Antiglaucoma Medications — MCQs
Which of the following antiglaucoma medications can cause drowsiness?
You are in the eye OPD and wish to use a topical Beta blocker in a patient. The chosen drug by you should have all the following properties except
Which drug for glaucoma can cause heterochromia iridis?
A patient presents with eye ache and difficulty in vision after watching a movie. What will be the first line of management?
Cardioselective β-blocker used in glaucoma?
A 58-year-old male presents with gradual loss of peripheral vision in both eyes. On fundus examination, significant cupping of the optic disc and arcuate scotomas were noted. IOP was 28 mmHg. Based on these findings, which pathway is most likely affected in this patient’s disease?
A patient has been diagnosed with Primary Open Angle Glaucoma (POAG). On eliciting history, it is observed that the patient is a known case of bronchial asthma. What is the drug of choice for POAG in this patient?
Which of the following is most likely to cause bilateral angle closure glaucoma?
Which triad is seen after an acute attack of angle-closure glaucoma?
The type of iridectomy shown in the image is:
Antiglaucoma Medications Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following antiglaucoma medications can cause drowsiness?
- A. Brimonidine (Correct Answer)
- B. Latanoprost
- C. Dorzolamide
- D. Timolol
Explanation: ***Brimonidine*** - **Brimonidine** is an **alpha-2 adrenergic agonist** [1] that can cause central nervous system depression, leading to side effects such as **drowsiness** and fatigue. - This systemic side effect is more common with the topical ophthalmic formulation due to systemic absorption. *Latanoprost* - **Latanoprost** is a **prostaglandin analog** that primarily works by increasing uveoscleral outflow, and its side effects are mainly localized to the eye (e.g., iris color change, eyelash growth). - It does not typically cause systemic side effects like drowsiness because its systemic absorption is minimal. *Dorzolamide* - **Dorzolamide** is a **topical carbonic anhydrase inhibitor** [1] that reduces aqueous humor production, and its most common side effects include local ocular irritation and a bitter taste. - While systemic carbonic anhydrase inhibitors can cause fatigue and drowsiness, the topical formulation has very limited systemic absorption, making drowsiness uncommon. *Timolol* - **Timolol** is a **non-selective beta-blocker** [1] that reduces aqueous humor production and can cause systemic side effects such as bradycardia, bronchospasm, and hypotension. - While some beta-blockers can cause fatigue, **drowsiness** as a prominent side effect is less common compared to alpha-2 agonists.
Question 2: You are in the eye OPD and wish to use a topical Beta blocker in a patient. The chosen drug by you should have all the following properties except
- A. High ocular capture
- B. High lipophilicity
- C. Low Systemic activity
- D. Strong local anaesthetic activity (Correct Answer)
Explanation: ***Strong local anaesthetic activity*** - Topical beta blockers for glaucoma should **not possess significant local anesthetic activity** as this property is not related to their mechanism of action in lowering intraocular pressure and could lead to unwanted corneal effects or masking of pain. - Their primary role is to **reduce aqueous humor production** by blocking beta-adrenergic receptors on the ciliary epithelium. *High ocular capture* - **High ocular capture** (good penetration into the eye) is a desirable property for topical eye medications, ensuring sufficient drug concentration at the target tissues (e.g., ciliary body) to exert its therapeutic effect. - This property allows the drug to effectively inhibit aqueous humor production and **lower intraocular pressure**. *High lipophilicity* - **High lipophilicity** is beneficial for topical ophthalmic drugs as it enhances their ability to **cross lipid-rich corneal barriers** and reach the aqueous humor and ciliary body. - This property contributes to improved drug penetration and overall **ocular bioavailability**. *Low Systemic activity* - **Low systemic activity** is a crucial characteristic for topical ophthalmic drugs, especially beta blockers, to minimize systemic side effects such as **bradycardia**, **bronchospasm**, or **hypotension**. - Systemic absorption is reduced by limiting drug access to the general circulation, for example, by **nasolacrimal occlusion**.
Question 3: Which drug for glaucoma can cause heterochromia iridis?
