Glaucoma — MCQs

Glaucoma Indian Medical PG Practice Questions and MCQs

Question 51: Cupping of the optic disc is not a feature of which of the following conditions?

A. Buphthalmos
B. Chronic simple glaucoma
C. Acute congestive glaucoma
D. Megalocornea (Correct Answer)

Explanation: **Explanation:** The core concept behind this question is distinguishing between conditions that involve **pathological intraocular pressure (IOP)** leading to optic nerve damage and those that are purely **anatomical variations**. **Why Megalocornea is the correct answer:** Megalocornea is a non-progressive, bilateral, X-linked recessive condition characterized by an enlarged corneal diameter (>13 mm) without any elevation in intraocular pressure. Since the IOP is normal, there is no mechanical or ischemic damage to the optic nerve head; therefore, **cupping is absent**. The optic disc remains healthy and the cup-to-disc ratio is normal. **Analysis of Incorrect Options:** * **Buphthalmos:** This is developmental glaucoma where high IOP causes stretching of the globe. The increased pressure leads to mechanical excavation of the optic nerve head, resulting in significant cupping. * **Chronic Simple Glaucoma (POAG):** This is the classic condition associated with progressive optic disc cupping due to sustained elevation of IOP and subsequent retinal ganglion cell death. * **Acute Congestive Glaucoma:** While the primary presentation is sudden pain and corneal edema, the severe spike in IOP can cause rapid damage to the optic nerve, leading to cupping if the attack is prolonged or recurrent. **Clinical Pearls for NEET-PG:** * **Megalocornea vs. Buphthalmos:** In Megalocornea, the IOP, axial length, and optic disc are **normal**. In Buphthalmos, IOP is **high**, axial length is **increased**, and the optic disc shows **cupping**. * **Haab’s Striae:** These are horizontal tears in Descemet’s membrane seen in Buphthalmos, but *not* in Megalocornea. * **High-Yield Association:** Megalocornea is often associated with lens subluxation (due to zonular stretching) and Marfan syndrome.

Question 52: Both soft and hard exudates are seen in which of the following conditions?

A. Hypertension
B. Diabetes
C. Eales disease
D. All of the above (Correct Answer)

Explanation: **Explanation:** The presence of both soft and hard exudates indicates a combination of microvascular leakage and retinal ischemia. * **Hard Exudates:** These are yellowish, waxy-looking deposits with well-defined borders. They are composed of lipid and proteinaceous material that leaks from damaged capillaries (increased vascular permeability) and settles in the Outer Plexiform Layer (Henle’s layer). * **Soft Exudates (Cotton Wool Spots):** These are not true exudates but rather micro-infarcts of the Retinal Nerve Fiber Layer (RNFL). They occur due to the occlusion of terminal retinal arterioles, leading to axoplasmic stasis. **Why "All of the Above" is correct:** 1. **Diabetes Mellitus:** In Diabetic Retinopathy, microaneurysms and damaged capillaries lead to hard exudates (often in circinate patterns), while capillary non-perfusion leads to soft exudates. 2. **Hypertension:** Grade III and IV Hypertensive Retinopathy are characterized by flame-shaped hemorrhages, cotton wool spots (soft exudates), and hard exudates (which may form a "macular star"). 3. **Eales Disease:** This is an idiopathic peripheral perivasculitis. The inflammatory process causes vascular leakage (hard exudates) and peripheral ischemia/non-perfusion (soft exudates). **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Hard exudates are found in the **Outer Plexiform Layer**; Soft exudates are found in the **Nerve Fiber Layer**. * **Macular Star:** A specific arrangement of hard exudates in the Henle’s layer of the macula, seen in Hypertension, Neuroretinitis, and Papilledema. * **Differential Diagnosis:** Other conditions showing both include Retinal Vein Occlusions (CRVO/BRVO) and Radiation Retinopathy.

Question 53: What is the treatment of choice for Eales disease?

