Glaucoma Practice Questions

Q: Following injury to the right temple region, a patient complains of pain in the right eye and loss of vision. On examination, the eye movements are normal, and the pupil normally reacts to light. The affected eye shows increased intraocular pressure of 32 mmHg (normal: 10-21 mmHg), mild corneal edema, and a small hyphema visible in the anterior chamber. The diagnosis is

Traumatic glaucoma. ***Traumatic glaucoma*** - Increased **intraocular pressure (32 mmHg)** after a **temple injury** with **corneal edema** and **hyphema** are classic signs of traumatic glaucoma. - The hyphema (blood in the anterior chamber) obstructs the **trabecular meshwork**, impeding aqueous humor outflow and leading to elevated IOP. *Optic nerve atrophy* - While optic nerve atrophy can cause **vision loss**, it is a chronic condition and typically not an acute presentation following trauma unless there is direct optic nerve damage. - It would not explain the acute findings of **hyphema**, **corneal edema**, or acutely elevated **intraocular pressure**. *Sub-arachnoid haemorrhage* - A **sub-arachnoid hemorrhage** might present with headache and loss of consciousness, or **papilledema** in severe cases, but typically would not cause such specific eye findings as **hyphema** or **corneal edema** from elevated IOP. - While a blow to the head could cause this, the direct eye findings point to a local ocular issue. *Functional loss of vision* - **Functional vision loss** (or psychogenic vision loss) is a diagnosis of exclusion where no organic cause can be found. - The presence of clear organic signs such as **hyphema**, **corneal edema**, and significantly elevated **intraocular pressure** rules out a functional cause.

Q: Secondary glaucoma associated with angle recession is seen in:

Concussion injury. ***Concussion injury*** - **Concussion injuries** (blunt trauma) to the eye lead to shearing forces between the ciliary body and sclera, causing a tear in the ciliary body and trabecular meshwork. - This anatomical alteration, known as **angle recession**, impairs aqueous humor outflow over time, leading to secondary open-angle glaucoma. *Penetrating injury* - **Penetrating injuries** breach the globe and can cause direct damage to ocular structures, but angle recession leading to glaucoma is more characteristic of blunt trauma. - Such injuries often lead to other forms of glaucoma, like **pupillary block** or **phacolytic glaucoma**, depending on the extent of damage and inflammation. *Chemical injury* - **Chemical injuries** (e.g., acid or alkali burns) cause severe inflammation, tissue necrosis, and scarring within the anterior segment. - Glaucoma following chemical injury is typically due to **trabecular meshwork damage** from inflammation and scarring, or **peripheral anterior synechiae formation**, rather than angle recession. *Radiation injury* - **Radiation injury** to the eye is rare but can occur with radiation therapy for tumors, causing damage to vascular structures and contributing to neovascularization. - Glaucoma associated with radiation injury is usually secondary to **neovascularization** of the angle or **inflammatory processes**, not angle recession.

Q: Epinephrine not used in:

Aphakic glaucoma. ***Aphakic glaucoma*** - Epinephrine is **contraindicated** in aphakic eyes due to the risk of developing **cystoid macular edema (CME)**, which can significantly impair vision. - The mechanism of CME in aphakic eyes treated with epinephrine is thought to involve increased vascular permeability in the macula. *Uveitis glaucoma* - Topical epinephrine can be used in some cases of uveitic glaucoma to reduce **intraocular pressure (IOP)** by decreasing aqueous humor production and increasing uveoscleral outflow. - However, its use requires careful consideration due to the potential for exacerbating ocular inflammation in some patients. *Open angle glaucoma* - Epinephrine (and its prodrug, dipivefrin) was historically used in the treatment of **open-angle glaucoma** to lower IOP. - It acts by stimulating alpha- and beta-adrenergic receptors, leading to decreased aqueous production and increased outflow. *Neovascular glaucoma* - While traditionally not a primary treatment, epinephrine can sometimes be used as an **adjunctive therapy** in neovascular glaucoma to help lower IOP, as it reduces aqueous humor production. - The primary treatment for neovascular glaucoma involves addressing the underlying cause of **neovascularization**, usually through panretinal photocoagulation or anti-VEGF injections.

