Glaucoma Practice Questions

Q: Normal cup-to-disc ratio of the optic disc is

0.2 to 0.3. ***Correct: 0.2 to 0.3*** - The **cup-to-disc ratio (CDR)** is a crucial ophthalmological measurement for assessing optic nerve health - The **most commonly cited normal range** in standard ophthalmology textbooks (Kanski, AAO guidelines) is **0.2 to 0.3** - This represents the **typical physiological range** seen in the majority of healthy individuals - CDR up to **0.3 is considered normal**, with the average being approximately 0.3 *Incorrect: 0.3 to 0.4* - This range is at the **upper limit of normal or borderline** territory - CDR values of **0.4 or higher** are concerning and warrant close monitoring for glaucoma - Not representative of the **typical normal range** for clinical assessment *Incorrect: 0.5 to 0.6* - A CDR in this range is **highly abnormal and suspicious for glaucoma** - Indicates significant **loss of neural rim tissue** characteristic of glaucomatous optic neuropathy - Represents advanced optic nerve damage *Incorrect: 0.1 to 0.3* - While technically encompassing normal values, this range is **not the standard clinical definition** used in practice - CDR values of **0.1 are uncommonly small** and may suggest **anomalous optic disc** or measurement error - The **clinically accepted and most frequently cited normal range** starts at 0.2, making this option less precise for standard clinical assessment - In exam context, **0.2 to 0.3** is the preferred answer as it represents the **conventional teaching**

Q: A patient presents with a history of evening halos and occasional headaches for some months. His examination shows normal intraocular pressure but shallow anterior chamber. What is the most likely diagnosis?

Primary angle-closure glaucoma. ***Primary angle-closure glaucoma*** - The combination of **evening halos**, **occasional headaches**, and a **shallow anterior chamber** is highly suggestive of primary angle-closure glaucoma. - While intraocular pressure might be normal at presentation, these symptoms indicate episodes of **intermittent angle closure**, leading to transient pressure spikes. *Normal-tension glaucoma* - This condition is characterized by **optic nerve damage** and vision loss despite **normal intraocular pressure**, but symptoms like halos are not typical. - The anterior chamber would typically be of normal depth. *Open-angle glaucoma* - This condition is often **asymptomatic** in its early stages and does not typically present with halos or headaches. - The anterior chamber is **open**, distinguishing it from angle-closure glaucoma. *Pigmentary glaucoma* - This type of glaucoma is caused by the release of **pigment** from the iris, which then blocks the **trabecular meshwork**. - While it can manifest with elevated intraocular pressure, it is not consistently associated with a shallow anterior chamber or episodes of halos and headaches in the same manner as angle-closure glaucoma.

Q: Cycloplegics are used for the treatment of:

Iridocyclitis. ***Iridocyclitis*** - **Cycloplegics** paralyze the **ciliary muscle** and **iris sphincter**, reducing spasm and pain associated with inflammation in iridocyclitis. - They also help prevent the formation of **posterior synechiae**, adhesions between the iris and the lens. - This is the **primary therapeutic indication** for cycloplegics in inflammatory conditions. *Lens-induced glaucoma* - This condition is caused by **lens swelling** or **leakage of lens material**, leading to elevated intraocular pressure. - Treatment typically involves **surgical removal of the cataractous lens**, not cycloplegics. *Closed-angle glaucoma* - Cycloplegics are **CONTRAINDICATED** in closed-angle glaucoma as they cause **pupillary dilation**, which can precipitate or worsen angle closure. - The condition is characterized by **blockage of aqueous humor outflow** due to the iris obstructing the trabecular meshwork. - Treatment involves methods to open the angle, such as **laser iridotomy** or medications that **constrict the pupil** (miotics) or reduce aqueous humor production. *Chorioretinitis* - This is an **inflammation of the choroid and retina**, layers located at the back of the eye (posterior segment). - Treatment primarily involves **systemic anti-inflammatory agents** and antimicrobials if infectious. - Cycloplegics do not directly address posterior segment inflammation, though they may be used for symptomatic relief if anterior chamber reaction is present.