A. Antibiotics
B. Corticosteroids (Correct Answer)
C. Antihistaminics
D. Surgery

Explanation: **Explanation:** **Eales disease** is an idiopathic, inflammatory peripheral retinal perivasculitis (primarily affecting the venules) that typically affects young healthy males. The pathogenesis is characterized by three stages: perivasculitis (inflammation), peripheral non-perfusion (ischemia), and neovascularization (proliferative stage). **Why Corticosteroids are the Treatment of Choice:** The primary underlying mechanism in the early/active stage of Eales disease is **inflammation** (perivasculitis). **Systemic corticosteroids** are the mainstay of treatment to suppress this active vasculitis and prevent further progression to the ischemic and proliferative stages. They help reduce vascular leakage and inflammatory exudates. **Analysis of Incorrect Options:** * **A. Antibiotics:** While Eales disease has a historical association with hypersensitivity to *Mycobacterium tuberculosis* (positive Mantoux test), the disease itself is non-infectious. Antibiotics are not the primary treatment, though Anti-Tubercular Treatment (ATT) may be considered as an adjunct in specific cases. * **C. Antihistaminics:** These are used for Type I hypersensitivity (allergic) reactions. Eales disease is a vasculitis, and antihistamines have no role in its management. * **D. Surgery:** Surgical intervention (Pars Plana Vitrectomy) is reserved only for **complications** of the disease, such as non-resolving vitreous hemorrhage or tractional retinal detachment. It is not the primary treatment of choice for the disease itself. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Classically affects young males (20–30 years). * **Clinical Sign:** Peripheral "candle-wax drippings" (perivascular sheathing). * **Complications:** Vitreous hemorrhage (most common cause of sudden vision loss in these patients) and neovascularization at the disc or elsewhere (NVD/NVE). * **Management of Ischemia:** If peripheral non-perfusion is present on FFA, **Laser Photocoagulation** is the treatment of choice to prevent neovascularization.

Question 54: A 68-year-old female presents with severe right eye pain, blurred vision, nausea, and vomiting. Earlier in the day, she underwent a difficult colonoscopy for Crohn's disease. What is the likely cause of her painful red eye?

A. Anterior uveitis
B. Acute conjunctivitis
C. Episcleritis
D. Acute angle closure glaucoma (Correct Answer)

Explanation: **Explanation:** The patient is presenting with a classic case of **Acute Angle Closure Glaucoma (AACG)**. The underlying mechanism is a sudden rise in intraocular pressure (IOP) due to the blockage of aqueous humor outflow at the iridocorneal angle. **Why it is the correct answer:** The clinical triad of severe ocular pain, blurred vision (often with halos), and systemic symptoms like nausea/vomiting is pathognomonic for AACG. The crucial "NEET-PG trigger" here is the **colonoscopy**. During difficult endoscopies, antispasmodic drugs like **Hyoscine (Buscopan)** or other anticholinergics are frequently administered. These drugs cause **mydriasis** (pupillary dilation), which can crowd the angle and precipitate an acute attack in predisposed individuals (e.g., elderly females with hypermetropia). **Why other options are incorrect:** * **Anterior Uveitis:** Presents with pain and photophobia, but the pupil is typically **constricted (miotic)** and irregular, not mid-dilated. It does not cause sudden nausea/vomiting. * **Acute Conjunctivitis:** Characterized by discharge and grittiness rather than severe deep-seated pain. Vision remains normal. * **Episcleritis:** Usually a localized, sectoral redness; it is typically painless or associated with mild discomfort and does not affect vision. **Clinical Pearls for NEET-PG:** * **Classic Sign:** A "mid-dilated, vertically oval, non-reactive pupil" with a "steamy/hazy cornea." * **Risk Factors:** Hypermetropia (short axial length), shallow anterior chamber, and increasing age. * **Immediate Management:** IV Acetazolamide, topical beta-blockers, and **Pilocarpine** (once IOP drops) to induce miosis. * **Definitive Treatment:** Peripheral Iridotomy (usually YAG laser) for both the affected and the fellow (prophylactic) eye.

Question 55: Which of the following characterizes chronic simple glaucoma?

A. Elevated intraocular pressure without optic nerve damage.
B. Elevated intraocular pressure with optic nerve damage. (Correct Answer)
C. Visual field defects without optic nerve changes.
D. A pink optic disc.

