Primary Angle-Closure Glaucoma — MCQs
Pilocarpine is used in all of the following except:
Select the diuretic that is most effective in acute angle-closure glaucoma.
Sudden painful loss of vision seen in
Sudden loss of vision without pain - Which of the following is NOT a cause?
Which of the following statements is false about phacolytic glaucoma?
Vogt's triad is indicative of:
Which of the following is most likely to cause bilateral angle closure glaucoma?
Intumescent cataract is associated with which type of glaucoma?
A patient presents with eye ache and difficulty in vision after watching a movie. What will be the first line of management?
Which of the following statements regarding glaucoma and its management is true?
Primary Angle-Closure Glaucoma Indian Medical PG Practice Questions and MCQs
Question 1: Pilocarpine is used in all of the following except:
- A. Primary, Open Angle Glaucoma
- B. Acute Angle Closure Glaucoma
- C. Malignant Glaucoma (Correct Answer)
- D. Chronic Synechial Angle Closure Glaucoma
Explanation: ***Malignant Glaucoma*** - **Pilocarpine** is contraindicated in **malignant glaucoma** because it can worsen the condition by causing **ciliary body edema** and anterior displacement of the lens-iris diaphragm. - This form of glaucoma requires treatment aimed at posterior displacement of the lens-iris diaphragm, often involving **cycloplegics**, **hyperosmotic agents**, or surgical interventions. *Primary, Open Angle Glaucoma* - **Pilocarpine** is an effective **miotic agent** that increases aqueous humor outflow through the **trabecular meshwork**, thereby lowering intraocular pressure. - It can be used as a treatment for **primary open-angle glaucoma**, although it is less commonly used due to its side effects and the availability of better-tolerated medications. *Acute Angle Closure Glaucoma* - **Pilocarpine** is typically used in the management of **acute angle-closure glaucoma** after the intraocular pressure has been acutely lowered by other agents. - It works by inducing **miosis**, which pulls the iris away from the **trabecular meshwork**, opening the angle and facilitating aqueous outflow. *Chronic Synechial Angle Closure Glaucoma* - In **chronic synechial angle-closure glaucoma**, **pilocarpine** can be used to break or prevent the formation of new **peripheral anterior synechiae** by constricting the pupil. - However, its effectiveness is limited if extensive synechiae have already formed, as these physically block the outflow pathway.
Question 2: Select the diuretic that is most effective in acute angle-closure glaucoma.
- A. Furosemide
- B. Amiloride
- C. Indapamide
- D. Mannitol (Correct Answer)
Explanation: ***Mannitol*** - **Mannitol** is an osmotic diuretic that creates an osmotic gradient, drawing fluid from the eye into the bloodstream, thereby **rapidly reducing intraocular pressure (IOP)**. - Its quick onset of action and potent IOP-lowering effect make it the **drug of choice for acute angle-closure glaucoma** when rapid pressure reduction is critical. *Furosemide* - **Furosemide** is a loop diuretic that primarily acts on the renal tubules to increase urine output, with **minimal direct effect on intraocular pressure**. - While it can lower systemic blood pressure, its efficacy in **rapidly reducing elevated IOP in acute glaucoma is limited** compared to osmotic agents. *Amiloride* - **Amiloride** is a potassium-sparing diuretic that works in the collecting ducts of the kidneys and is primarily used for **hypertension and heart failure**, often in combination with other diuretics. - It does not have a significant or rapid effect on **intraocular pressure**, making it ineffective for acute angle-closure glaucoma. *Indapamide* - **Indapamide** is a thiazide-like diuretic that acts on the distal convoluted tubule and is primarily used for the treatment of **hypertension and edema**. - It has a slower onset of action and **does not effectively reduce intraocular pressure** in acute settings, making it unsuitable for acute angle-closure glaucoma.
Question 3: Sudden painful loss of vision seen in
- A. Angle closure glaucoma (Correct Answer)
- B. Endophthalmitis
- C. Acute uveitis
- D. Central retinal artery occlusion
Explanation: ***Angle closure glaucoma*** - This is the **classic presentation** of sudden, painful vision loss in ophthalmology - Characterized by **acute increase in intraocular pressure** (often >40 mmHg) causing severe eye pain, headache, nausea, and vomiting - Vision loss is rapid due to damage to the **optic nerve** and corneal edema - The pain is intense and sharp due to stretching of ocular structures - **Key distinguishing feature**: Mid-dilated fixed pupil, corneal edema, shallow anterior chamber *Endophthalmitis* - Also causes **sudden painful vision loss** and is a sight-threatening emergency - Pain is severe with rapid onset of vision loss, redness, and hypopyon - **Differentiating features**: History of recent ocular surgery, trauma, or intravitreal injection; presence of hypopyon (layered pus in anterior chamber) - While both can present similarly, endophthalmitis typically has **obvious intraocular inflammation** and relevant preceding history *Acute uveitis* - Presents with **ocular pain**, **redness**, **photophobia**, and blurred vision - Vision loss is usually **gradual**, not sudden and complete - Pain is moderate, described as dull aching rather than severe acute pain - Rarely causes sudden severe vision loss unless complicated *Central retinal artery occlusion* - Causes **sudden, painless loss of vision** - this is the key distinguishing feature - Described as "curtain coming down" or sudden blackout of vision - **Absence of pain** differentiates it from acute angle-closure glaucoma - Cherry-red spot on fundoscopy is pathognomonic
Question 4: Sudden loss of vision without pain - Which of the following is NOT a cause?
