Glaucoma — MCQs
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Which of the following is not a feature of open-angle glaucoma?
Which of the following is the first visual field defect in open-angle glaucoma?
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?
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?
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?
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?
Which type of glaucoma is characterized by a sudden onset of symptoms and is often associated with a shallow anterior chamber?
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?
In a patient presenting with an acute unilateral red eye and visual impairment, what is the most likely diagnosis?
Which technique is considered the gold standard for evaluating the angle of the anterior chamber in the eye?
Glaucoma Indian Medical PG Practice Questions and MCQs
Question 351: Which of the following is not a feature of open-angle glaucoma?
- A. Elevated intraocular pressure
- B. Increased cup-to-disc ratio
- C. Gradual peripheral vision loss
- D. Pain and redness (Correct Answer)
Explanation: ***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.
Question 352: Which of the following is the first visual field defect in open-angle glaucoma?
- A. Ring scotoma
- B. Paracentral scotoma (Correct Answer)
- C. Bitemporal hemianopia
- D. Tunnel vision
Explanation: ***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.
Question 353: 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?
- A. Increased aqueous humor production
- B. Retinal ganglion cell apoptosis (Correct Answer)
- C. Retinal detachment
- D. Phototransduction in rods and cones
Explanation: ***Retinal ganglion cell apoptosis*** - This is the **fundamental pathway** affected in glaucoma and directly explains all the clinical findings in this patient. - The patient's **peripheral vision loss**, **optic disc cupping**, and **arcuate scotomas** all result from progressive **death of retinal ganglion cells (RGCs)** and their axons. - In **primary open-angle glaucoma**, sustained elevated IOP (28 mmHg in this case) causes **mechanical compression** and **ischemic injury** at the optic nerve head, triggering RGC apoptosis. - Loss of RGC axons creates the characteristic **optic disc cupping** and **nerve fiber bundle defects** (arcuate scotomas), leading to irreversible vision loss. *Increased aqueous humor production* - While aqueous humor dynamics are involved in glaucoma pathophysiology, the primary issue is **impaired trabecular outflow**, not increased production. - Increased production alone would elevate IOP but does not explain the specific **RGC damage pattern**, optic disc cupping, or arcuate scotomas seen in this patient. - This addresses the mechanism of elevated IOP, not the pathway of vision loss. *Retinal detachment* - Retinal detachment presents with **sudden onset** symptoms like **photopsia (flashes)**, **floaters**, and a **curtain-like visual field defect**, not gradual peripheral vision loss. - Fundoscopy would show a **detached, elevated retina**, not the optic disc cupping and arcuate scotomas characteristic of glaucoma. - This condition involves separation of the neurosensory retina from the retinal pigment epithelium, not RGC damage. *Phototransduction in rods and cones* - Phototransduction abnormalities affect **photoreceptor cells** (rods and cones), seen in conditions like **retinitis pigmentosa** or **cone-rod dystrophies**. - These conditions present with **night blindness**, **tunnel vision** (from peripheral rod loss), or **central vision loss** (from cone dysfunction), and do not cause elevated IOP or optic disc cupping. - The patient's elevated IOP and specific glaucomatous findings indicate damage to **ganglion cells**, not photoreceptors.
Question 354: 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?
- A. Central retinal artery occlusion (CRAO)
- B. Fuchs' heterochromic iridocyclitis
- C. Malignant glaucoma
- D. Phacolytic glaucoma (Correct Answer)
Explanation: ***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.
Question 355: 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?
- A. Laser trabeculoplasty
- B. Trabeculectomy
- C. Oral acetazolamide
- D. Prostaglandin analogs (e.g., latanoprost) (Correct Answer)
Explanation: ***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.
Question 356: 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?
- A. Trabeculectomy with antifibrotics (Correct Answer)
- B. Tube shunt surgery
- C. Trabeculectomy without antifibrotics
- D. Cyclodestructive procedure for refractory cases
Explanation: ***Trabeculectomy with antifibrotics*** - In a patient with **uncontrolled narrow-angle glaucoma** despite maximal medical therapy, **trabeculectomy with antifibrotics** (mitomycin C or 5-fluorouracil) is the **gold standard first-line surgical intervention**. - Antifibrotics are essential adjuncts that **prevent fibroblast proliferation and scarring** at the surgical site, significantly improving success rates from approximately 60-70% to over 90% at one year. - This approach provides excellent **IOP control** while maintaining a favorable risk-benefit profile in primary surgical cases. *Trabeculectomy without antifibrotics* - Plain trabeculectomy without antifibrotics has a **high failure rate** (30-40%) due to postoperative scarring and bleb fibrosis. - The success rate is significantly lower compared to augmented trabeculectomy, making it a suboptimal choice when antifibrotics are available. - Modern practice essentially always includes antifibrotic agents in trabeculectomy procedures. *Tube shunt surgery* - **Tube shunt devices** (Ahmed, Baerveldt) are typically considered when trabeculectomy has failed, in cases with high risk of trabeculectomy failure (neovascular glaucoma, previous conjunctival surgery), or in pediatric/refractory glaucoma. - While effective, they carry risks including **tube erosion, corneal decompensation, diplopia,** and hypotony, making them generally second-line after trabeculectomy. - The Tube Versus Trabeculectomy (TVT) study showed comparable long-term IOP control, but trabeculectomy remains preferred first-line due to lower complication rates in primary cases. *Cyclodestructive procedure for refractory cases* - **Cyclodestructive procedures** (transscleral cyclophotocoagulation, endocyclophotocoagulation) destroy ciliary body tissue to reduce aqueous production. - Reserved for **end-stage refractory glaucoma** where other surgeries have failed or in eyes with poor visual potential, due to risks of prolonged inflammation, hypotony, phthisis, and vision loss. - Not appropriate as first-line surgical management in a patient with reasonable visual prognosis.
Question 357: Which type of glaucoma is characterized by a sudden onset of symptoms and is often associated with a shallow anterior chamber?
- A. Normal-tension glaucoma
- B. Secondary glaucoma
- C. Primary angle-closure glaucoma
- D. Acute angle-closure glaucoma (Correct Answer)
Explanation: ***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.
Question 358: 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?
- A. Trabeculectomy (Correct Answer)
- B. Cyclophotocoagulation
- C. Goniotomy
- D. Laser trabeculoplasty
Explanation: ***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.
Question 359: In a patient presenting with an acute unilateral red eye and visual impairment, what is the most likely diagnosis?
- A. Conjunctivitis
- B. Corneal abrasion
- C. Uveitis
- D. Acute angle-closure glaucoma (Correct Answer)
Explanation: ***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**.
Question 360: Which technique is considered the gold standard for evaluating the angle of the anterior chamber in the eye?
- A. Gonioscopy (Correct Answer)
- B. Anterior segment OCT
- C. Slit-lamp biomicroscopy
- D. Ultrasound biomicroscopy
Explanation: ***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.
Practice by Chapter
Aqueous Humor Dynamics
Practice Questions
Primary Open-Angle Glaucoma
Practice Questions
Primary Angle-Closure Glaucoma
Practice Questions
Secondary Open-Angle Glaucomas
Practice Questions
Secondary Angle-Closure Glaucomas
Practice Questions
Developmental and Congenital Glaucomas
Practice Questions
Medical Management of Glaucoma
Practice Questions
Laser Therapy in Glaucoma
Practice Questions
Glaucoma Filtration Surgery
Practice Questions
Glaucoma Drainage Devices
Practice Questions
Angle Assessment Techniques
Practice Questions
Visual Field Testing in Glaucoma
Practice Questions
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