Q: Which diagnostic procedure is not done in a dilated pupil?

Gonioscopy. ***Gonioscopy*** - **Gonioscopy** is the examination of the **anterior chamber angle**, where the **iris** meets the **cornea**. - It is crucial for assessing **glaucoma** and is typically performed with a **nondilated pupil** to allow the iris to lie in its natural anatomical position, which helps visualize the angle structures accurately. *Laser interferometry* - **Laser interferometry** is used to assess **potential visual acuity** in patients with **media opacities** such as cataracts. - This procedure benefits from a **dilated pupil** as it allows more light to pass through existing clear areas of the lens, improving the measurement. *Electroretinography* - **Electroretinography (ERG)** measures the **electrical responses of the retina** to light stimulation. - **Pupil dilation** is generally performed to maximize the amount of light reaching the retina, ensuring a comprehensive assessment of retinal function. *Fundus examination* - A **fundus examination** visualizes the **retina, optic disc, macula, and retinal blood vessels**. - **Dilation of the pupil** is a standard practice for a thorough fundus examination, as it allows for a wider and more complete view of the posterior segment of the eye, facilitating detection of various retinal pathologies.

Q: Sudden painful loss of vision seen in

Angle closure glaucoma. ***Angle closure glaucoma*** - This is the **classic presentation** of sudden, painful vision loss in ophthalmology - Characterized by **acute increase in intraocular pressure** (often >40 mmHg) causing severe eye pain, headache, nausea, and vomiting - Vision loss is rapid due to damage to the **optic nerve** and corneal edema - The pain is intense and sharp due to stretching of ocular structures - **Key distinguishing feature**: Mid-dilated fixed pupil, corneal edema, shallow anterior chamber *Endophthalmitis* - Also causes **sudden painful vision loss** and is a sight-threatening emergency - Pain is severe with rapid onset of vision loss, redness, and hypopyon - **Differentiating features**: History of recent ocular surgery, trauma, or intravitreal injection; presence of hypopyon (layered pus in anterior chamber) - While both can present similarly, endophthalmitis typically has **obvious intraocular inflammation** and relevant preceding history *Acute uveitis* - Presents with **ocular pain**, **redness**, **photophobia**, and blurred vision - Vision loss is usually **gradual**, not sudden and complete - Pain is moderate, described as dull aching rather than severe acute pain - Rarely causes sudden severe vision loss unless complicated *Central retinal artery occlusion* - Causes **sudden, painless loss of vision** - this is the key distinguishing feature - Described as "curtain coming down" or sudden blackout of vision - **Absence of pain** differentiates it from acute angle-closure glaucoma - Cherry-red spot on fundoscopy is pathognomonic

Q: Commonest complication of topical corticosteroids is -

Glaucoma. ***Glaucoma*** - **Topical corticosteroids** are well-known to increase **intraocular pressure** by reducing the outflow of aqueous humor, leading to **steroid-induced glaucoma**. - This complication can result in irreversible **optic nerve damage** and vision loss if not managed properly. *Ptosis* - **Ptosis** is a drooping of the upper eyelid and is not a common complication directly associated with topical corticosteroid use. - It is more often linked to issues like **muscle weakness**, nerve damage, or age-related changes. *Proptosis* - **Proptosis** refers to the bulging of the eye and is typically associated with conditions like **Graves' ophthalmopathy** or orbital tumors. - It is not a common or direct side effect of topical corticosteroid application. *Cataract* - While **steroid-induced cataracts** (specifically **posterior subcapsular cataracts**) are a known complication of chronic systemic corticosteroid use, they are less common with topical corticosteroids and usually require prolonged, high-dose therapy. - In contrast, a rise in intraocular pressure (leading to glaucoma) can occur more acutely and with lower doses of topical corticosteroids.