Explanation: **Explanation:** Chronic Simple Glaucoma, also known as **Primary Open-Angle Glaucoma (POAG)**, is a chronic, progressive optic neuropathy. The diagnosis is fundamentally based on a triad: **elevated intraocular pressure (IOP)**, characteristic **optic nerve head changes** (cupping), and corresponding **visual field defects**. 1. **Why Option B is correct:** In POAG, the resistance to aqueous outflow occurs at the level of the trabecular meshwork. The resulting elevation in IOP leads to mechanical and ischemic damage to the retinal ganglion cells, manifesting as pathological cupping of the optic disc and progressive vision loss. 2. **Why other options are incorrect:** * **Option A:** Elevated IOP without optic nerve damage or field loss is termed **Ocular Hypertension**, not glaucoma. * **Option C:** Visual field defects in glaucoma are a direct consequence of optic nerve fiber loss. You cannot have glaucomatous field defects without corresponding structural changes in the optic nerve. * **Option D:** A pink optic disc indicates a healthy, well-perfused nerve. In glaucoma, the disc appears **pale** (due to atrophy) and shows increased **cupping**. **Clinical Pearls for NEET-PG:** * **Risk Factors:** Age >40, high myopia, family history, and Diabetes Mellitus. * **Early Sign:** The earliest visual field defect is often a **Siedel’s scotoma** (extension of the blind spot), progressing to a **Bjerrum’s (arcuate) scotoma**. * **Gold Standard Diagnosis:** Applanation tonometry for IOP, Automated Perimetry (HFA) for fields, and slit-lamp biomicroscopy for disc evaluation. * **Treatment:** Prostaglandin analogues (e.g., Latanoprost) are the first-line medical management.

Question 56: Increased episcleral venous pressure can affect intraocular pressure (IOP) in which way?

A. Increase IOP (Correct Answer)
B. Decrease IOP
C. Have no effect on IOP
D. Initially increase then decrease IOP

Explanation: **Explanation:** The relationship between episcleral venous pressure (EVP) and intraocular pressure (IOP) is governed by **Goldmann’s Equation**: **IOP = (F / C) + Pe** *(Where F = rate of aqueous formation, C = facility of outflow, and Pe = episcleral venous pressure).* In a healthy eye, aqueous humor flows from the anterior chamber through the trabecular meshwork and Schlemm’s canal into the episcleral veins. Because this is a pressure-dependent drainage system, any rise in the downstream pressure (EVP) creates resistance to the outflow of aqueous. According to the equation, for every **1 mmHg rise in EVP, there is a corresponding 1 mmHg rise in IOP**. **Analysis of Options:** * **Option A (Correct):** Increased EVP directly resists aqueous drainage, leading to a linear increase in IOP. * **Option B & C:** These are incorrect because the outflow system is passive; if the "exit" pressure increases, the "internal" pressure must rise to maintain flow. * **Option D:** There is no physiological compensatory mechanism that eventually decreases IOP if the EVP remains chronically elevated. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Signs:** Patients often present with **dilated, tortuous (corkscrew) episcleral vessels**. * **Blood in Schlemm’s Canal:** On gonioscopy, blood may be seen in Schlemm’s canal due to backflow from high venous pressure. * **Common Causes:** 1. **Carotid-Cavernous Fistula (CCF):** Most common cause of sudden, pulsatile proptosis with high EVP. 2. **Sturge-Weber Syndrome:** Associated with episcleral hemangiomas. 3. **Thyroid Eye Disease:** Due to venous compression by enlarged extraocular muscles. 4. **Superior Vena Cava Syndrome.**

Question 57: Iridectomy is a treatment option in which of the following conditions?

