Glaucoma Practice Questions

Q: Which drug is primarily used in the treatment of acute angle-closure glaucoma?

Pilocarpine. ***Pilocarpine*** - **Pilocarpine** is a **direct-acting miotic agent** that causes pupillary constriction, which pulls the iris away from the trabecular meshwork, thereby opening the angle and facilitating aqueous humor outflow. - This action effectively **reduces intraocular pressure (IOP)** in **acute angle-closure glaucoma** by directly addressing the anatomical cause of angle closure. - It is the **primary topical agent** used to mechanically open the closed angle in acute attacks. *Acetazolamide* - **Acetazolamide** is a **carbonic anhydrase inhibitor** that reduces aqueous humor production and is highly effective in rapidly lowering IOP. - Given **systemically (IV or oral)**, it is often used **alongside pilocarpine** in the acute management of angle-closure glaucoma. - While both drugs are essential in treatment, pilocarpine is considered primary because it directly addresses the **mechanical angle closure**, whereas acetazolamide provides rapid IOP reduction through decreased aqueous production. *Atropine* - **Atropine** is a **mydriatic agent** (dilates the pupil) and would worsen acute angle-closure glaucoma by further closing the angle and increasing IOP. - It works by **blocking muscarinic acetylcholine receptors**, leading to paralysis of the iris sphincter muscle. - Contraindicated in acute angle-closure glaucoma. *None of the options* - This option is incorrect as **Pilocarpine** is the primary drug that mechanically addresses the pathophysiology of acute angle-closure glaucoma.

Q: What condition are miotics the treatment of choice for?

Open-angle glaucoma. ***Open-angle glaucoma*** - Miotics, such as **pilocarpine**, are a classical treatment option for **primary open-angle glaucoma (POAG)**. - They work by **contracting the ciliary muscle**, which opens up the **trabecular meshwork** and increases aqueous humor outflow. - This results in **reduction of intraocular pressure (IOP)**, the primary goal in glaucoma management. - Though less commonly used today due to side effects (brow ache, miosis affecting vision), they remain effective and are particularly useful in patients who cannot tolerate other medications. *Angle closure glaucoma* - Miotics are **contraindicated in acute angle-closure glaucoma** as they can worsen pupillary block during the acute attack. - The initial treatment involves **IOP-lowering agents, systemic medications, and laser iridotomy**, not miotics. - Miotics may have a limited role in chronic angle closure after definitive treatment, but they are NOT the treatment of choice. *Buphthalmos* - This refers to **enlargement of the eyeball** in infants due to congenital glaucoma. - Management primarily involves **surgical intervention** (goniotomy, trabeculotomy) to address the developmental anomalies of the drainage angle. - Medical management alone, including miotics, is insufficient. *Sympathetic ophthalmia* - A rare **bilateral granulomatous panuveitis** following penetrating trauma or surgery to one eye. - Treated with **corticosteroids and immunosuppressive agents**. - Miotics have no role in managing this inflammatory condition.

Q: What is the primary function of glaucoma drainage devices?

Drain aqueous humour to an external device. **Drain aqueous humour to an external device** - Glaucoma drainage devices create an artificial outflow pathway, channeling excess **aqueous humour** from the anterior chamber to an external reservoir (usually under the conjunctiva) to lower intraocular pressure. - This bypasses the compromised natural drainage system, preventing further damage to the **optic nerve**. *Drain aqueous humour to the posterior segment* - Glaucoma drainage devices are designed to drain aqueous humour from the **anterior segment** (specifically the anterior chamber) of the eye, not the posterior segment. - The posterior segment primarily contains the **vitreous humour**, and drainage to this area is not the intended mechanism for IOP reduction. *Open the trabeculae mechanically* - Glaucoma drainage devices do not mechanically open the **trabecular meshwork**; this is the mechanism of action for procedures like goniotomy or trabeculoplasty. - These devices create an entirely new drainage pathway, bypassing the dysfunctional trabecular meshwork. *Reduce the aqueous secretion by compressing the ciliary epithelium* - Reducing aqueous humour secretion is the mechanism of action for medications like **beta-blockers** or **carbonic anhydrase inhibitors**, which act on the **ciliary epithelium**. - Glaucoma drainage devices focus on increasing outflow, not on reducing the production of aqueous humour.

