Glaucoma Practice Questions

Q: A 63-year-old woman presents with a complaint of pain in her right eye. On examination, the pupil is dilated with a hazy cornea. What is the most likely diagnosis?

Acute angle closure glaucoma. **Explanation:** The clinical presentation of **Acute Angle Closure Glaucoma (AACG)** is a classic medical emergency frequently tested in NEET-PG. The diagnosis is based on the triad of sudden ocular pain, a **hazy (edematous) cornea**, and a **vertically oval, semi-dilated, non-reactive pupil**. The haziness is caused by a rapid rise in intraocular pressure (IOP) leading to corneal edema, while the pupil becomes fixed and dilated due to ischemia of the iris sphincter muscle. **Why the other options are incorrect:** * **Scleritis:** Presents with severe, boring pain and deep-seated redness, but the cornea remains clear and the pupil is normal in size and reaction. * **Anterior Uveitis:** Characterized by a **constricted (miotic) pupil** due to ciliary spasm and a clear cornea (though keratic precipitates may be seen on slit-lamp). * **Conjunctivitis:** A painless condition (or mild grittiness) with discharge. The cornea is clear, and the pupil reacts normally to light. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Hypermetropia (small eyes), shallow anterior chamber, and increasing age. * **Symptoms:** Halos around lights (due to corneal edema) and systemic symptoms like nausea/vomiting (often misdiagnosed as an abdominal issue). * **Gold Standard Diagnosis:** Gonioscopy (to visualize the closed angle). * **Immediate Management:** IV Acetazolamide and topical pilocarpine (once IOP drops). * **Definitive Treatment:** Peripheral Iridotomy (PI) – usually performed in both eyes as the fellow eye is at high risk.

Q: Which topical drug can cause Heterochromia Iridis?

Latanoprost. **Explanation:** **Latanoprost** is a Prostaglandin Analogue (PGA) used as a first-line treatment for Open-Angle Glaucoma. It causes **Heterochromia Iridis** (specifically hyperpigmentation) by increasing the production of melanin within the stromal melanocytes of the iris. It is important to note that this occurs due to increased melanogenesis, not an increase in the number of melanocytes (no hyperplasia). This change is usually permanent and most noticeable in individuals with hazel or multicolored eyes. **Analysis of Incorrect Options:** * **Timolol (Option A):** A non-selective beta-blocker. Its primary side effects are systemic (bradycardia, bronchospasm) and local (stinging, dry eye), but it does not affect iris pigmentation. * **Olopatadine (Option B):** An antihistamine and mast cell stabilizer used for allergic conjunctivitis. It has no role in glaucoma management or iris color changes. * **Brimonidine (Option C):** An alpha-2 agonist. Common side effects include follicular conjunctivitis and lethargy (especially in children), but it does not cause heterochromia. **High-Yield Clinical Pearls for NEET-PG:** 1. **PGA Side Effects (Mnemonic: "3 L's"):** **L**ashes (Hypertrichosis/lengthening), **L**ids (Pigmentation of periorbital skin), and **L**iris (Heterochromia). 2. **Prostaglandin-Associated Periorbitopathy (PAP):** PGAs can cause deepening of the upper eyelid sulcus and fat atrophy. 3. **Contraindication:** PGAs should be avoided in **Uveitic Glaucoma** as they are pro-inflammatory and can exacerbate cystoid macular edema (CME).

Q: Glaukomflecken is a feature of which condition?

Acute narrow-angle glaucoma. **Explanation:** **Glaukomflecken** (also known as Vogt’s spots) are small, grayish-white, subepithelial opacities found in the anterior lens capsule. They represent **focal areas of lens epithelial necrosis** caused by a sudden, severe rise in intraocular pressure (IOP). 1. **Why Option A is Correct:** In **Acute Narrow-Angle Glaucoma**, the IOP rises rapidly and significantly (often >60 mmHg). This extreme pressure compromises the metabolic exchange between the aqueous humor and the lens epithelium, leading to localized cell death. These necrotic spots are pathognomonic of a *previous* attack of acute congestive glaucoma. 2. **Why Other Options are Incorrect:** * **Pseudoexfoliative Glaucoma:** Characterized by "dandruff-like" white deposits on the lens capsule and pupillary margin, not focal epithelial necrosis. * **Juvenile Glaucoma:** A form of primary open-angle glaucoma occurring in young individuals; it typically presents with a gradual rise in IOP, which does not cause Glaukomflecken. * **Phacolytic Glaucoma:** A lens-induced glaucoma where proteins leak from a hypermature cataract. While IOP is high, the primary feature is a heavy flare and macrophages in the anterior chamber, not these specific lens opacities. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Post-Acute Attack:** Glaukomflecken, iris atrophy (patchy), and a vertically oval, semi-dilated non-reacting pupil. * **Location:** Always located in the **anterior** subepithelial region of the lens. * **Significance:** Their presence is a "diagnostic footprint" indicating that the patient has suffered a severe acute angle-closure attack in the past, even if the current IOP is normal.

