Glaucoma Practice Questions

Q: A 66-year-old patient presents to the emergency department with sudden onset of severe pain and blurred vision in the right eye. Examination reveals decreased visual acuity with a shallow and hazy cornea in the affected eye. The eye has a stony hard consistency. What is the likely diagnosis?

Glaucoma. The clinical presentation described is a classic case of **Acute Angle-Closure Glaucoma (AACG)**, a medical emergency characterized by a sudden, critical rise in intraocular pressure (IOP). ### Why Glaucoma is Correct The diagnosis is confirmed by the triad of **sudden severe pain**, **blurred vision** (due to corneal edema), and a **"stony hard" eye** on palpation. The "stony hard" consistency is a pathognomonic sign of severely elevated IOP. The **shallow anterior chamber** and **hazy cornea** (corneal edema) occur because the high pressure forces fluid into the corneal stroma and compromises the drainage angle. ### Why Other Options are Incorrect * **Keratitis:** While it causes pain and blurred vision, it typically presents with a corneal ulcer or infiltrate and a normal-depth anterior chamber. It does not cause a "stony hard" eye. * **Uveitis:** Acute anterior uveitis presents with pain and photophobia, but the pupil is usually **constricted (miotic)** and the IOP is often low or normal. In AACG, the pupil is typically **mid-dilated and vertically oval**. * **Conjunctivitis:** This presents with discharge, grittiness, and redness, but **never** with severe pain, loss of vision, or increased eye hardness. ### NEET-PG High-Yield Pearls * **Classic Triad:** Severe ocular pain, colored halos (due to corneal edema), and vomiting (often misdiagnosed as a GI issue). * **Pupil Sign:** Mid-dilated, vertically oval, and non-reactive to light. * **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.

Q: In an acute attack of glaucoma, which of the following is excluded from Vogt's triad?

Pigment dispersal. **Explanation:** **Vogt’s Triad** is a clinical sign indicating a **previous episode** of acute congestive glaucoma (Angle-Closure Glaucoma). It represents the permanent structural damage caused by a sudden, severe rise in intraocular pressure (IOP). **Why Pigment Dispersal is the correct answer:** While pigment dispersion can occur during an acute attack due to iris ischemia, it is **not** a component of the classic Vogt’s Triad. Pigment dispersal is more typically associated with Pigmentary Glaucoma (an open-angle variant) or general iris trauma, rather than being a specific diagnostic marker for a post-congestive state. **Analysis of Vogt’s Triad components (Incorrect Options):** 1. **Glaukomflecken (Glaucoma floaters):** These are small, grey-white subcapsular lenticular opacities caused by localized necrosis of the lens epithelium due to high IOP. These are pathognomonic for a prior acute attack. 2. **Iris Atrophy:** Ischemia during the attack leads to permanent thinning and sector atrophy of the iris stroma, often resulting in a distorted or fixed pupil. 3. **Goniosynechiae (Peripheral Anterior Synechiae):** The high pressure forces the peripheral iris against the trabecular meshwork, leading to permanent adhesions (synechiae) that close the angle. **NEET-PG High-Yield Pearls:** * **Glaukomflecken** is considered the most specific sign of a past acute attack. * The pupil in acute glaucoma is typically **mid-dilated and vertically oval**. * **Post-congestive triad:** Vogt’s Triad is often seen alongside a non-reacting, dilated pupil and Descemet’s membrane folds. * **Management:** The definitive treatment for the fellow eye (prophylaxis) and the affected eye is **Laser Peripheral Iridotomy (LPI)**.

Q: Which of the following is true about Buphthalmos?