- A. CRAO
- B. CSR
- C. Acute congestive glaucoma (Correct Answer)
- D. Vitreous Hemorrhage
Explanation: ***Acute congestive glaucoma*** - This condition is characterized by **sudden, severe eye pain** along with blurred vision, redness, and a fixed, mid-dilated pupil. - The pain arises from abrupt elevation of **intraocular pressure**, which differentiates it from painless vision loss. *CRAO* - **Central Retinal Artery Occlusion** (CRAO) typically presents as **sudden, profound, painless monocular vision loss**. - Funduscopic examination often reveals a **cherry-red spot** in the fovea with generalized retinal whitening. *CSR* - **Central Serous Retinopathy** (CSR) causes **sudden, painless blurred vision** or a scotoma, often described as a "watery" or "shimmering" effect. - It involves leakage of fluid under the retina, typically in the macula. *Vitreous Hemorrhage* - Presents as **sudden, painless loss of vision** or a shower of floaters, often described as cobwebs or clouds. - It results from bleeding into the **vitreous cavity**, which can obscure the retina.
Question 5: Which of the following statements is false about phacolytic glaucoma?
- A. Open angle glaucoma
- B. Lens induced glaucoma
- C. Primarily caused by iris-lens contact (Correct Answer)
- D. Seen in hypermature stage of cataract
Explanation: ***Primarily caused by iris-lens contact*** - This statement is **FALSE** because **phacolytic glaucoma** is caused by the leakage of **lens proteins** from a **hypermature cataract** into the **anterior chamber**, not by iris-lens contact. - **Iris-lens contact** is the mechanism in **pupillary block glaucoma** and **acute angle-closure glaucoma**, not in phacolytic glaucoma. - The pathophysiology involves **macrophages** engulfing leaked lens proteins and obstructing the **trabecular meshwork**. *Open angle glaucoma* - This statement is true because **phacolytic glaucoma** is definitively an **open-angle glaucoma**. - It involves obstruction of the **trabecular meshwork** by **macrophages** laden with **lens proteins**, which is an open-angle mechanism. - The angle remains anatomically open but functionally blocked. *Seen in hypermature stage of cataract* - This statement is true because **phacolytic glaucoma** develops when the **lens capsule** of a **hypermature (Morgagnian) cataract** becomes permeable. - This permeability allows **high-molecular-weight lens proteins** to leak into the **aqueous humor**. *Lens induced glaucoma* - This statement is true as **phacolytic glaucoma** is a specific type of **lens-induced glaucoma**, arising from the toxic effects of **leaked lens material**. - Other forms of **lens-induced glaucoma** include **phacomorphic glaucoma**, **lens-particle glaucoma**, and **phacoanaphylactic glaucoma**.
Question 6: Vogt's triad is indicative of:
- A. Past attack of acute iridocyclitis
- B. Vogt-Koyanagi-Harada syndrome
- C. Past attack of acute angle-closure glaucoma (Correct Answer)
- D. Past attack of herpes zoster ophthalmicus
Explanation: ***Past attack of acute-angle closure glaucoma*** - Vogt's triad refers to three specific signs observed in the eye after an episode of **acute angle-closure glaucoma**. - The triad includes **glaukomflecken** (anterior subcapsular lens opacities), **iris stromal atrophy**, and **pupil dilation or distortion**. *Vogt-Koyanagi-Harada syndrome* - This is a **multisystem inflammatory disease** primarily affecting pigmented structures, not characterized by Vogt's triad. - It involves **uveitis**, dermatological manifestations (e.g., poliosis, vitiligo), neurological symptoms (e.g., tinnitus, meningitis), and auditory symptoms. *Past attack of acute iridocyclitis* - While iridocyclitis involves **inflammation of the iris and ciliary body**, it does not typically lead to the specific triad of signs seen in Vogt's triad. - Complications of severe iridocyclitis might include synechiae or cataract, but not glaukomflecken or specific iris atrophy described by Vogt. *Past attack of herpes zoster ophthalmicus* - This condition is caused by the **reactivation of the varicella-zoster virus** in the ophthalmic division of the trigeminal nerve. - Ocular manifestations include keratitis, uveitis, and neurotrophic keratopathy, but not the specific changes of Vogt's triad.
Question 7: Which of the following is most likely to cause bilateral angle closure glaucoma?