Q: Peripheral iridectomy is indicated in which of the following conditions?

Open angle glaucoma. **Explanation:** **1. Why Open Angle Glaucoma (OAG) is the correct answer:** In the context of this specific question, **Peripheral Iridectomy (PI)** is indicated in Open Angle Glaucoma when it is performed as a prophylactic or preparatory step during a **Trabeculectomy** (filtering surgery). During trabeculectomy, a small piece of the peripheral iris is removed to prevent the iris root from being sucked into the new internal ostium, which would otherwise cause sudden blockage and surgical failure. **2. Why the other options are incorrect:** * **Angle Closure Glaucoma (ACG):** While a hole in the iris is the definitive treatment for ACG, the modern "Gold Standard" is **Laser Peripheral Iridotomy (LPI)**. Surgical Peripheral Iridectomy is now rarely performed and is reserved only for cases where laser treatment is impossible (e.g., hazy cornea or lack of patient cooperation). * **Malignant Glaucoma (Ciliary Block Glaucoma):** This is a posterior segment problem where aqueous is misdirected into the vitreous. The treatment involves cycloplegics, vitreous aspiration, or vitrectomy. A simple iridectomy does not resolve the underlying ciliary block. **High-Yield Clinical Pearls for NEET-PG:** * **Laser vs. Surgical:** Always remember: **LPI** is for Angle Closure; **Surgical PI** is a component of Trabeculectomy (OAG). * **Mechanism:** The primary goal of PI in ACG is to bypass **pupillary block** by equalizing pressure between the posterior and anterior chambers. * **Triple Procedure:** PI is also performed during a "Triple Procedure" (Cataract extraction + IOL + Trabeculectomy). * **YAG Laser:** The most common laser used for Iridotomy is the Nd:YAG laser.

Q: Which of the following is NOT a treatment for acute congestive glaucoma?

Trabeculoplasty. In **Acute Congestive Glaucoma** (Acute Angle Closure), the primary pathology is a sudden, total mechanical obstruction of the drainage angle by the iris. The goal of treatment is to rapidly lower intraocular pressure (IOP) and physically open the angle. ### Why Trabeculoplasty is the Correct Answer **Trabeculoplasty** (specifically Argon Laser Trabeculoplasty or ALT) is used in **Open Angle Glaucoma**. It involves applying laser burns to the trabecular meshwork to increase outflow. In acute congestive glaucoma, the angle is physically closed (the iris is touching the cornea), making the trabecular meshwork **invisible and inaccessible** to the laser. Therefore, it is contraindicated and ineffective in an acute attack. ### Analysis of Other Options * **Sclerectomy:** This is a type of filtering surgery where a portion of the sclera is removed to create a new drainage channel. While not the first-line treatment, it is a surgical option for refractory cases. * **Trabeculectomy:** This is the "gold standard" filtering surgery. It is performed in acute glaucoma if medical management and peripheral iridotomy fail to control the IOP. ### NEET-PG High-Yield Pearls * **Immediate Management:** The first step is medical—**IV Mannitol** (osmotic diuretic) and **Acetazolamide** to rapidly lower IOP, followed by topical Pilocarpine (once IOP <40 mmHg) to pull the iris away from the angle. * **Definitive Treatment:** **Laser Peripheral Iridotomy (LPI)** is the treatment of choice for both the affected eye and the fellow (prophylactic) eye. * **The "Mid-Dilated Pupil":** A vertically oval, non-reactive, mid-dilated pupil is a classic clinical sign of an acute attack. * **Trabeculoplasty vs. Iridotomy:** Remember, *Trabeculoplasty* is for Open Angle; *Iridotomy* is for Closed Angle.

Q: Which of the following is NOT a feature of absolute angle closure glaucoma?

