Glaucoma Practice Questions

Q: Which of the following is not a feature of open-angle glaucoma?

Pain and redness. ***Pain and redness*** - **Open-angle glaucoma** is typically a **painless** condition, often referred to as the "silent thief of sight", because central vision is preserved until late stages. - **Pain** and **redness** are more characteristic of **acute angle-closure glaucoma** or other inflammatory eye conditions, not the chronic, progressive nature of open-angle glaucoma. *Elevated intraocular pressure* - **Elevated intraocular pressure** (IOP) is a primary risk factor and a hallmark feature of **open-angle glaucoma**, although normal-tension glaucoma exists. - Sustained high IOP can lead to **optic nerve damage** over time. *Increased cup-to-disc ratio* - An **increased cup-to-disc ratio** on examination of the optic disc is a key diagnostic feature of **open-angle glaucoma**, indicating **optic nerve damage** and atrophy. - This enlargement of the optic cup is due to the loss of nerve fibers. *Gradual peripheral vision loss* - **Gradual peripheral vision loss** is the characteristic pattern of vision loss in **open-angle glaucoma**, often unnoticed by the patient until advanced stages. - The central vision remains relatively intact until late in the disease, making early detection challenging.

Q: Which of the following is the first visual field defect in open-angle glaucoma?

Paracentral scotoma. ***Paracentral scotoma*** - This is the **earliest visual field defect** detected in open-angle glaucoma, typically appearing in the **Bjerrum area** (10-20° from fixation). - Most commonly occurs as a **superior or inferior arcuate scotoma** in the nasal field. - Results from damage to the **retinal nerve fiber layer** around the **optic disc**, which is particularly vulnerable to elevated intraocular pressure. - These scotomas respect the **horizontal raphe** and follow the arcuate nerve fiber bundle pattern. *Ring scotoma* - A **ring scotoma** (Bjerrum scotoma) typically occurs later in the progression of glaucoma, when superior and inferior arcuate defects coalesce to form a ring-like pattern. - This represents **advanced glaucomatous damage** and is not an early finding. *Bitemporal hemianopia* - This visual field defect is characteristic of **optic chiasm compression**, commonly due to a **pituitary tumor** or other suprasellar lesions. - It is **not associated with glaucoma**, which causes damage to the optic nerve fibers within the eye, not at the chiasm. *Tunnel vision* - **Tunnel vision** represents severe, **end-stage glaucoma**, where only a small central island of vision remains. - It indicates extensive loss of peripheral visual field and is a late finding, not an early one.

Q: An 80-year-old patient complains of pain, redness, and diminished vision in the left eye. On examination, the intraocular pressure (IOP) in the right eye is 16 mmHg, while the left eye shows 50 mmHg. The left eye also exhibits deep anterior chamber flare and a white cataract. What is the most likely diagnosis?

Phacolytic glaucoma. ***Phacolytic glaucoma*** - The combination of **extremely high intraocular pressure** (50 mmHg) in the left eye, along with a **mature (white) cataract** and **deep anterior chamber flare**, is highly suggestive of phacolytic glaucoma. - This condition occurs when **lens proteins leak** from a hypermature cataract, triggering a macrophagic inflammatory response that **clogs the trabecular meshwork**, leading to an acute rise in IOP. *Central retinal artery occlusion (CRAO)* - While CRAO causes acute, profound **vision loss** in one eye, it is generally associated with a **normal or low IOP**, not the extremely high pressure seen in the left eye. - Fundoscopic examination would typically reveal a **cherry-red spot** and **pale retina**, which are not described. *Fuchs' heterochromic iridocyclitis* - This condition is characterized by **chronic, low-grade anterior uveitis** and often leads to **heterochromia** (different colored irises) and **secondary glaucoma**. - However, it typically presents with **mild IOP elevation** (if at all) and not the acute, markedly high pressure and visible white cataract with flare described here. *Malignant glaucoma* - Malignant glaucoma (also known as aqueous misdirection) presents with an **elevated IOP** and is characterized by a **shallow or flat anterior chamber**, often in the presence of a pupillary block mechanism. - The patient's left eye is described as having a **deep anterior chamber** with flare, which contradicts the typical findings of malignant glaucoma.

Q: A 60-year-old male presents with a gradual loss of peripheral vision and is diagnosed with open-angle glaucoma. Which of the following is the first line of treatment?

