Opacity

Question 2

Which of the following is incorrect about a 2-yearold child presenting with watering from both eyes?

Accepted Answer

Nasolacrimal duct malformation

Answer

Corneal clouding

Answer

Corneal edema

Answer

Deep anterior chamber

Question 3

Which of the following methods of visual field testing is shown below?

Accepted Answer

Humphrey analyzer

Answer

Bjerrum screen

Answer

Goldmann perimeter

Answer

Lister's perimeter

Question 4

All are causes for the visual defect shown below except:

Accepted Answer

Tobacco alcohol amblyopia

Answer

Retinitis pigmentosa

Answer

High myopia

Answer

Glaucoma

Question 5

Which field defect is shown in the image below?

Accepted Answer

Roenne's nasal step

Answer

Bjerrum scotoma

Answer

Seidel scotoma

Answer

Superior paracentral scotoma

Question 6

Which of the given field defects is shown in the image given below?

Accepted Answer

Bjerrum scotoma

Answer

Roenne's nasal step

Answer

Seidel scotoma

Answer

Superior paracentral scotoma

Question 7

The given fundus examination reveals presence of:

Accepted Answer

Papilledema

Answer

Glaucoma

Answer

Retinitis pigmentosa

Answer

Temporal crescent

Question 8

What is the test being performed in the image shown below?

Accepted Answer

Perkins applanation tonometry

Answer

Goldmann's applanation tonometry

Answer

Schiotz tonometry

Answer

Noncontact tonometry

Question 9

A 25 -year-old lady with past history of seeing colored haloes was watching a movie in a theater when she started having right eye pain. She started feeling nauseous and had to leave the movie midway due to vomiting. On examination she is found to have ciliary and conjunctival congestion and the pupil is vertically oval. The picture of the eye is given below. All are true about the condition shown except:

Accepted Answer

Present PL

Answer

Loss of iris pattern

Answer

Steamy insensitive cornea

Answer

Absent reaction to light and accommodation

Question 10

Name the test being performed in the image shown below:

Accepted Answer

Schiotz tonometry

Answer

Goldmann's applanation tonometry

Answer

Perkins applanation tonometry

Answer

Noncontact tonometry

Glaucoma — MCQs

Glaucoma — MCQs

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