Q: In which of the following conditions is the intraocular pressure very high, and inflammation is minimal?

Glaucomatocyclic crises. ***Glaucomatocyclic crises*** - This condition is characterized by recurrent, self-limiting episodes of markedly **elevated intraocular pressure (IOP)** with minimal or no overt signs of inflammation in the anterior chamber. - The elevated IOP is thought to result from **altered humor outflow** due to subtle inflammation of the trabecular meshwork. *Acute iridocyclitis* - Presents with significant signs of **intraocular inflammation**, including **cells and flare** in the anterior chamber, typically with pain and photophobia. - While IOP can be elevated, it's a direct result of inflammation reducing outflow, and the inflammation itself is prominent. *Angle closure glaucoma* - This condition involves a sudden and severe rise in **IOP** due to blockage of the aqueous humor outflow pathway by the peripheral iris, but it's not primarily an inflammatory process. - While the eye can appear red and painful, this is due to ischemia and corneal edema, not marked **intraocular inflammation** like that seen in uveitis. *Hypertensive uveitis* - Refers to any **uveitis** that causes a rise in **intraocular pressure**, meaning significant inflammation is present. - The high IOP is secondary to the inflammation, which can obstruct the trabecular meshwork or stimulate prostaglandin release, both causing reduced outflow.

Q: Krukenberg's spindles are seen in?

Pigmentary glaucoma. **Pigmentary glaucoma** - **Krukenberg's spindles** are vertical, spindle-shaped deposits of pigment on the **corneal endothelium**, a characteristic sign of pigment dispersion syndrome and pigmentary glaucoma. - This occurs due to the rubbing of the iris pigment epithelium against the lens zonules, releasing pigment into the **anterior chamber**. *Sympathetic ophthalmia* - This is a rare, bilateral **granulomatous uveitis** that occurs after penetrating ocular trauma or surgery to one eye, with inflammation developing in the other eye. - It is characterized by signs of **uveitis**, such as keratic precipitates and posterior synechiae, but not Krukenberg's spindles. *Chalazion* - A **chalazion** is a sterile, chronic **lipogranulomatous inflammation** of a Meibomian gland in the eyelid, usually presenting as a painless lump. - It does not involve the anterior segment structures like the cornea or iris and therefore does not cause Krukenberg's spindles. *Retinitis pigmentosa* - This is a group of inherited retinal degenerations characterized by progressive loss of photoreceptor cells and the retinal pigment epithelium, leading to **night blindness** and **peripheral vision loss**. - Funduscopic examination typically reveals **bone-spicule pigmentations** in the retina, but it is not associated with Krukenberg's spindles.

Q: A child presents with lid lag and an enlarged cornea with a diameter of 13 mm. Examination of the eye reveals double-contoured opacities concentric to the limbus. Which of the following is the most likely diagnosis?

Congenital Glaucoma. ***Congenital Glaucoma*** - The presence of **lagophthalmos** (incomplete eyelid closure, sometimes termed "lid lag" but distinct from thyroid-related lid lag), an **enlarged cornea** (13 mm diameter, indicative of **buphthalmos**), and **double-contoured opacities concentric to the limbus** (corresponding to **Haab's striae**) are classic signs of congenital glaucoma. - **Buphthalmos** occurs due to increased intraocular pressure in infancy, stretching the sclera and cornea, while **Haab's striae** are ruptures in Descemet's membrane resulting from this stretching. - The enlarged globe prevents complete lid closure, creating the appearance of "lid lag" (lagophthalmos). *Superficial keratitis* - This condition typically presents with **corneal inflammation** affecting the epithelial or superficial stromal layers, often causing pain, photophobia, and foreign body sensation. - It does not typically cause **corneal enlargement** or **Haab's striae**, which are characteristic of increased intraocular pressure. *Deep keratitis* - Involves inflammation deeper within the corneal stroma, potentially leading to significant vision loss and corneal scarring. - While it can cause corneal opacities, it does not typically lead to **corneal enlargement (buphthalmos)** or **Haab's striae**, which are associated with elevated intraocular pressure from birth. *Thyroid Endocrinopathy* - **Thyroid eye disease** can cause true **lid lag** (von Graefe's sign) due to sympathetic overstimulation of Muller's muscle—this is different from the lagophthalmos seen in congenital glaucoma. - However, thyroid disease does not cause **corneal enlargement** or **Haab's striae**, and is primarily an inflammatory and autoimmune condition affecting orbital tissues, not directly leading to congenital corneal changes.