Q: In case of blunt injury which one does not cause glaucoma :

Optic neuropathy. ***Optic neuropathy*** - While blunt injury can cause **optic neuropathy**, this condition directly affects the **optic nerve** and does not lead to glaucoma, which involves elevated intraocular pressure. - **Glaucoma** is characterized by damage to the optic nerve secondary to increased intraocular pressure, whereas direct traumatic optic neuropathy is a primary nerve injury. *Hyphema* - **Hyphema**, or blood in the anterior chamber, can directly block the **trabecular meshwork**, leading to impaired aqueous outflow and secondary glaucoma. - The breakdown products of red blood cells can also **clog** the drainage system, further increasing intraocular pressure. *Uveitis* - Traumatic **uveitis** can cause inflammation and swelling of the **trabecular meshwork**, impeding aqueous humor outflow and leading to secondary glaucoma. - Inflammatory cells and protein exudates can also **obstruct** the outflow pathways, increasing intraocular pressure. *Angle recession* - **Angle recession** occurs when a blunt injury tears the **ciliary body** from its attachment to the scleral spur, causing damage to the trabecular meshwork. - This damage to the outflow pathway can lead to a long-term increase in **intraocular pressure** and **secondary glaucoma**.

Q: A 35-year-old lady, Malti, has unilateral headache, nausea, vomiting, and visual blurring. The diagnosis is:

Glaucoma. ***Glaucoma (Acute Angle-Closure)*** - The combination of **unilateral headache**, **nausea**, **vomiting**, and **visual blurring** is highly suggestive of **acute angle-closure glaucoma**. - This condition involves a sudden increase in **intraocular pressure**, which can cause a severe headache, often localized to the affected eye, and systemic symptoms due to vagal stimulation. *Posterior fossa cyst* - A posterior fossa cyst could cause headaches, nausea, and vomiting due to increased **intracranial pressure** or mass effect. - However, it typically presents with **bilateral** or generalized headache and specific neurological deficits related to cerebellar or brainstem compression, not typically unilateral visual blurring as the primary ocular symptom. *Subarachnoid hemorrhage* - A subarachnoid hemorrhage characteristically presents with a **sudden-onset**, severe "thunderclap" headache, often described as the "worst headache of my life." - While it can cause nausea and vomiting, visual blurring is not the primary or unilateral symptom, and the headache rarely gradually progresses as might be implied by "unilateral headache" without further qualification of its onset. *Cluster headache* - Cluster headaches are characterized by **severe unilateral pain**, typically around the eye or temple, accompanied by **autonomic symptoms** like tearing, nasal congestion, and ptosis on the affected side. - While visual blurring can occur, nausea and vomiting are less prominent than in acute glaucoma, and the pain is usually described as excruciating and stabbing, without the significant visual loss.

Q: Which of the following statements regarding glaucoma and its management is true?

Topiramate can cause bilateral angle closure glaucoma. ***Topiramate can cause bilateral angle closure glaucoma*** - **Topiramate**, a sulfonamide derivative, can cause acute **myopia** and **ciliary body swelling**, leading to anterior displacement of the lens-iris diaphragm and subsequent **bilateral angle closure glaucoma**. - This adverse effect typically occurs within the first few weeks of starting the drug, and prompt discontinuation can often resolve the condition. *Latanoprost is used with caution in patients of bronchial asthma* - **Latanoprost** is a **prostaglandin analog** and is generally safe for patients with bronchial asthma as it does not affect pulmonary function. - Beta-blockers, rather than latanoprost, are the class of glaucoma medications that require caution in patients with bronchial asthma due to their potential to cause **bronchospasm**. *Central scotoma is seen in open angle glaucoma* - **Central scotoma** is more characteristic of conditions affecting the **macula** or optic nerve pathologies other than typical open-angle glaucoma. - The classic visual field defect in **open-angle glaucoma** is a **paracentral scotoma** or **nasal step**, often progressing to peripheral field loss. *Methazolamide causes decrease in ocular blood flow* - **Methazolamide**, a carbonic anhydrase inhibitor (CAI), primarily acts by reducing aqueous humor production, which can **lower intraocular pressure**. - Although CAIs can cause systemic side effects, they are not known to significantly decrease **ocular blood flow**; in fact, some studies suggest they may even have a mild beneficial effect on optic nerve head blood flow.

