Pediatric Glaucoma — MCQs
A child presents with unilateral white reflex (leukocoria) and raised intraocular pressure, raising suspicion of retinoblastoma. Which of the following investigations is the most appropriate to perform?
Which of the following is not a feature of keratoconus?
A 2-year-old child presents with unilateral leukocoria and poor vision. What is the most likely diagnosis?
In a child presenting unilateral watering and photophobia which of the following is the least likely disorder?
SAFE strategy is for:
What is the most common symptom associated with congenital glaucoma?
Which of the following statements about congenital glaucoma is incorrect?
Which of the following lens is used in direct gonioscopy?
In primary open-angle glaucoma (POAG), which of the following findings is NOT typically seen?
A patient with cataract presents with pain and redness of eye. On examination he had deep anterior chamber. What is the diagnosis?
Pediatric Glaucoma Indian Medical PG Practice Questions and MCQs
Question 1: A child presents with unilateral white reflex (leukocoria) and raised intraocular pressure, raising suspicion of retinoblastoma. Which of the following investigations is the most appropriate to perform?
- A. Ultrasound imaging of the eye
- B. Measurement of intraocular pressure
- C. Detailed examination under anesthesia (Correct Answer)
- D. CT imaging of the orbit and head
Explanation: ***Detailed examination under anesthesia*** - A **detailed examination under anesthesia (EUA)** is crucial for accurately assessing the extent of intraocular lesions in children, particularly those with suspected retinoblastoma. It allows for a thorough and precise evaluation of tumor size, location, and multifocality that is otherwise difficult to achieve in an awake child. - EUA often includes fundus photography, ultrasonography, and sometimes anterior segment examination, all performed systematically without the child moving. It is the gold standard for **diagnosing and staging retinoblastoma**. *Ultrasound imaging of the eye* - **Ocular ultrasound** is a key component of the investigation and can help identify the intraocular mass and detect calcifications, which are characteristic of retinoblastoma. - However, ultrasound alone is often insufficient to fully characterize the tumor's extent or for precise staging, and it doesn't replace the need for direct visualization and comprehensive examination. *Measurement of intraocular pressure* - **Raised intraocular pressure** is a symptom that can be present in retinoblastoma but is not a diagnostic tool for the condition itself; it indicates secondary glaucoma due to the tumor. - While important for clinical management, measuring IOP does not directly visualize or characterize the tumor to confirm the diagnosis of retinoblastoma. *CT imaging of the orbit and head* - While **CT imaging** can detect orbital and intracranial extension of retinoblastoma, it involves **ionizing radiation**, which is a significant concern in children, especially those with an increased genetic risk for secondary cancers. - **MRI** is generally preferred over CT for assessing extraocular extension and possible central nervous system involvement due to its superior soft tissue contrast and lack of radiation exposure.
Question 2: Which of the following is not a feature of keratoconus?
- A. Haab's striae (Correct Answer)
- B. Irregular astigmatism
- C. Scissoring reflex
- D. Munson's sign
Explanation: ***Haab's striae*** - **Haab's striae** are characteristic of congenital glaucoma, presenting as horizontal breaks in Descemet's membrane due to increased intraocular pressure and corneal stretching. - In contrast, keratoconus involves **vertical breaks in Descemet's membrane** (due to corneal thinning and protrusion), known as Vautin's striae or Vogt's striae, not Haab's striae. *Irregular astigmatism* - **Irregular astigmatism** is a hallmark of keratoconus, resulting from the asymmetric and non-uniform thinning and protrusion of the cornea. - This irregular corneal shape leads to a significant reduction in visual acuity that cannot be fully corrected with spherical or regular cylindrical lenses. *Scissoring reflex* - The **scissoring reflex** (or scissoring phenomena) is an objective finding observed during retinoscopy in patients with keratoconus, indicating significant irregular astigmatism. - It refers to the opposing movements of the retinoscopic reflex, resembling the opening and closing of scissors, as the light across the pupil is neutralized. *Munson's sign* - **Munson's sign** is a classic clinical finding in advanced keratoconus, where the lower eyelid protrudes in a V-shape when the patient looks downwards. - This protrusion is caused by the conical shape of the cornea pushing against the eyelid.
Question 3: A 2-year-old child presents with unilateral leukocoria and poor vision. What is the most likely diagnosis?