Phthisis. ### **Explanation: Absolute Angle Closure Glaucoma** Absolute glaucoma is the final, end-stage stage of primary angle-closure glaucoma where the eye has **no light perception (NLP)**. It is characterized by a chronically high Intraocular Pressure (IOP) that leads to irreversible damage. **Why Option D (Phthisis) is the Correct Answer:** Phthisis bulbi refers to a shrunken, non-functional eye with **low intraocular pressure (hypotony)**, usually resulting from ciliary body failure. In contrast, absolute glaucoma is defined by a **stony hard eye** due to severely **elevated IOP**. While an absolute glaucomatous eye may eventually degenerate, phthisis is not a feature of the "absolute stage" itself; rather, it is a separate pathological end-point. **Analysis of Incorrect Options:** * **A. Painful blind eye:** This is the hallmark of absolute glaucoma. The extremely high IOP causes chronic congestion and nerve irritation, leading to severe ocular pain. * **B. Bullous keratopathy:** Persistent high IOP damages the corneal endothelial pump, leading to chronic corneal edema. This results in the formation of epithelial vesicles and bullae (bullous keratopathy), which can rupture and cause further pain. * **C. Atrophic iris:** Long-standing high pressure causes ischemia of the iris tissue, leading to iris atrophy, a fixed dilated pupil, and sometimes ectropion uveae. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** The eye is "stony hard" on digital palpation. * **Optic Disc:** Shows total **glaucomatous cupping** (Cup-Disc Ratio of 1.0). * **Management Goal:** The focus is on **pain relief**, not vision restoration. Modalities include cyclodestructive procedures (e.g., Diode Laser Cyclophotocoagulation), retrobulbar alcohol injections, or enucleation if pain is intractable. * **Distinction:** Absolute Glaucoma = High IOP; Phthisis Bulbi = Low IOP.

Q: A middle-aged patient is referred to rule out open angle glaucoma. Which of the following findings will help in the diagnosis?

Cupping of the optic disc. **Explanation:** Primary Open-Angle Glaucoma (POAG) is a chronic, progressive optic neuropathy characterized by specific morphological changes in the optic nerve head and corresponding visual field defects, occurring in the presence of an open iridocorneal angle. **Why Option A is Correct:** **Cupping of the optic disc** is a hallmark structural sign of glaucomatous damage. It occurs due to the loss of the neuroretinal rim and the backward bowing of the lamina cribrosa. In the diagnosis of POAG, identifying structural damage (pathological cupping, such as a cup-disc ratio >0.7 or asymmetry >0.2) and functional loss (visual field defects) is essential, as Intraocular Pressure (IOP) alone is no longer the sole diagnostic criterion. **Why Other Options are Incorrect:** * **Option B & D:** The **depth and angle of the anterior chamber** are used to *classify* the type of glaucoma (Open-angle vs. Angle-closure) rather than diagnose the presence of the disease itself. In POAG, the angle must be open (Grade 3 or 4 on Shaffer’s grading) and the chamber depth is typically normal. * **Option C:** **Visual acuity** is usually preserved until the very late stages of POAG. While high myopia is a risk factor for POAG, refractive error is not a diagnostic finding for the disease. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign:** The earliest clinical sign of POAG is often an increase in the **Cup-Disc Ratio (CDR)** or focal thinning of the neuroretinal rim (ISNT rule violation). * **Gold Standard for Angle:** **Gonioscopy** is the gold standard to differentiate between open and closed angles. * **Gold Standard for IOP:** **Goldmann Applanation Tonometry (GAT)**. * **Earliest Visual Field Defect:** Small isolated paracentral scotomas (specifically, the **Baring of the Blind Spot** is often cited as an early sign, though **Siedel’s scotoma** is the first clinically significant functional defect).

Q: What is the drug of choice for the treatment of an acute attack of primary angle-closure glaucoma?

Pilocarpine. **Explanation:** Primary Angle-Closure Glaucoma (PACG) is a medical emergency characterized by a sudden rise in intraocular pressure (IOP) due to the apposition of the iris against the trabecular meshwork. **Why Pilocarpine is the Correct Answer:** Pilocarpine, a direct-acting miotic, is the definitive pharmacological treatment for an acute attack. It causes **miosis** (contraction of the sphincter pupillae), which pulls the peripheral iris away from the trabecular meshwork, thereby "opening" the angle and allowing aqueous humor to drain. *Note:* In very high IOP (>40-50 mmHg), the iris sphincter becomes ischemic and unresponsive to pilocarpine. Therefore, IOP must often be lowered initially with systemic agents before pilocarpine becomes effective. **Analysis of Incorrect Options:** * **Mannitol (A):** An osmotic diuretic used to rapidly reduce IOP by dehydrating the vitreous. While highly effective for immediate pressure reduction, it does not address the underlying anatomical closure of the angle. * **Latanoprost (B):** A Prostaglandin analogue used as the first-line treatment for *Open-Angle Glaucoma*. It is generally avoided in acute angle closure as it may worsen inflammation and takes 24 hours to reach peak effect. * **Acetazolamide (D):** A carbonic anhydrase inhibitor that decreases aqueous production. It is used as an initial systemic adjunct to lower IOP but is not the definitive drug to reverse the mechanical angle closure. **High-Yield Clinical Pearls for NEET-PG:** * **Definitive Treatment:** The gold standard definitive management for PACG is **Peripheral Iridotomy (Laser or Surgical)** to prevent recurrence. * **The "Mid-Dilated" Pupil:** An acute attack typically presents with a vertically oval, non-reactive, mid-dilated pupil. * **Avoid Atropine:** Mydriatics are strictly contraindicated as they further crowd the angle and can precipitate an attack.