Large cornea. **Explanation:** **Buphthalmos** (literally "ox-eye") refers to the marked enlargement of the globe that occurs in **Primary Congenital Glaucoma**. 1. **Why "Large Cornea" is the correct answer:** In infants (usually under age 3), the sclera and cornea are highly distensible. When intraocular pressure (IOP) rises, the entire globe stretches. A corneal diameter **>12 mm before age 1** or **>13 mm at any age** is diagnostic. This enlargement is the hallmark of buphthalmos. 2. **Analysis of other options:** * **Haab’s striae:** While these are characteristic of congenital glaucoma, they are **horizontal breaks in Descemet’s membrane** caused by stretching. They are a *consequence* of the enlargement, but "Buphthalmos" specifically refers to the physical enlargement (large eye/cornea) itself. * **Shallow anterior chamber:** This is **incorrect**. In buphthalmos, the anterior chamber is characteristically **deep** due to the stretching of the anterior segment. Shallow chambers are seen in primary angle-closure glaucoma. * **Glaucoma:** While glaucoma is the *cause* of buphthalmos, the term "Buphthalmos" describes the clinical sign (the enlarged eye), not the disease process itself. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Epiphora (tearing), Photophobia, and Blepharospasm. * **Haab’s Striae:** Horizontal or curvilinear (unlike vertical tears in birth trauma). * **Management:** The treatment is primarily **surgical**. **Goniotomy** is preferred if the cornea is clear; **Trabeculotomy** is performed if the cornea is hazy. * **CCT:** Central corneal thickness is often increased in these patients.

Q: Which retinal nerve fibres are most sensitive to glaucomatous damage?

Superior and inferior arcuate fibres. **Explanation:** In glaucoma, the primary site of damage is the optic nerve head. The **superior and inferior arcuate fibres** (also known as the Bjerrum area fibres) are the most sensitive to increased intraocular pressure (IOP). This susceptibility is due to the structural anatomy of the **Lamina Cribrosa**. The pores in the superior and inferior poles of the lamina cribrosa are larger and provide less structural support to the nerve fiber bundles compared to the nasal and temporal sectors. Consequently, these fibers are the first to undergo mechanical compression and ischemic damage, leading to characteristic early glaucomatous field defects like Seidel’s scotoma and Arcuate (Bjerrum) scotoma. **Analysis of Incorrect Options:** * **B. Macular fibres:** These form the papillomacular bundle. They are highly resistant to early glaucomatous damage and are typically the last to be affected, which is why "central vision" is preserved until the end-stage of the disease. * **C & D. Radiating fibres:** These fibers are located in the nasal retina. While they can be affected as the disease progresses (forming a nasal step), they are not as vulnerable as the arcuate bundles in the early stages. **High-Yield Clinical Pearls for NEET-PG:** * **ISNT Rule:** In a healthy eye, the Neuroretinal Rim thickness follows the order Inferior > Superior > Nasal > Temporal. In glaucoma, this rule is broken (Inferior and Superior thinning occurs first). * **Early Field Defect:** The earliest clinically significant field defect is often the **Nasal (Roenne’s) Step**, but the most characteristic early defect is the **Siedel’s scotoma**. * **10-2 Perimetry:** Used specifically when only macular fibers remain (advanced glaucoma) to monitor the remaining central visual field.

Q: In acute congestive glaucoma, what is the typical pupil appearance?

Oval and vertical. In **Acute Congestive Glaucoma** (Acute Angle Closure Glaucoma), the sudden and severe rise in intraocular pressure (IOP) leads to ischemia and paralysis of the iris sphincter muscle. ### Why the pupil is Oval and Vertical: The correct answer is **B**. The extreme elevation of IOP (often >60 mmHg) causes pressure-induced ischemia of the iris stroma. The iris sphincter muscle becomes paretic (paralyzed), particularly in the superior and inferior segments. This segmental paralysis, combined with the radial pull of the dilator muscle, results in a **vertically oval, mid-dilated, and non-reactive pupil**. ### Why the other options are incorrect: * **A. Oval and horizontal:** This is not a standard clinical finding in glaucoma. Vertical elongation is the hallmark due to the specific distribution of iris ischemia. * **C. Circular:** A circular pupil is seen in normal eyes or in cases of pharmacological miosis/mydriasis. In acute glaucoma, the pupil loses its circularity due to segmental muscle failure. * **D. Slit-like:** Slit-like pupils are characteristic of certain animals (like cats) or may occur in specific iris traumas/congenital anomalies (e.g., persistent pupillary membrane), but not in acute glaucoma. ### High-Yield Clinical Pearls for NEET-PG: * **The Triad of Acute Glaucoma:** Mid-dilated vertical oval pupil + Steamy/Cloudy cornea + Stony hard eyeball on palpation. * **Symptoms:** Sudden onset excruciating pain, halos around lights (due to corneal edema), and vomiting (often misdiagnosed as an abdominal emergency). * **Immediate Management:** IV Mannitol (osmotic diuretic) and Acetazolamide to lower IOP, followed by topical Pilocarpine (once IOP drops below 40 mmHg) and definitive **Laser Peripheral Iridotomy (LPI)**. * **Glaukomflecken:** Small, grey-white anterior subcapsular lens opacities—a pathognomonic sign of a previous attack of acute angle closure.