Prostaglandin analogs (e.g., latanoprost). ***Prostaglandin analogs (e.g., latanoprost)*** - **Prostaglandin analogs** are generally considered the **first-line treatment** for open-angle glaucoma due to their efficacy in lowering intraocular pressure (IOP) and their favorable dosing schedule (typically once daily). - They work by increasing the **outflow of aqueous humor** through the uveoscleral pathway, thereby reducing IOP. *Laser trabeculoplasty* - This procedure is often considered a **second-line treatment** or an adjunct therapy when topical medications alone are insufficient. - It works by improving the outflow of aqueous humor through the **trabecular meshwork**, but it's typically not the initial approach. *Trabeculectomy* - **Trabeculectomy** is a surgical procedure usually reserved for cases of glaucoma that **do not respond to medication or laser treatment**, or when there is advanced disease. - It creates a new drainage pathway for the aqueous humor to bypass the blocked trabecular meshwork. *Oral acetazolamide* - **Oral acetazolamide** is a carbonic anhydrase inhibitor that can effectively lower IOP, but it is typically used for **short-term management** or in acute glaucoma crises. - Its use is limited as a first-line treatment due to significant **systemic side effects**, such as metabolic acidosis, kidney stones, and paresthesias.

Q: Which type of glaucoma is characterized by a sudden onset of symptoms and is often associated with a shallow anterior chamber?

Acute angle-closure glaucoma. ***Acute angle-closure glaucoma*** - This type of glaucoma is characterized by a **sudden and painful increase in intraocular pressure (IOP)** due to the abrupt closure of the anterior chamber angle. - It is frequently associated with a **shallow anterior chamber**, which predisposes the iris to block the outflow of aqueous humor. - Presents with **acute symptoms**: severe eye pain, blurred vision, halos around lights, nausea, and vomiting. *Primary angle-closure glaucoma* - This is the **broad diagnostic category** of angle-closure glaucoma not due to other diseases, encompassing a spectrum from chronic angle-closure to acute episodes. - While PACG includes cases with sudden onset (acute angle-closure), the term itself is more general and includes both **chronic angle-closure** (gradual progression) and **acute presentations**. - The question specifically asks for the type characterized by sudden onset, which is more precisely termed "acute angle-closure glaucoma." *Normal-tension glaucoma* - In this condition, optic nerve damage and visual field loss occur despite **intraocular pressure remaining within the statistically normal range** (below 21 mmHg). - It is an **open-angle glaucoma** variant not characterized by a sudden onset or a shallow anterior chamber. *Secondary glaucoma* - This is a broad category of glaucomas where **elevated intraocular pressure is a consequence of another underlying disease** or condition, such as inflammation, trauma, or certain medications. - While it can manifest acutely, the general term does not specifically point to the sudden onset of symptoms or a shallow anterior chamber as its defining feature without further specification of the cause.

Q: A 60-year-old man with primary open-angle glaucoma presents with progressive visual field loss despite maximal medical therapy. What is the next step in management?

Trabeculectomy. ***Trabeculectomy*** - This **surgical procedure** creates a new drainage pathway for aqueous humor, bypassing the clogged **trabecular meshwork**. - It is often the next step when maximal medical therapy fails to control intraocular pressure and prevent **progressive visual field loss** in open-angle glaucoma. *Cyclophotocoagulation for refractory cases* - This procedure uses **laser energy** to destroy parts of the ciliary body, reducing aqueous humor production. - It is typically reserved for **refractory glaucoma** cases that have failed other surgical interventions or in eyes with poor visual potential, which is not implied here. *Goniotomy for congenital glaucoma* - **Goniotomy** is a surgical procedure that incises the **trabecular meshwork** to improve outflow. - It is primarily used for **congenital glaucoma** in infants and young children, not in a 60-year-old man with primary open-angle glaucoma. *Laser trabeculoplasty as an adjunctive treatment* - **Laser trabeculoplasty** (either Argon or Selective) uses a laser to improve the aqueous outflow through the **trabecular meshwork**. - While it can be an initial or adjunctive treatment, the patient in this scenario is already on **maximal medical therapy** with progressive visual field loss, indicating a need for a more definitive surgical intervention.

Q: In a patient presenting with an acute unilateral red eye and visual impairment, what is the most likely diagnosis?

Acute angle-closure glaucoma. ***Acute angle-closure glaucoma*** - This condition presents with a **sudden onset of unilateral red eye**, **severe pain**, and **rapidly progressive visual impairment** due to increased intraocular pressure. - Other symptoms often include **halos around lights**, **nausea**, and **vomiting**. - Classic findings include a **mid-dilated fixed pupil**, **hazy cornea**, and **shallow anterior chamber**. *Conjunctivitis* - While it causes a **red eye**, the primary symptom is usually **itching or foreign body sensation**, not significant pain or severe visual loss. - Vision is typically **unaffected**, or only mildly blurred by discharge. *Corneal abrasion* - This condition would cause a **red eye**, **pain**, and **photophobia**, but the visual impairment is usually **less severe** and localized to the area of abrasion. - It is typically associated with a **history of trauma** or foreign body sensation. *Uveitis* - This can cause a **red eye**, pain, and **photophobia**, with varying degrees of visual impairment, but the onset is typically **subacute or chronic**, and the pain is often described as a **dull ache** rather than the severe pain of acute angle-closure glaucoma. - It often presents with **miosis** and **ciliary flush**.