Q: Intumescent cataract is associated with which type of glaucoma?

Phacomorphic glaucoma. ***Phacomorphic glaucoma*** - **Intumescent cataract** refers to a mature or hypermature cataract that has absorbed water, leading to a swollen lens. - This swelling can cause the lens to push the iris forward, leading to secondary **angle closure glaucoma** due to pupillary block, which is characteristic of phacomorphic glaucoma. *Phacolytic glaucoma* - This type of glaucoma is caused by leakage of **high-molecular-weight lens proteins** from a mature or hypermature cataract into the aqueous humor, triggering a macrophagic response and obstruction of the trabecular meshwork. - It results in an **open-angle glaucoma** and anterior chamber inflammation, unlike the angle closure seen with intumescent cataracts. *Phacotopic glaucoma* - This is a rare term and not a recognized distinct category of glaucoma related to lens swelling. It may refer loosely to glaucoma associated with **lens dislocation** or subluxation. - It does not specifically describe glaucoma caused by an **intumescent cataract**. *Pseudophakic glaucoma* - This refers to glaucoma that develops in patients who have undergone **cataract surgery** and have an **intraocular lens (IOL)** implant (pseudophakia). - It can be caused by various mechanisms post-surgery, such as inflammation, steroid response, or IOL-related issues, but it is not directly associated with the presence of an intumescent natural lens.

Q: What are glaukomflecken?

Lens opacities associated with acute angle-closure glaucoma. ***Lens opacities associated with acute angle-closure glaucoma*** - **Glaukomflecken** are small, grey-white capsular and subcapsular lens opacities that form as a result of **ischemic necrosis** of the lens epithelium. - They are a specific sign of prior **acute angle-closure glaucoma**, caused by a sudden, severe rise in **intraocular pressure (IOP)**. *Acute uveitis due to glaucoma* - **Uveitis** is inflammation of the uvea, and while it can be associated with glaucoma (e.g., in Posner-Schlossman syndrome), **glaukomflecken** specifically refer to lens damage, not uveal inflammation. - Uveitis is typically diagnosed by observing **inflammatory cells in the anterior chamber** and different patterns of globe redness, not lens opacities. *Retinal detachment due to glaucoma* - **Retinal detachment** is a separation of the neurosensory retina from the underlying retinal pigment epithelium. - While glaucoma can cause vision loss, it does not directly cause **retinal detachment**; glaukomflecken are specifically lens findings. *Corneal opacity due to glaucoma* - **Corneal edema** can occur during an acute attack of angle-closure glaucoma due to high IOP, leading to a hazy cornea. - However, **glaukomflecken** are specific lesions found in the **lens**, not the cornea.

Q: In open-angle glaucoma, which investigation is least useful for diagnosis?

Indirect ophthalmoscopy. ***Indirect ophthalmoscopy*** - While useful for viewing the peripheral retina, **indirect ophthalmoscopy** is less effective than other methods for assessing the optic nerve head and retinal nerve fiber layer changes characteristic of open-angle glaucoma. - Its primary utility is for detecting **retinal detachment** or other peripheral retinal pathologies, which are not directly diagnostic of glaucoma. *Tonometry* - **Tonometry** measures the intraocular pressure (IOP), a primary risk factor for open-angle glaucoma, and is essential for monitoring treatment effectiveness. - Elevated IOP is a key indicator, though not always present, and normal-tension glaucoma exists. *Direct ophthalmoscopy* - **Direct ophthalmoscopy** allows for visualization of the optic nerve head, enabling detection of characteristic glaucoma changes such as **cupping** and loss of the neuroretinal rim. - This method is crucial for assessing **optic nerve damage**, a hallmark of glaucoma. *Perimetry* - **Perimetry**, or visual field testing, assesses the functional impact of glaucoma by detecting **peripheral vision loss**. - This test identifies specific patterns of visual field defects that correlate with nerve fiber layer damage and is vital for staging and monitoring disease progression.