Q: Which of the following statements about congenital glaucoma is incorrect?

Anterior chamber is shallow. ***Anterior chamber is shallow*** - In congenital glaucoma, the **anterior chamber depth is typically normal or deep**, not shallow. - A shallow anterior chamber is more characteristic of **angle-closure glaucoma**, which is mechanistically different. - This makes the statement incorrect, as congenital glaucoma is associated with a **deep anterior chamber** due to globe enlargement. *Photophobia is most common symptom* - **Photophobia** (sensitivity to light) is indeed one of the classic presenting symptoms in congenital glaucoma. - It forms part of the classic triad: **photophobia, epiphora (tearing), and blepharospasm**. - This occurs due to **increased intraocular pressure** causing corneal edema and irritation. *Thin and blue sclera seen* - The **sclera** can appear thin and blue due to **buphthalmos** (enlargement of the eye) and stretching of the globe. - The stretching allows the underlying **uveal tissue** to show through, giving the characteristic blue appearance. - This is a direct consequence of elevated intraocular pressure in a developing eye. *Haab's Striae may be seen* - **Haab's striae** are **Descemet's membrane tears** that are pathognomonic of congenital glaucoma. - These horizontal or curvilinear breaks occur due to stretching of the cornea from **elevated intraocular pressure**. - They appear as visible linear opacities on corneal examination.

Q: Which of the following is NOT a feature of Primary Infantile (Congenital) glaucoma?

Aniridia may be associated. ***Aniridia may be associated*** - **Aniridia** is a congenital absence of the iris that causes **secondary glaucoma**, not primary infantile glaucoma. - Aniridia-associated glaucoma is a distinct entity from primary congenital glaucoma (PCG), which occurs due to isolated developmental abnormalities of the anterior chamber angle. - This is **NOT a feature** of primary infantile glaucoma, making it the correct answer to this negation question. *Treatment includes trabeculotomy* - **Trabeculotomy** or **goniotomy** are the primary surgical treatments for primary infantile glaucoma. - These procedures aim to improve aqueous outflow by incising or opening the trabecular meshwork. - This is a **true feature** of the management of primary infantile glaucoma. *Buphthalmos can occur* - **Buphthalmos** (\"ox eye\") refers to the enlargement of the globe due to elevated intraocular pressure in infants when the sclera is still distensible. - It is a **classic clinical sign** of primary infantile glaucoma, typically occurring before age 3 years. - This is a **characteristic feature** of the condition. *Cornea is typically enlarged and cloudy* - The **cornea becomes enlarged** (increased horizontal corneal diameter >12 mm in newborns) due to stretching from elevated IOP. - **Corneal cloudiness** results from corneal edema and Haab's striae (breaks in Descemet's membrane). - These are **pathognomonic findings** in primary infantile glaucoma.

Q: What is the most common etiopathogenetic cause of glaucoma?

Decreased outflow. ***Decreased outflow*** - The most common cause of glaucoma is an **obstruction** or inefficiency in the drainage of **aqueous humor** from the eye, leading to its accumulation. - This reduced outflow results in an increase in **intraocular pressure (IOP)**, which damages the optic nerve. *Raised pressure in episcleral veins* - While elevated episcleral venous pressure can contribute to increased IOP and glaucoma, it is a **less common primary etiopathogenetic mechanism** compared to impaired outflow facility. - Conditions like **Sturge-Weber syndrome** or an **arteriovenous fistula** can cause this, but they are not the typical presentation of primary open-angle glaucoma. *Increased formation of aqueous humour* - An increase in the production of **aqueous humor** is rarely the primary cause of glaucoma. - The eye's regulatory mechanisms usually compensate, or if overproduction occurs, it is an **anatomical issue**, not an outflow issue. *Increased scleral outflow* - Increased **scleral outflow** (also known as uveoscleral outflow, which is a non-conventional drainage pathway) would actually lead to a **decrease** in intraocular pressure, not an increase. - This mechanism is often targeted by certain glaucoma medications (e.g., **prostaglandin analogues**) to lower IOP by facilitating drainage.