Q: Which of the following is most likely to cause bilateral angle closure glaucoma?

Topiramate. ***Topiramate can cause bilateral angle closure glaucoma*** - **Topiramate** is known to cause a unique form of **bilateral angle closure glaucoma** due to ciliary body edema and anterior displacement of the iris-lens diaphragm, leading to acute myopia and angle closure. - This reaction typically occurs within the first few weeks of starting the drug, is **bilateral**, and is not related to angle anatomy. *Sulfonamide medications* - While some **sulfonamides** can cause acute myopia and secondary angle closure, similar to topiramate, this is a less consistently reported and less recognized association compared to topiramate. - The mechanism involves **ciliary body edema** leading to anterior displacement of the iris-lens diaphragm, but topiramate is a more classic example. *Adrenergic agonists* - **Adrenergic agonists** typically cause **mydriasis** (pupil dilation), which can precipitate acute angle closure in eyes with an already **narrow angle**. - However, they usually trigger **unilateral** angle closure and do not cause the same ciliary body edema mechanism seen with topiramate that results in bilateral involvement. *Anticholinergic drugs* - **Anticholinergic drugs** also cause **mydriasis** and can lead to **acute angle closure glaucoma** by widening the pupil and potentially blocking aqueous outflow in susceptible individuals. - Similar to adrenergic agonists, this is usually a **unilateral** event and does not involve the characteristic ciliary body edema and resultant bilateral acute myopia associated with topiramate.

Question 1

Following injury to the right temple region, a patient complains of pain in the right eye and loss of vision. On examination, the eye movements are normal, and the pupil normally reacts to light. The affected eye shows increased intraocular pressure of 32 mmHg (normal: 10-21 mmHg), mild corneal edema, and a small hyphema visible in the anterior chamber. The diagnosis is

Accepted Answer

Traumatic glaucoma

Answer

Optic nerve atrophy

Answer

Sub-arachnoid haemorrhage

Answer

Functional loss of vision

Question 2

Secondary glaucoma associated with angle recession is seen in:

Accepted Answer

Concussion injury

Answer

Penetrating injury

Answer

Chemical injury

Answer

Radiation injury

Question 3

Epinephrine not used in:

Accepted Answer

Aphakic glaucoma

Answer

Uveitis glaucoma

Answer

Open angle glaucoma

Answer

Neovascular glaucoma

Question 4

Which diagnostic procedure is not done in a dilated pupil?

Accepted Answer

Gonioscopy

Answer

Laser interferometry

Answer

Electroretinography

Answer

Fundus examination

Question 5

Sudden painful loss of vision seen in

Accepted Answer

Angle closure glaucoma

Answer

Endophthalmitis

Answer

Acute uveitis

Answer

Central retinal artery occlusion

Question 6

Commonest complication of topical corticosteroids is -

Accepted Answer

Glaucoma

Answer

Ptosis

Answer

Proptosis

Answer

Cataract

Question 7

In case of blunt injury which one does not cause glaucoma :

Accepted Answer

Optic neuropathy

Answer

Hyphema

Answer

Uveitis

Answer

Angle recession

Question 8

A 35-year-old lady, Malti, has unilateral headache, nausea, vomiting, and visual blurring. The diagnosis is:

Accepted Answer

Glaucoma

Answer

Posterior fossa cyst

Answer

Subarachnoid hemorrhage

Answer

Cluster headache

Question 9

Which of the following statements regarding glaucoma and its management is true?

Accepted Answer

Topiramate can cause bilateral angle closure glaucoma

Answer

Latanoprost is used with caution in patients of bronchial asthma

Answer

Central scotoma is seen in open angle glaucoma

Answer

Methazolamide causes decrease in ocular blood flow

Question 10

Which of the following is most likely to cause bilateral angle closure glaucoma?

Accepted Answer

Topiramate

Answer

Sulfonamide medications

Answer

Adrenergic agonists

Answer

Anticholinergic drugs

Glaucoma — MCQs

Glaucoma — MCQs

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