Q: An elderly male with a history of glaucoma presents with a bulging cornea on examination. What is the most likely diagnosis?

Staphyloma. ### Explanation **Correct Answer: B. Staphyloma** The correct answer is **Staphyloma**. A staphyloma is a localized bulging of the outer coat of the eye (sclera or cornea) lined by uveal tissue. In the context of chronic, uncontrolled glaucoma, the persistent elevation of intraocular pressure (IOP) leads to thinning and stretching of the ocular coats. When the cornea thins and bulges forward due to high IOP, it is specifically termed an **Anterior Staphyloma**. This is a classic complication of secondary glaucoma following corneal perforation or severe thinning. **Why other options are incorrect:** * **Keratoconus (A):** While this involves a cone-shaped bulging of the cornea, it is a non-inflammatory, progressive thinning disorder usually bilateral and unrelated to high intraocular pressure or glaucoma. * **Glaucomatous iridocyclitis (C):** This refers to inflammation of the iris and ciliary body associated with glaucoma (e.g., Posner-Schlossman Syndrome). It presents with cells/flare in the anterior chamber, not a structural bulging of the cornea. * **Keratomalacia (D):** This is corneal melting and necrosis caused by severe Vitamin A deficiency. While it can lead to perforation and subsequent staphyloma, the term itself refers to the acute melting process, not the chronic bulging state. **Clinical Pearls for NEET-PG:** * **Definition:** Staphyloma = Ectasia (thinning) + Uveal tissue lining. * **Types of Staphyloma:** * **Anterior:** Involves the cornea (common after perforated corneal ulcers). * **Intercalary:** At the limbus (up to the ciliary body). * **Ciliary:** Over the ciliary body (2–8 mm behind the limbus). * **Equatorial:** At the exit of vortex veins. * **Posterior:** At the posterior pole (common in Pathological Myopia). * **Buphthalmos:** In **Congenital Glaucoma**, the *entire* eyeball enlarges (distensible sclera in infants), whereas Staphyloma is a *localized* bulge in adults.

Q: Which of the following is NOT a triad of congenital glaucoma?

Buphthalmos. The classic clinical presentation of **Primary Congenital Glaucoma (PCG)** is characterized by a specific diagnostic triad. Understanding the distinction between symptoms (what the patient/parent notices) and signs (what the doctor finds) is key to answering this question. ### Why "Buphthalmos" is the Correct Answer While **Buphthalmos** (enlargement of the globe due to high intraocular pressure) is a hallmark clinical **sign** of congenital glaucoma, it is **not** part of the classic symptomatic triad. The triad consists of the three primary irritative symptoms caused by corneal edema and epithelial irritation. ### Explanation of the Triad (Incorrect Options) The classic triad includes: 1. **Photophobia (Option A):** Sensitivity to light is often the earliest symptom. 2. **Hyperlacrimation/Epiphora (Option C):** Excessive tearing occurs due to corneal irritation. 3. **Blepharospasm (Option D):** Involuntary squeezing of the eyelids. These three symptoms occur because the elevated intraocular pressure (IOP) causes stretching of the corneal endothelium and subsequent corneal edema, which irritates the corneal nerve endings. ### Clinical Pearls for NEET-PG * **Buphthalmos:** Occurs because the infant's sclera and cornea are elastic and distend when IOP is >21 mmHg. This is typically seen in children under the age of 3. * **Haab’s Striae:** These are horizontal or curvilinear breaks in the **Descemet’s membrane** due to corneal stretching. They are a pathognomonic sign. * **Large Corneal Diameter:** A diameter >12 mm in an infant is highly suggestive of glaucoma (normal is ~10–10.5 mm). * **Management:** Unlike adult glaucoma, the primary treatment for congenital glaucoma is **surgical** (Goniotomy or Trabeculotomy). Medical therapy is only a temporary measure.