- A. Sulfonamide medications
- B. Adrenergic agonists
- C. Topiramate (Correct Answer)
- D. Anticholinergic drugs
Explanation: ***Topiramate can cause bilateral angle closure glaucoma*** - **Topiramate** is known to cause a unique form of **bilateral angle closure glaucoma** due to ciliary body edema and anterior displacement of the iris-lens diaphragm, leading to acute myopia and angle closure. - This reaction typically occurs within the first few weeks of starting the drug, is **bilateral**, and is not related to angle anatomy. *Sulfonamide medications* - While some **sulfonamides** can cause acute myopia and secondary angle closure, similar to topiramate, this is a less consistently reported and less recognized association compared to topiramate. - The mechanism involves **ciliary body edema** leading to anterior displacement of the iris-lens diaphragm, but topiramate is a more classic example. *Adrenergic agonists* - **Adrenergic agonists** typically cause **mydriasis** (pupil dilation), which can precipitate acute angle closure in eyes with an already **narrow angle**. - However, they usually trigger **unilateral** angle closure and do not cause the same ciliary body edema mechanism seen with topiramate that results in bilateral involvement. *Anticholinergic drugs* - **Anticholinergic drugs** also cause **mydriasis** and can lead to **acute angle closure glaucoma** by widening the pupil and potentially blocking aqueous outflow in susceptible individuals. - Similar to adrenergic agonists, this is usually a **unilateral** event and does not involve the characteristic ciliary body edema and resultant bilateral acute myopia associated with topiramate.
Question 8: Intumescent cataract is associated with which type of glaucoma?
- A. Phacolytic glaucoma
- B. Phacotopic glaucoma
- C. Pseudophakic glaucoma
- D. Phacomorphic glaucoma (Correct Answer)
Explanation: ***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.
Question 9: A patient presents with eye ache and difficulty in vision after watching a movie. What will be the first line of management?
- A. Mannitol with Moxifloxacin
- B. Mannitol with Atropine
- C. Mannitol with lubricating eye drops
- D. Mannitol with Pilocarpine (Correct Answer)
Explanation: ***Mannitol with Pilocarpine*** - This combination is appropriate for **acute angle-closure glaucoma (AACG)**, which can be triggered by pupillary dilation (e.g., in a dark movie theater). **Mannitol** is an osmotic diuretic that rapidly reduces intraocular pressure. - **Pilocarpine** is a miotic agent that constricts the pupil, pulling the iris away from the trabecular meshwork and opening the drainage angle to facilitate aqueous humor outflow. *Mannitol with Moxifloxacin* - While mannitol helps with intraocular pressure, **Moxifloxacin is an antibiotic** used to treat bacterial infections. - There is no indication of an ocular infection in this scenario, so an antibiotic would not be the first-line treatment for sudden eye pain and vision difficulty after watching a movie. *Mannitol with Atropine* - Adding **Atropine, a cycloplegic agent**, would cause further pupillary dilation, which would worsen acute angle-closure glaucoma and increase intraocular pressure. - Atropine is contraindicated in AACG and would exacerbate the patient's condition. *Mannitol with lubricating eye drops* - While mannitol helps with intraocular pressure, **lubricating eye drops** are used for dry eyes or surface irritation, not for acute angle-closure glaucoma. - Lubricating drops do not address the underlying pathology of increased intraocular pressure due to angle closure.
Question 10: Which of the following statements regarding glaucoma and its management is true?
- A. Latanoprost is used with caution in patients of bronchial asthma
- B. Central scotoma is seen in open angle glaucoma
- C. Topiramate can cause bilateral angle closure glaucoma (Correct Answer)
- D. Methazolamide causes decrease in ocular blood flow
Explanation: ***Topiramate can cause bilateral angle closure glaucoma*** - **Topiramate**, a sulfonamide derivative, can cause acute **myopia** and **ciliary body swelling**, leading to anterior displacement of the lens-iris diaphragm and subsequent **bilateral angle closure glaucoma**. - This adverse effect typically occurs within the first few weeks of starting the drug, and prompt discontinuation can often resolve the condition. *Latanoprost is used with caution in patients of bronchial asthma* - **Latanoprost** is a **prostaglandin analog** and is generally safe for patients with bronchial asthma as it does not affect pulmonary function. - Beta-blockers, rather than latanoprost, are the class of glaucoma medications that require caution in patients with bronchial asthma due to their potential to cause **bronchospasm**. *Central scotoma is seen in open angle glaucoma* - **Central scotoma** is more characteristic of conditions affecting the **macula** or optic nerve pathologies other than typical open-angle glaucoma. - The classic visual field defect in **open-angle glaucoma** is a **paracentral scotoma** or **nasal step**, often progressing to peripheral field loss. *Methazolamide causes decrease in ocular blood flow* - **Methazolamide**, a carbonic anhydrase inhibitor (CAI), primarily acts by reducing aqueous humor production, which can **lower intraocular pressure**. - Although CAIs can cause systemic side effects, they are not known to significantly decrease **ocular blood flow**; in fact, some studies suggest they may even have a mild beneficial effect on optic nerve head blood flow.
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