Q: Best treatment for buphthalmos?

Goniotomy. ***Goniotomy*** - Primary surgical treatment for **congenital glaucoma** (buphthalmos) with clear cornea - Directly incises the **trabecular meshwork** to relieve the outflow obstruction at the **angle structures** - Success rate of 70-90% in appropriate cases, making it the first-line surgical intervention - Addresses the underlying pathophysiology of congenital glaucoma *Trabeculectomy* - **Filtering surgery** that creates a new drainage pathway from anterior chamber to subconjunctival space - Reserved as a **secondary procedure** when goniotomy/trabeculotomy fails in congenital glaucoma - More commonly used as primary surgery in adult-onset glaucoma - Carries higher risk of complications in infants *Cryotherapy* - **Cyclodestructive procedure** that destroys ciliary body tissue to reduce aqueous humor production - Reserved for **refractory cases** where conventional surgeries have failed - Does not address the primary anatomical obstruction in congenital glaucoma - Higher risk of complications including phthisis bulbi *Conservative* - Buphthalmos indicates **congenital glaucoma**, a surgical disease requiring prompt intervention - Medical management alone is **insufficient** due to structural trabecular meshwork abnormalities - Topical medications may serve as temporary bridge to surgery but are rarely definitive - Delayed surgical treatment risks irreversible optic nerve damage and vision loss

Question 1

Normal cup-to-disc ratio of the optic disc is

Accepted Answer

0.2 to 0.3

Answer

0.5 to 0.6

Answer

0.1 to 0.3

Answer

0.3 to 0.4

Question 2

A patient presents with a history of evening halos and occasional headaches for some months. His examination shows normal intraocular pressure but shallow anterior chamber. What is the most likely diagnosis?

Accepted Answer

Primary angle-closure glaucoma

Answer

Normal-tension glaucoma

Answer

Pigmentary glaucoma

Answer

Open-angle glaucoma

Question 3

Cycloplegics are used for the treatment of:

Accepted Answer

Iridocyclitis

Answer

Lens-induced glaucoma

Answer

Closed-angle glaucoma

Answer

Chorioretinitis

Question 4

In which of the following conditions is the intraocular pressure very high, and inflammation is minimal?

Accepted Answer

Glaucomatocyclic crises

Answer

Angle closure glaucoma

Answer

Acute iridocyclitis

Answer

Hypertensive uveitis

Question 5

Krukenberg's spindles are seen in?

Accepted Answer

Pigmentary glaucoma

Answer

Chalazion

Answer

Retinitis pigmentosa

Answer

Sympathetic ophthalmia

Question 6

A child presents with lid lag and an enlarged cornea with a diameter of 13 mm. Examination of the eye reveals double-contoured opacities concentric to the limbus. Which of the following is the most likely diagnosis?

Accepted Answer

Congenital Glaucoma

Answer

Superficial keratitis

Answer

Deep keratitis

Answer

Thyroid Endocrinopathy

Question 7

Intumescent cataract is associated with which type of glaucoma?

Accepted Answer

Phacomorphic glaucoma

Answer

Phacolytic glaucoma

Answer

Phacotopic glaucoma

Answer

Pseudophakic glaucoma

Question 8

What are glaukomflecken?

Accepted Answer

Lens opacities associated with acute angle-closure glaucoma

Answer

Acute uveitis due to glaucoma

Answer

Retinal detachment due to glaucoma

Answer

Corneal opacity due to glaucoma

Question 9

In open-angle glaucoma, which investigation is least useful for diagnosis?

Accepted Answer

Indirect ophthalmoscopy

Answer

Tonometry

Answer

Direct ophthalmoscopy

Answer

Perimetry

Question 10

Best treatment for buphthalmos?

Accepted Answer

Goniotomy

Answer

Trabeculectomy

Answer

Cryotherapy

Answer

Conservative

Glaucoma — MCQs

Glaucoma — MCQs

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