Q: Which of the following conditions is NOT treated with Pilocarpine?

Malignant Glaucoma. ***Malignant Glaucoma*** - **Malignant glaucoma** (also known as aqueous misdirection syndrome) is characterized by posterior misdirection of aqueous humor into the vitreous, causing anterior displacement of the lens-iris diaphragm and marked intraocular pressure elevation. - Pilocarpine is **contraindicated** in malignant glaucoma because it causes **miosis** and increases ciliary muscle contraction, which can **exacerbate aqueous misdirection** and worsen the condition. - Treatment requires **cycloplegics** (atropine), not miotics like pilocarpine. *Primary Open-Angle Glaucoma* - **Pilocarpine** is a **miotic agent** that increases **aqueous humor outflow** through the trabecular meshwork, thereby lowering intraocular pressure (IOP). - It is used as medical therapy for controlling IOP in **primary open-angle glaucoma**, although it has largely been replaced by prostaglandin analogs, beta-blockers, and other agents with fewer side effects. *Acute Angle-Closure Glaucoma* - **Pilocarpine** is used in acute angle-closure glaucoma (after initial IOP reduction) to induce **miosis**, which pulls the iris away from the **trabecular meshwork** and opens the angle. - It works by constricting the pupil and causing ciliary muscle contraction, which helps relieve pupillary block and facilitate aqueous outflow. *Chronic Synechial Angle-Closure Glaucoma* - In chronic synechial angle-closure glaucoma with **extensive peripheral anterior synechiae (PAS)**, pilocarpine has **very limited effectiveness** because the angle is mechanically closed by permanent adhesions. - While pilocarpine may be attempted in **early cases** where some functional angle remains open, once extensive synechiae have formed, miosis cannot reopen the closed angle, and **surgical intervention** is typically required. - However, pilocarpine is not absolutely **contraindicated** in this condition, unlike malignant glaucoma.

Q: Type of laser used for iridotomy?

Nd:YAG laser. ***Nd:YAG laser*** - The **Nd:YAG laser** is the most commonly used laser for performing a laser peripheral iridotomy due to its ability to create a small perforation in the iris. - Its **photodisruptive** mechanism allows for precise tissue disruption with minimal thermal damage to surrounding structures. *Excimer laser* - **Excimer lasers** operate in the **ultraviolet (UV) spectrum** and are primarily used in refractive surgery (e.g., LASIK) for corneal reshaping. - They are not suitable for iridotomy due to their limited penetrating ability and potential for corneal damage. *Krypton laser* - **Krypton lasers** produce red and yellow light, and were historically used for **photocoagulation** in retinal diseases. - They are not typically used for iridotomy as their primary mechanism is thermal coagulation rather than tissue disruption. *Diode laser* - **Diode lasers** are used in ophthalmology for various applications, including **photocoagulation** in the retina and transscleral cyclophotocoagulation for glaucoma. - While they can deliver energy to tissues, they are generally less effective and precise for creating a peripheral iridotomy compared to the Nd:YAG laser.

Q: What is the first-line treatment for acute angle closure glaucoma?

Acetazolamide. **Acetazolamide** - **Acetazolamide** (oral or intravenous) is a carbonic anhydrase inhibitor that rapidly reduces intraocular pressure by decreasing aqueous humor production, making it the **first-line medical treatment** for acute angle-closure glaucoma. - While other agents are used, acetazolamide provides the quickest and most significant initial reduction in **intraocular pressure (IOP)**, which is crucial in preventing permanent vision loss. *IV mannitol* - **Intravenous mannitol** is an osmotic diuretic used to draw fluid from the vitreous humor to lower **IOP** significantly, but it is typically reserved for cases where **acetazolamide** alone is insufficient or for very high **IOPs**. - It is often considered a second-line or adjunctive agent rather than the initial first-line treatment. *Pilocarpine* - **Pilocarpine** is a miotic agent that constricts the pupil, which helps to pull the iris away from the trabecular meshwork and open the angle. - However, it should only be administered *after* the **intraocular pressure** has been significantly lowered (e.g., with acetazolamide), as it can worsen angle closure in an inflamed eye with very high **IOP**. *Beta blocker eyedrops* - **Topical beta-blockers** (e.g., timolol) reduce **IOP** by decreasing aqueous humor production and are a common treatment for various types of glaucoma. - While useful in acute angle-closure glaucoma, they act more slowly than **acetazolamide** and are typically used as an adjunct rather than the sole initial first-line treatment.