- A. Latanoprost (Correct Answer)
- B. Dorzolamide
- C. Brimonidine
- D. Timolol
Explanation: ***Latanoprost*** - **Latanoprost** is a **prostaglandin analog** commonly used to treat glaucoma by increasing uveoscleral outflow. - A well-known side effect of latanoprost, and other prostaglandin analogs, is **heterochromia iridis**, which is a gradual change in eye color, typically making blue or green eyes turn brown. *Dorzolamide* - **Dorzolamide** is a **carbonic anhydrase inhibitor** that reduces aqueous humor production. - It does not cause heterochromia; common side effects include ocular burning, stinging, and blurred vision. *Brimonidine* - **Brimonidine** is an **alpha-2 adrenergic agonist** that decreases aqueous humor production and increases uveoscleral outflow. - While effective for glaucoma, it does not lead to changes in iris pigmentation. *Timolol* - **Timolol** is a **beta-blocker** used as an ophthalmic solution that works by reducing the production of aqueous humor. - Common side effects include dry eyes and ocular discomfort, but it is not associated with heterochromia.
Question 4: 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 5: Cardioselective β-blocker used in glaucoma?
- A. Timolol
- B. Betaxolol (Correct Answer)
- C. Acebutalol
- D. Carvedilol
Explanation: ***Betaxolol*** - **Betaxolol** is a **cardioselective β1-adrenergic receptor blocker** that reduces aqueous humor production, making it suitable for glaucoma patients, especially those with pulmonary disease. - Its **selectivity for β1 receptors** minimizes systemic side effects on the lungs (bronchoconstriction) compared to non-selective β-blockers. *Timolol* - **Timolol** is a **non-selective β-blocker** commonly used in glaucoma to reduce intraocular pressure. - It blocks both **β1 and β2 receptors**, which can lead to systemic side effects like bronchoconstriction and bradycardia, making it less suitable for patients with **asthma or COPD**. *Acebutalol* - **Acebutalol** is a **cardioselective β1-blocker** with **intrinsic sympathomimetic activity (ISA)**, primarily used for hypertension and arrhythmias. - While cardioselective, it is **not commonly formulated or indicated for topical ocular use** in glaucoma. *Carvedilol* - **Carvedilol** is a **non-selective β-blocker** with **alpha-1 adrenergic blocking activity**, primarily used for heart failure and hypertension. - It is **not used for glaucoma** as it is not formulated for topical ophthalmic application and its systemic effects are not ideal for this purpose.
Question 6: A 58-year-old male presents with gradual loss of peripheral vision in both eyes. On fundus examination, significant cupping of the optic disc and arcuate scotomas were noted. IOP was 28 mmHg. Based on these findings, which pathway is most likely affected in this patient’s disease?
- A. Increased aqueous humor production
- B. Retinal ganglion cell apoptosis (Correct Answer)
- C. Retinal detachment
- D. Phototransduction in rods and cones
Explanation: ***Retinal ganglion cell apoptosis*** - This is the **fundamental pathway** affected in glaucoma and directly explains all the clinical findings in this patient. - The patient's **peripheral vision loss**, **optic disc cupping**, and **arcuate scotomas** all result from progressive **death of retinal ganglion cells (RGCs)** and their axons. - In **primary open-angle glaucoma**, sustained elevated IOP (28 mmHg in this case) causes **mechanical compression** and **ischemic injury** at the optic nerve head, triggering RGC apoptosis. - Loss of RGC axons creates the characteristic **optic disc cupping** and **nerve fiber bundle defects** (arcuate scotomas), leading to irreversible vision loss. *Increased aqueous humor production* - While aqueous humor dynamics are involved in glaucoma pathophysiology, the primary issue is **impaired trabecular outflow**, not increased production. - Increased production alone would elevate IOP but does not explain the specific **RGC damage pattern**, optic disc cupping, or arcuate scotomas seen in this patient. - This addresses the mechanism of elevated IOP, not the pathway of vision loss. *Retinal detachment* - Retinal detachment presents with **sudden onset** symptoms like **photopsia (flashes)**, **floaters**, and a **curtain-like visual field defect**, not gradual peripheral vision loss. - Fundoscopy would show a **detached, elevated retina**, not the optic disc cupping and arcuate scotomas characteristic of glaucoma. - This condition involves separation of the neurosensory retina from the retinal pigment epithelium, not RGC damage. *Phototransduction in rods and cones* - Phototransduction abnormalities affect **photoreceptor cells** (rods and cones), seen in conditions like **retinitis pigmentosa** or **cone-rod dystrophies**. - These conditions present with **night blindness**, **tunnel vision** (from peripheral rod loss), or **central vision loss** (from cone dysfunction), and do not cause elevated IOP or optic disc cupping. - The patient's elevated IOP and specific glaucomatous findings indicate damage to **ganglion cells**, not photoreceptors.