Q: Glaucoma associated with intraocular tumors is due to which of the following mechanisms?

All the above. Secondary glaucoma is a common complication of intraocular tumors (such as Uveal Melanoma or Retinoblastoma). The elevation in intraocular pressure (IOP) is **multifactorial**, involving both open-angle and closed-angle mechanisms. **Explanation of Mechanisms:** * **A. Trabecular block by tumor cells:** This is a common mechanism where the tumor directly sheds cells into the aqueous humor. These cells, along with tumor-associated macrophages (melanomalytic glaucoma) or necrotic debris, physically obstruct the trabecular meshwork, reducing aqueous outflow. * **B. Neovascularization of the angle:** Large or necrotic tumors often release pro-angiogenic factors (like VEGF) due to ischemia. This leads to the formation of a fibrovascular membrane over the angle (Neovascular Glaucoma), which contracts and causes synechial angle closure. * **C. Venous stasis following obstruction to vortex veins:** Large posterior segment tumors can physically compress the vortex veins. This leads to increased venous pressure, congestion of the uveal tract, and subsequent displacement of the lens-iris diaphragm forward, causing secondary angle-closure glaucoma. **Why "All the above" is correct:** Intraocular tumors do not rely on a single pathway; they can cause glaucoma through direct infiltration, biochemical signaling (VEGF), or mechanical displacement/compression. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause** of glaucoma in a child with Retinoblastoma is **neovascularization of the iris (Rubeosis Iridis)**. * **Ring Melanoma** is a specific variant of ciliary body melanoma that classically presents with refractory glaucoma due to circumferential infiltration of the angle. * In any adult presenting with **unilateral** unexplained glaucoma and a masked fundus, always perform an **ultrasound (B-scan)** to rule out an underlying intraocular malignancy.

Q: All of the following can precipitate an attack of narrow-angle glaucoma except:

Prolonged work in bright light. ### Explanation The fundamental mechanism behind **Acute Angle-Closure Glaucoma (AACG)** is the narrowing of the iridocorneal angle, which leads to pupillary block and a sudden rise in intraocular pressure (IOP). **Why "Prolonged work in bright light" is the correct answer:** Bright light triggers the **pupillary light reflex**, causing **miosis** (constriction of the pupil). Miosis pulls the peripheral iris away from the trabecular meshwork, thereby opening the angle and reducing the risk of an attack. In fact, miotics like Pilocarpine are used therapeutically to manage AACG. **Why the other options are wrong:** * **Mydriatics (B):** Drugs that cause mydriasis (dilation) result in a "bunched up" peripheral iris that blocks the drainage angle. Mid-dilatation is the most dangerous position as it maximizes contact between the iris and the lens (pupillary block). * **Prolonged prone position (A):** Staying in a face-down position for a long duration causes the lens to shift forward due to gravity. This increases iridolenticular contact, promoting pupillary block and shallowing the anterior chamber. * **Emotional upsets (D):** Strong emotions trigger a sympathetic surge, leading to **mydriasis**. This physiological dilation can precipitate an attack in predisposed individuals with narrow angles. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Hypermetropia (small eyes), shallow anterior chambers, and increasing age (enlarging lens). * **Classic Presentation:** Sudden ocular pain, "halos" around lights (due to corneal edema), and a semi-dilated, non-reactive pupil. * **Drug of Choice (Immediate):** IV Acetazolamide to lower IOP. * **Definitive Treatment:** Peripheral Iridotomy (usually via YAG laser) to create a bypass for aqueous humor.

Q: Increased intraocular tension can be diagnosed by?