A. Pigmentary glaucoma
B. Angle closure glaucoma (Correct Answer)
C. Pseudoexfoliative glaucoma
D. Open angle glaucoma

Explanation: **Explanation:** **1. Why Angle Closure Glaucoma (ACG) is correct:** The primary mechanism in primary angle-closure glaucoma is **pupillary block**. In this condition, the contact between the iris and the lens prevents aqueous humor from flowing from the posterior chamber to the anterior chamber. This creates a pressure gradient that pushes the peripheral iris forward (**iris bombé**), physically blocking the trabecular meshwork. * **Iridectomy** (surgical or laser peripheral iridotomy) creates a bypass channel in the iris. This equalizes the pressure between the chambers, allows the iris to fall back into its normal position, and opens the drainage angle. It is the definitive treatment for ACG. **2. Why the other options are incorrect:** * **A & C (Pigmentary and Pseudoexfoliative Glaucoma):** These are types of **Secondary Open Angle Glaucomas**. In these conditions, the drainage angle is physically open, but the trabecular meshwork is clogged by pigment granules or fibrillary material, respectively. Since there is no pupillary block, an iridectomy will not lower the intraocular pressure. * **D (Open Angle Glaucoma):** In Primary Open Angle Glaucoma (POAG), the pathology lies within the microscopic resistance of the trabecular meshwork itself. The anatomical relationship between the iris and lens is normal; therefore, an iridectomy serves no therapeutic purpose. **Clinical Pearls for NEET-PG:** * **Laser Peripheral Iridotomy (LPI)** is the preferred modern procedure over surgical iridectomy. * **Prophylaxis:** In a patient with acute congestive glaucoma, the **fellow eye** must always undergo a prophylactic iridectomy because there is a high risk of a similar attack. * **Nd:YAG Laser** is the most common tool used for performing a peripheral iridotomy.

Question 58: A patient presents with acute pain and redness of the eye, diminished vision, and vomiting. What is the most likely finding?

A. Mid-dilated pupil (Correct Answer)
B. Hypopyon
C. Dislocated eye lens
D. Dendritic ulcer

Explanation: ### Explanation The clinical presentation of acute ocular pain, redness, diminished vision, and systemic symptoms like vomiting is a classic triad for **Acute Angle Closure Glaucoma (AACG)**. **1. Why "Mid-dilated pupil" is correct:** In AACG, a sudden rise in intraocular pressure (IOP) causes ischemia and paralysis of the iris sphincter muscle. This results in a pupil that is **vertically oval, mid-dilated, and non-reactive to light**. The vomiting is a result of the oculo-emetic reflex triggered by the extremely high IOP (often >50–60 mmHg). **2. Why the other options are incorrect:** * **Hypopyon:** This refers to a collection of inflammatory cells in the anterior chamber, typically seen in **Endophthalmitis** or severe **Uveitis**. While these cause pain and redness, the pupil is usually constricted (miotic) due to ciliary spasm, not mid-dilated. * **Dislocated eye lens:** While a dislocated lens (Ectopia lentis) can cause secondary glaucoma (e.g., phacomorphic glaucoma), it is not a primary finding of the acute attack itself. It is usually associated with trauma or systemic syndromes like Marfan’s. * **Dendritic ulcer:** This is the hallmark of **Herpes Simplex Keratitis**. It presents with pain and redness, but vision loss is usually less sudden, and the pupil is typically normal or miotic. **Clinical Pearls for NEET-PG:** * **Corneal appearance:** In AACG, the cornea appears "steamy" or "cloudy" due to epithelial edema. * **Shallow Anterior Chamber:** This is a predisposing anatomical factor. * **Immediate Management:** IV Acetazolamide and topical pilocarpine (once IOP drops below 40 mmHg). * **Definitive Treatment:** Peripheral Iridotomy (Laser or Surgical) for both the affected and the fellow (prophylactic) eye.

Question 59: Facility of aqueous outflow is ______ I/min/mm Hg.