Question 7: A patient has been diagnosed with Primary Open Angle Glaucoma (POAG). On eliciting history, it is observed that the patient is a known case of bronchial asthma. What is the drug of choice for POAG in this patient?
- A. Gemeprost
- B. Alprostadil
- C. Latanoprost (Correct Answer)
- D. Carboprost
Explanation: ***Latanoprost*** - **Latanoprost** is a **prostaglandin analog** and is considered a **first-line drug of choice** for POAG due to its excellent efficacy and tolerability profile, especially in patients with **bronchial asthma**. - It works by increasing the **uveoscleral outflow** of aqueous humor, thus lowering **intraocular pressure** without causing systemic effects like bronchoconstriction. *Gemeprost* - **Gemeprost** is a **prostaglandin E1 analog** primarily used for **cervical ripening** and **abortion**, not for glaucoma treatment. - It has no role in managing **intraocular pressure** and would be an inappropriate choice for POAG. *Alprostadil* - **Alprostadil** is another **prostaglandin E1 analog** used for **erectile dysfunction** and maintaining **patency of the ductus arteriosus** in neonates. - It does not lower **intraocular pressure** and is not indicated for the treatment of glaucoma. *Carboprost* - **Carboprost** is a **prostaglandin F2α analog** mainly used to **manage postpartum hemorrhage** due to its potent uterotonic effects. - While it is a prostaglandin, it is not used in the treatment of glaucoma and has significant systemic side effects.
Question 8: 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 9: Which triad is seen after an acute attack of angle-closure glaucoma?
- A. Gaucher triad
- B. Virchow triad
- C. Vogt's triad (Correct Answer)
- D. Hutchinson's triad
Explanation: ***Vogt's triad*** - **Vogt's triad** refers to the classical findings seen after an acute attack of **angle-closure glaucoma**. - The triad consists of: **glaukomflecken** (anterior subcapsular lens opacities from ischemic necrosis of lens epithelium), **iris stromal atrophy** (sectoral iris atrophy in the area of ischemia), and **fixed mid-dilated pupil** (due to iris sphincter damage). - These signs indicate **ischemic damage** to the anterior segment following the acute episode of elevated intraocular pressure. *Gaucher triad* - **Gaucher triad** refers to the characteristic systemic symptoms of **Gaucher disease**, an inherited lipid storage disorder. - It involves **hepatosplenomegaly**, **bone pain**, and **thrombocytopenia**, which are unrelated to glaucoma. *Virchow triad* - The **Virchow triad** describes the three main factors contributing to **thrombus formation**: **stasis** of blood flow, **endothelial injury**, and **hypercoagulability**. - This triad is relevant to cardiovascular pathology, not the effects of angle-closure glaucoma. *Hutchinson's triad* - **Hutchinson's triad** is a set of symptoms associated with **congenital syphilis**. - It includes **interstitial keratitis**, **Hutchinson's teeth**, and **eighth nerve deafness**, which are entirely distinct from ocular hypertension.
Question 10: The type of iridectomy shown in the image is:
- A. Peripheral basal iridectomy (Correct Answer)
- B. Sector iridectomy
- C. Button-hole iridectomy
- D. Complete iridectomy
Explanation: ***Peripheral basal iridectomy*** - The image clearly depicts an iris with a small, circular opening located at its **periphery**, specifically at the base near the ciliary body. - This type of opening is characteristic of a **peripheral basal iridectomy**, which creates an alternative pathway for aqueous humor flow to relieve pupillary block, often associated with angle-closure glaucoma. *Sector iridectomy* - A **sector iridectomy** involves removing a full-thickness, wedge-shaped section of the iris that extends from the pupillary margin to the iris root, creating a keyhole-shaped pupil. - The image does not show a wedge-shaped defect extending to the pupil. *Button-hole iridectomy* - A **button-hole iridectomy** is typically a small, central opening in the iris that is completely surrounded by iris tissue, often performed for optical purposes. - The image shows a peripheral opening, not a central one. *Complete iridectomy* - A **complete iridectomy** implies the removal of the entire iris, or at least a very large portion, which would result in a highly enlarged and distorted pupil. - The image shows a small, localized opening, not extensive iris removal.
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