- A. Congenital cataract
- B. Retinoblastoma (Correct Answer)
- C. Endophthalmitis
- D. Coats disease
Explanation: ***Retinoblastoma*** - **Leukocoria** (white pupillary reflex) is the **most common presenting sign** of retinoblastoma, occurring in approximately 60% of cases - The combination of **unilateral leukocoria** and **poor vision** in a **2-year-old child** (peak age 18-24 months) is highly suggestive - It is a **rapidly growing malignant intraocular tumor** arising from the neural retina, requiring urgent evaluation and treatment - Other presenting features may include **strabismus**, **red eye**, and in advanced cases, **proptosis** *Congenital cataract* - Can also present with **leukocoria** due to opacification of the lens - However, congenital cataracts are typically **bilateral** (75% of cases) and diagnosed earlier in infancy - The **static, non-progressive nature** distinguishes it from the rapidly growing retinoblastoma - Family history and associated systemic conditions (TORCH infections, metabolic disorders) are common *Endophthalmitis* - Severe **intraocular infection** affecting vitreous and aqueous humor - Typically presents with **acute pain**, **severe redness**, **hypopyon**, and **rapid vision loss** - Usually follows **penetrating trauma** or **intraocular surgery**, which would be uncommon in a 2-year-old - **Leukocoria without acute inflammatory signs** makes this diagnosis unlikely *Coats disease* - Characterized by **abnormal telangiectatic retinal vessels** with **exudative retinal detachment** and **yellow subretinal exudates** - Can present with leukocoria (yellow reflex due to lipid deposits) in young children - However, it typically affects **older children** (mean age 5-8 years), is predominantly **unilateral**, and has a **more indolent course** - More common in **males** and usually lacks the rapid progression of retinoblastoma
Question 4: In a child presenting unilateral watering and photophobia which of the following is the least likely disorder?
- A. Congenital entropion
- B. Congenital glaucoma
- C. Congenital NLDO (Correct Answer)
- D. Congenital dacryocystitis
Explanation: **Congenital NLDO** - **Congenital nasolacrimal duct obstruction (NLDO)** typically presents with **unilateral watering** (epiphora) due to blockage of tear drainage. - While it causes watering, **photophobia** is not a characteristic symptom of isolated NLDO, making it less likely given the combined presentation. *Congenital entropion* - **Congenital entropion** involves the inward turning of the eyelid margin, causing eyelashes to rub against the cornea. - This irritation can lead to **unilateral watering** and **photophobia** due to corneal abrasion and discomfort. *Congenital glaucoma* - **Congenital glaucoma** is characterized by elevated intraocular pressure, which can cause corneal edema and stretching. - These changes commonly result in **unilateral watering** (epiphora) and marked **photophobia**, often accompanied by **buphthalmos** (enlarged eye). *Congenital dacryocystitis* - **Congenital dacryocystitis** is an infection of the lacrimal sac, often secondary to NLDO. - It presents with **unilateral watering**, discharge, and inflammation of the lacrimal sac, and the associated irritation can induce **photophobia**.
Question 5: SAFE strategy is for:
- A. Onchocerciasis
- B. Glaucoma
- C. Diabetic retinopathy
- D. Trachoma (Correct Answer)
Explanation: ***Trachoma*** - The **SAFE strategy** is a comprehensive public health approach designed to eliminate **trachoma**, a preventable cause of blindness. - SAFE stands for **Surgery** for trichiasis, **Antibiotics** to treat active infection, **Facial cleanliness** to reduce transmission, and **Environmental improvement** (especially access to water and sanitation) to prevent reinfection. *Onchocerciasia* - This condition, also known as **river blindness**, is primarily managed through mass drug administration of **ivermectin**. - While public health interventions are crucial for onchocerciasis, the specific SAFE acronym is not associated with its control program. *Glaucoma* - The management of glaucoma focuses on lowering **intraocular pressure** through medications, laser treatment, or surgery. - It is a chronic eye condition that does not involve infectious agents like trachoma, and the SAFE strategy is irrelevant. *Diabetic retinopathy* - This complication of diabetes is managed by controlling **blood sugar**, blood pressure, and lipids, along with specific ophthalmological treatments like laser photocoagulation or anti-VEGF injections. - It is a non-infectious, metabolic disease, making the SAFE strategy inapplicable.
Question 6: What is the most common symptom associated with congenital glaucoma?
- A. Excessive tearing (Correct Answer)
- B. Eye pain
- C. Sensitivity to light
- D. Itching of the eyes
Explanation: ***Excessive tearing*** - **Epiphora**, or excessive tearing, is one of the most common early symptoms of **congenital glaucoma** in infants. - This symptom occurs due to **corneal irritation** and **damage** resulting from elevated intraocular pressure. *Eye pain* - While glaucoma can cause eye pain, it is less commonly reported as the *initial* and *most frequent* symptom in **congenital glaucoma** in infants who cannot verbalize their discomfort. - **Irritability** or excessive crying might be indirect signs of pain, but tearing is a more direct and observable sign. *Sensitivity to light* - **Photophobia**, or sensitivity to light, is another common symptom of congenital glaucoma. - However, **excessive tearing** often precedes or co-occurs with photophobia as an initial presenting symptom in infants. *Itching of the eyes* - **Ocular itching** is typically associated with **allergic conjunctivitis** or other inflammatory conditions, not directly with congenital glaucoma. - Itching is not a primary or common symptom of elevated intraocular pressure in infants.
Question 7: Which of the following statements about congenital glaucoma is incorrect?