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

Acetazolamide. **Explanation:** Acute Angle-Closure Glaucoma (AACG) is an ophthalmic emergency characterized by a sudden rise in intraocular pressure (IOP) due to the blockage of aqueous humor outflow. **Why Acetazolamide is the Correct Answer:** Acetazolamide, a potent **Carbonic Anhydrase Inhibitor (CAI)**, is the first-line systemic treatment for the immediate management of AACG. It works by inhibiting the enzyme carbonic anhydrase in the ciliary body, which rapidly decreases the production of aqueous humor. In an emergency, it is typically administered intravenously (or orally) to lower IOP quickly before definitive surgical or laser treatment (like peripheral iridotomy) can be performed. **Analysis of Incorrect Options:** * **Physostigmine:** While miotics (like Pilocarpine) are used in glaucoma to pull the iris away from the angle, Physostigmine is a reversible anticholinesterase not typically used as a first-line agent for acute closure. Furthermore, miotics are often ineffective until the IOP is first lowered by CAIs. * **Brimonidine:** This is an alpha-2 agonist used primarily in chronic open-angle glaucoma or as an adjunctive therapy. It is not the primary drug for an acute emergency. * **Atropine:** This is **contraindicated**. As a mydriatic (dilator), it causes the iris to bunch up in the drainage angle, further obstructing outflow and potentially precipitating or worsening an attack of angle-closure glaucoma. **Clinical Pearls for NEET-PG:** * **Definitive Treatment:** The definitive treatment for AACG is **Laser Peripheral Iridotomy**. * **Hyperosmotics:** Intravenous **Mannitol** is another emergency agent used if IOP does not respond to Acetazolamide. * **Side Effects:** Watch for hypokalemia, metabolic acidosis, and paresthesia with Acetazolamide use. * **Avoid Mydriatics:** Always remember that drugs with anticholinergic properties (like Atropine or TCAs) can trigger AACG in predisposed individuals with narrow angles.

Question 1

A 63-year-old woman presents with a complaint of pain in her right eye. On examination, the pupil is dilated with a hazy cornea. What is the most likely diagnosis?

Accepted Answer

Acute angle closure glaucoma

Answer

Scleritis

Answer

Anterior uveitis

Answer

Conjunctivitis

Question 2

Which topical drug can cause Heterochromia Iridis?

Accepted Answer

Latanoprost

Answer

Timolol

Answer

Olopatadine

Answer

Brimonidine

Question 3

Glaukomflecken is a feature of which condition?

Accepted Answer

Acute narrow-angle glaucoma

Answer

Pseudoexfoliative glaucoma

Answer

Juvenile glaucoma

Answer

Phacolytic glaucoma

Question 4

Peripheral iridectomy is indicated in which of the following conditions?

Accepted Answer

Open angle glaucoma

Answer

Angle closure glaucoma

Answer

Malignant glaucoma

Answer

All of the above

Question 5

Which of the following is NOT a treatment for acute congestive glaucoma?

Accepted Answer

Trabeculoplasty

Answer

Sclerectomy

Answer

Trabeculectomy

Answer

All of the above

Question 6

Which of the following is NOT a feature of absolute angle closure glaucoma?

Accepted Answer

Phthisis

Answer

Painful blind eye

Answer

Bullous keratopathy

Answer

Atrophic iris

Question 7

A middle-aged patient is referred to rule out open angle glaucoma. Which of the following findings will help in the diagnosis?

Accepted Answer

Cupping of the optic disc

Answer

Depth of the anterior chamber

Answer

Visual acuity and refractive error

Answer

Angle of the anterior chamber

Question 8

What is the drug of choice for the treatment of an acute attack of primary angle-closure glaucoma?

Accepted Answer

Pilocarpine

Answer

Mannitol

Answer

Latanoprost

Answer

Acetazolamide

Question 9

What is the definitive treatment for primary angle closure glaucoma?

Accepted Answer

Iridectomy

Answer

Trabeculectomy

Answer

Pilocarpine

Answer

Timolol

Question 10

What is the first-line drug for angle closure glaucoma?

Accepted Answer

Acetazolamide

Answer

Physostigmine

Answer

Brimonidine

Answer

Atropine

Glaucoma — MCQs

Glaucoma — MCQs

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