A. 0.8
B. 0.6
C. 0.4
D. 0.2 (Correct Answer)

Explanation: ### Explanation The **facility of aqueous outflow (C)** is a measure of the ease with which aqueous humor leaves the eye through the trabecular meshwork and uveoscleral pathways. It is defined as the volume of aqueous humor (in microliters) that leaves the eye per minute for every millimeter of mercury (mm Hg) of intraocular pressure (IOP). **1. Why Option D (0.2) is Correct:** The normal average value for the facility of outflow in a healthy adult eye is approximately **0.22 µl/min/mm Hg** (commonly rounded to **0.2** in exams). This value is calculated using the Tonography equation: $F = C \times (IOP - P_e)$, where $F$ is the rate of aqueous formation and $P_e$ is the episcleral venous pressure. A value below **0.18** is often considered suspicious, and below **0.11** is diagnostic of glaucoma. **2. Why Other Options are Incorrect:** * **Options A (0.8) and B (0.6):** These values are significantly higher than physiological norms. Such high facility would result in hypotony (abnormally low IOP), as the fluid would exit the eye too rapidly. * **Option C (0.4):** While closer to the range, this is still double the normal physiological average. **3. High-Yield Clinical Pearls for NEET-PG:** * **Aqueous Production Rate:** Normal rate is **2.0 to 2.5 µl/min**. * **Outflow Pathways:** * **Trabecular (Conventional):** 90% of outflow; pressure-dependent. * **Uveoscleral (Unconventional):** 10% of outflow; pressure-independent (targeted by Prostaglandin analogues). * **Goldmann Equation:** $P = (F/C) + P_e$. * **Ageing Effect:** The facility of outflow **decreases** with age and is significantly reduced in Primary Open Angle Glaucoma (POAG) due to increased resistance in the trabecular meshwork.

Question 60: A 55-year-old female presents with severe eye pain, redness, and diminished vision. Examination reveals a visual acuity of 6/60, circumcorneal congestion, corneal edema, and a shallow anterior chamber. What is the best initial drug of choice?

A. Atropine ointment
B. Intravenous Mannitol (Correct Answer)
C. Ciprofloxacin eye drops
D. Betamethasone eye drops

Explanation: ### Explanation **Diagnosis:** The clinical presentation of severe eye pain, redness, diminished vision, circumcorneal congestion, corneal edema, and a shallow anterior chamber in a middle-aged female is classic for **Acute Angle Closure Glaucoma (AACG)**. This is an ocular emergency characterized by a sudden, massive rise in Intraocular Pressure (IOP). **Why Intravenous Mannitol is Correct:** In an acute attack of AACG, the primary goal is to lower the IOP rapidly to prevent permanent optic nerve damage and clear corneal edema. **IV Mannitol (20%)** is a potent hyperosmotic agent. It increases the osmotic pressure of the plasma relative to the vitreous, drawing water out of the eye into the systemic circulation. This rapidly reduces the vitreous volume and IOP, making it the most effective initial intervention to "break" the acute attack when IOP is severely elevated. **Why Other Options are Incorrect:** * **Atropine ointment:** This is a strong **mydriatic** (dilates the pupil). In AACG, the angle is already closed; dilating the pupil further bunches up the iris tissue in the angle, worsening the blockage and potentially causing a catastrophic rise in IOP. It is strictly contraindicated. * **Ciprofloxacin eye drops:** This is a fluoroquinolone antibiotic used for bacterial infections (e.g., keratitis or conjunctivitis). It has no role in lowering IOP. * **Betamethasone eye drops:** This is a corticosteroid. While it may reduce secondary inflammation, it does not address the mechanical closure of the angle or the acute pressure rise. **High-Yield Clinical Pearls for NEET-PG:** * **Definitive Treatment:** While Mannitol is the initial medical choice, the definitive treatment for AACG is **Laser Peripheral Iridotomy (LPI)**, performed on both the affected and the fellow (prophylactic) eye. * **First-line Oral Drug:** Acetazolamide (Carbonic anhydrase inhibitor) is often given alongside Mannitol. * **The "Rock Hard" Eye:** On palpation, the eyeball in AACG feels stony hard due to the extreme IOP (often >60 mmHg). * **Demographics:** Most common in hypermetropic (small) eyes and females aged 50–70 years.

Practice by Chapter

Aqueous Humor Dynamics

Practice Questions

Primary Open-Angle Glaucoma

Practice Questions

Primary Angle-Closure Glaucoma

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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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Glaucoma — MCQs

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