- A. Thin and blue sclera seen
- B. Anterior chamber is shallow (Correct Answer)
- C. Photophobia is most common symptom
- D. Haab's Striae may be seen
Explanation: ***Anterior chamber is shallow*** - In congenital glaucoma, the **anterior chamber depth is typically normal or deep**, not shallow. - A shallow anterior chamber is more characteristic of **angle-closure glaucoma**, which is mechanistically different. - This makes the statement incorrect, as congenital glaucoma is associated with a **deep anterior chamber** due to globe enlargement. *Photophobia is most common symptom* - **Photophobia** (sensitivity to light) is indeed one of the classic presenting symptoms in congenital glaucoma. - It forms part of the classic triad: **photophobia, epiphora (tearing), and blepharospasm**. - This occurs due to **increased intraocular pressure** causing corneal edema and irritation. *Thin and blue sclera seen* - The **sclera** can appear thin and blue due to **buphthalmos** (enlargement of the eye) and stretching of the globe. - The stretching allows the underlying **uveal tissue** to show through, giving the characteristic blue appearance. - This is a direct consequence of elevated intraocular pressure in a developing eye. *Haab's Striae may be seen* - **Haab's striae** are **Descemet's membrane tears** that are pathognomonic of congenital glaucoma. - These horizontal or curvilinear breaks occur due to stretching of the cornea from **elevated intraocular pressure**. - They appear as visible linear opacities on corneal examination.
Question 8: Which of the following lens is used in direct gonioscopy?
- A. Koeppe (Correct Answer)
- B. Goldmann
- C. Richardson
- D. Zeiss
Explanation: ***Koeppe*** - The **Koeppe lens** is designed for direct gonioscopy, providing a wide-angle view of the **anterior chamber angle**. - It is typically used with the patient in a **supine position** and requires a coupling solution to be placed directly on the cornea. *Goldmann* - The **Goldmann lens** (3-mirror lens) is used for **indirect gonioscopy** and is characterized by mirrors that reflect the image of the angle. - It is used at a **slit lamp** and provides a magnified view as the light is reflected through the mirrors. *Richardson* - The **Richardson-Shaffer lens** is another direct gonioscopy lens, similar to the Koeppe lens. - However, the question asks for "**the**" lens used in direct gonioscopy, and **Koeppe** is the most commonly recognized and frequently used direct gonioscopy lens. - Richardson-Shaffer is less commonly used in modern practice compared to Koeppe. *Zeiss* - The **Zeiss lens** (4-mirror lens) is used for **indirect gonioscopy** and allows a rapid 360-degree view of the angle. - It is commonly used with a **slit lamp** and requires minimal or no coupling fluid due to its small contact surface.
Question 9: In primary open-angle glaucoma (POAG), which of the following findings is NOT typically seen?
- A. Bayoneting sign (arteriovenous crossing changes)
- B. Peripapillary atrophy
- C. Horizontal cupping of the optic disc
- D. Macular edema (Correct Answer)
Explanation: ***Macular edema*** - **Macular edema** is characterized by fluid accumulation in the fovea or retina, causing blurry vision and metamorphopsia. - While it can occur in conditions like **diabetic retinopathy** or **uveitis**, it is **not a typical finding in POAG**, which primarily affects the optic nerve. *Horizontal cupping of the optic disc* - **Horizontal cupping** (or vertical elongation of the optic cup) is a common sign of **glaucomatous damage**, reflecting the loss of retinal ganglion cells. - This morphological change suggests the progression of optic nerve atrophy. *Bayoneting sign (arteriovenous crossing changes)* - The **bayoneting sign**, where blood vessels appear to dip below the optic disc margin and then sharply bend, is a feature of **advanced glaucomatous cupping**. - It indicates significant loss of optic nerve tissue and is often associated with deeply excavated optic discs. *Peripapillary atrophy* - **Peripapillary atrophy** (PPA) refers to areas of RPE and choroidal atrophy surrounding the optic disc, commonly seen in glaucoma. - While its presence and extent may correlate with **glaucoma severity**, it is a recognized clinical feature of the disease.
Question 10: A patient with cataract presents with pain and redness of eye. On examination he had deep anterior chamber. What is the diagnosis?
- A. Acute phacolytic glaucoma (Correct Answer)
- B. Acute angle closure glaucoma
- C. Acute neovascular glaucoma
- D. Acute phacomorphic glaucoma
Explanation: ***Acute phacolytic glaucoma*** - This condition occurs when **lens proteins leak** from a mature or hypermature cataract into the aqueous humor, causing an inflammatory reaction and **trabecular meshwork obstruction**, leading to elevated intraocular pressure. - The presence of a **deep anterior chamber** distinguishes it from phacomorphic glaucoma, which is characterized by a shallow anterior chamber due to lens intumescence. *Acute angle closure glaucoma* - This typically presents with a **shallow anterior chamber** as the iris bows forward, blocking the trabecular meshwork. - While it causes pain and redness, the deep anterior chamber described in the patient makes this diagnosis unlikely. *Acute neovascular glaucoma* - This type of glaucoma results from the formation of **new blood vessels** on the iris and in the angle of the anterior chamber, often due to conditions like **diabetic retinopathy** or **retinal vein occlusion**. - There is no mention of such predisposing factors or visible neovascularization in the patient's presentation. *Acute phacomorphic glaucoma* - This condition is caused by the **intumescence (swelling) of a cataractous lens**, which pushes the iris forward, leading to a **shallow anterior chamber** and angle closure. - The patient's presentation of a **deep anterior chamber** rules out phacomorphic glaucoma.
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