Q: Which technique is considered the gold standard for evaluating the angle of the anterior chamber in the eye?

Gonioscopy. ***Gonioscopy*** - **Gonioscopy** utilizes a specialized lens placed on the eye to directly visualize the **iridocorneal angle** and its structures. - This direct visualization allows for a comprehensive and dynamic assessment of the angle, making it the **gold standard** for evaluation. *Anterior segment OCT* - **Anterior segment OCT** (Optical Coherence Tomography) provides high-resolution cross-sectional images of the anterior chamber, including the angle. - While excellent for imaging and quantitative measurements, it is a **non-contact technique** and does not offer the dynamic, direct visualization of the angle that gonioscopy provides. *Slit-lamp biomicroscopy* - **Slit-lamp biomicroscopy** uses a narrow beam of light to examine the anterior segment but cannot directly visualize the **iridocorneal angle** due to the total internal reflection at the limbus. - It can indirectly estimate angle depth using the **Van Herick technique**, which provides a rough estimate but not direct angle visualization. *Ultrasound biomicroscopy* - **Ultrasound biomicroscopy (UBM)** uses high-frequency ultrasound to image the anterior segment, particularly useful for structures obscured by opaque media. - While it provides detailed images of angle structures and is good for imaging behind the iris, it is typically used when **optical methods are limited** and is not the primary method for routine angle evaluation.

Question 1

Which of the following is not a feature of open-angle glaucoma?

Accepted Answer

Pain and redness

Answer

Elevated intraocular pressure

Answer

Increased cup-to-disc ratio

Answer

Gradual peripheral vision loss

Question 2

Which of the following is the first visual field defect in open-angle glaucoma?

Accepted Answer

Paracentral scotoma

Answer

Ring scotoma

Answer

Bitemporal hemianopia

Answer

Tunnel vision

Question 3

A 58-year-old male presents with gradual loss of peripheral vision in both eyes. On fundus examination, significant cupping of the optic disc and arcuate scotomas were noted. IOP was 28 mmHg. Based on these findings, which pathway is most likely affected in this patient’s disease?

Accepted Answer

Retinal ganglion cell apoptosis

Answer

Increased aqueous humor production

Answer

Retinal detachment

Answer

Phototransduction in rods and cones

Question 4

An 80-year-old patient complains of pain, redness, and diminished vision in the left eye. On examination, the intraocular pressure (IOP) in the right eye is 16 mmHg, while the left eye shows 50 mmHg. The left eye also exhibits deep anterior chamber flare and a white cataract. What is the most likely diagnosis?

Accepted Answer

Phacolytic glaucoma

Answer

Central retinal artery occlusion (CRAO)

Answer

Fuchs' heterochromic iridocyclitis

Answer

Malignant glaucoma

Question 5

A 60-year-old male presents with a gradual loss of peripheral vision and is diagnosed with open-angle glaucoma. Which of the following is the first line of treatment?

Accepted Answer

Prostaglandin analogs (e.g., latanoprost)

Answer

Laser trabeculoplasty

Answer

Trabeculectomy

Answer

Oral acetazolamide

Question 6

In a 65-year-old patient with a history of narrow-angle glaucoma and an intraocular pressure of 30 mmHg despite maximal medical therapy, which surgical option is preferred for better intraocular pressure control?

Accepted Answer

Trabeculectomy with antifibrotics

Answer

Tube shunt surgery

Answer

Trabeculectomy without antifibrotics

Answer

Cyclodestructive procedure for refractory cases

Question 7

Which type of glaucoma is characterized by a sudden onset of symptoms and is often associated with a shallow anterior chamber?

Accepted Answer

Acute angle-closure glaucoma

Answer

Normal-tension glaucoma

Answer

Secondary glaucoma

Answer

Primary angle-closure glaucoma

Question 8

A 60-year-old man with primary open-angle glaucoma presents with progressive visual field loss despite maximal medical therapy. What is the next step in management?

Accepted Answer

Trabeculectomy

Answer

Cyclophotocoagulation

Answer

Goniotomy

Answer

Laser trabeculoplasty

Question 9

In a patient presenting with an acute unilateral red eye and visual impairment, what is the most likely diagnosis?

Accepted Answer

Acute angle-closure glaucoma

Answer

Conjunctivitis

Answer

Corneal abrasion

Answer

Uveitis

Question 10

Which technique is considered the gold standard for evaluating the angle of the anterior chamber in the eye?

Accepted Answer

Gonioscopy

Answer

Anterior segment OCT

Answer

Slit-lamp biomicroscopy

Answer

Ultrasound biomicroscopy

Glaucoma — MCQs

Glaucoma — MCQs

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