Q: What is the most common symptom associated with congenital glaucoma?

Excessive tearing. ***Excessive tearing*** - **Epiphora**, or excessive tearing, is one of the most common early symptoms of **congenital glaucoma** in infants. - This symptom occurs due to **corneal irritation** and **damage** resulting from elevated intraocular pressure. *Eye pain* - While glaucoma can cause eye pain, it is less commonly reported as the *initial* and *most frequent* symptom in **congenital glaucoma** in infants who cannot verbalize their discomfort. - **Irritability** or excessive crying might be indirect signs of pain, but tearing is a more direct and observable sign. *Sensitivity to light* - **Photophobia**, or sensitivity to light, is another common symptom of congenital glaucoma. - However, **excessive tearing** often precedes or co-occurs with photophobia as an initial presenting symptom in infants. *Itching of the eyes* - **Ocular itching** is typically associated with **allergic conjunctivitis** or other inflammatory conditions, not directly with congenital glaucoma. - Itching is not a primary or common symptom of elevated intraocular pressure in infants.

Question 1

Which drug is primarily used in the treatment of acute angle-closure glaucoma?

Accepted Answer

Pilocarpine

Answer

Acetazolamide

Answer

Atropine

Answer

None of the options

Question 2

What condition are miotics the treatment of choice for?

Accepted Answer

Open-angle glaucoma

Answer

Angle closure glaucoma

Answer

Buphthalmos

Answer

Sympathetic ophthalmia

Question 3

What is the primary function of glaucoma drainage devices?

Accepted Answer

Drain aqueous humour to an external device

Answer

Drain aqueous humour to the posterior segment

Answer

Open the trabeculae mechanically

Answer

Reduce the aqueous secretion by compressing the ciliary epithelium

Question 4

Which of the following statements about congenital glaucoma is incorrect?

Accepted Answer

Anterior chamber is shallow

Answer

Thin and blue sclera seen

Answer

Photophobia is most common symptom

Answer

Haab's Striae may be seen

Question 5

Which of the following is NOT a feature of Primary Infantile (Congenital) glaucoma?

Accepted Answer

Aniridia may be associated

Answer

Treatment includes trabeculotomy

Answer

Buphthalmos can occur

Answer

Cornea is typically enlarged and cloudy.

Question 6

What is the most common etiopathogenetic cause of glaucoma?

Accepted Answer

Decreased outflow

Answer

Raised pressure in episcleral veins

Answer

Increased formation of aqueous humour

Answer

Increased scleral outflow

Question 7

Which of the following conditions is NOT treated with Pilocarpine?

Accepted Answer

Malignant Glaucoma

Answer

Primary, Open Angle Glaucoma

Answer

Acute Angle Closure Glaucoma

Answer

Chronic Synechial Angle Closure Glaucoma

Question 8

Type of laser used for iridotomy?

Accepted Answer

Nd:YAG laser

Answer

Excimer laser

Answer

Krypton laser

Answer

Diode laser

Question 9

What is the first-line treatment for acute angle closure glaucoma?

Accepted Answer

Acetazolamide

Answer

Pilocarpine

Answer

Beta blocker eyedrops

Answer

IV mannitol

Question 10

What is the most common symptom associated with congenital glaucoma?

Accepted Answer

Excessive tearing

Answer

Eye pain

Answer

Sensitivity to light

Answer

Itching of the eyes

Glaucoma — MCQs

Glaucoma — MCQs

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