Tonometer. **Explanation:** **Correct Answer: A. Tonometer** Intraocular pressure (IOP) is the fluid pressure within the eye, maintained by the balance between aqueous humor production and drainage. **Tonometry** is the objective method used to measure this pressure. The Goldmann Applanation Tonometer (GAT) is considered the "Gold Standard" for measuring IOP, operating on the Imbert-Fick principle ($P = F/A$). Other types include the Schiotz tonometer (indentation), Non-contact tonometer (air-puff), and Tonopen. **Why the other options are incorrect:** * **B. Pachymeter:** This device measures **corneal thickness**. While central corneal thickness (CCT) is crucial for adjusting tonometer readings (thicker corneas give falsely high IOP), the pachymeter itself does not measure tension. * **C. Placido’s Disc:** This is used to assess the **regularity of the anterior corneal surface**. It helps in the qualitative diagnosis of corneal irregularities and astigmatism by reflecting concentric rings onto the cornea. * **D. Keratometer:** This instrument measures the **curvature of the anterior corneal surface**. It is primarily used to calculate the power of intraocular lenses (IOL) and to prescribe contact lenses. **High-Yield Clinical Pearls for NEET-PG:** * **Normal IOP:** 10–21 mmHg. * **Gold Standard:** Goldmann Applanation Tonometry (GAT). * **Schiotz Tonometry:** Based on the principle of indentation; it is portable but less accurate due to variations in scleral rigidity. * **Diurnal Variation:** IOP is usually highest in the early morning; a variation of >8 mmHg is suggestive of glaucoma. * **Correction Factor:** For every 50 $\mu$m deviation from a standard CCT (approx. 540 $\mu$m), the IOP reading changes by roughly 2.5–3 mmHg.

Question 1

A 66-year-old patient presents to the emergency department with sudden onset of severe pain and blurred vision in the right eye. Examination reveals decreased visual acuity with a shallow and hazy cornea in the affected eye. The eye has a stony hard consistency. What is the likely diagnosis?

Accepted Answer

Glaucoma

Answer

Keratitis

Answer

Uveitis

Answer

Conjunctivitis

Question 2

In an acute attack of glaucoma, which of the following is excluded from Vogt's triad?

Accepted Answer

Pigment dispersal

Answer

Iris atrophy

Answer

Goniosynechiae

Answer

Glaucoma floaters

Question 3

Which of the following is true about Buphthalmos?

Accepted Answer

Large cornea

Answer

Haab's striae

Answer

Shallow anterior chamber

Answer

Glaucoma

Question 4

Which retinal nerve fibres are most sensitive to glaucomatous damage?

Accepted Answer

Superior and inferior arcuate fibres

Answer

Macular fibres

Answer

Superior radiating fibres

Answer

Inferior radiating fibres

Question 5

In acute congestive glaucoma, what is the typical pupil appearance?

Accepted Answer

Oval and vertical

Answer

Oval and horizontal

Answer

Circular

Answer

Slit-like

Question 6

An elderly male with a history of glaucoma presents with a bulging cornea on examination. What is the most likely diagnosis?

Accepted Answer

Staphyloma

Answer

Keratoconus

Answer

Glaucomatous iridocyclitis

Answer

Keratomalacia

Question 7

Which of the following is NOT a triad of congenital glaucoma?

Accepted Answer

Buphthalmos

Answer

Photophobia

Answer

Hyperlacrimation

Answer

Blepharospasm

Question 8

Glaucoma associated with intraocular tumors is due to which of the following mechanisms?

Accepted Answer

All the above

Answer

Trabecular block by tumor cells

Answer

Neovascularization of the angle

Answer

Venous stasis following obstruction to vortex veins

Question 9

All of the following can precipitate an attack of narrow-angle glaucoma except:

Accepted Answer

Prolonged work in bright light

Answer

Prolonged prone position

Answer

Mydriatics

Answer

Emotional upsets

Question 10

Increased intraocular tension can be diagnosed by?

Accepted Answer

Tonometer

Answer

Pachymeter

Answer

Placido's disc

Answer

Keratometer

Glaucoma — MCQs

Glaucoma — MCQs

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