Glaucoma (PACG, POAG, Tonometry, Congenital, Treatment) MCQs

Ophthalmology · 92 free questions with answers & explanations.

  1. A 58-year-old woman presents with sudden severe pain in the right eye, nausea, vomiting, and diminished vision. The cornea appears steamy, the pupil is mid-dilated and fixed, and the eye is hard on palpation. Gonioscopy reveals a closed angle. What is the mechanism of intraocular pressure rise in this condition?
  2. In a patient with primary open-angle glaucoma (POAG) on maximum tolerated medical therapy, which surgical procedure is considered the gold standard first-line surgical intervention?
  3. A newborn is noted to have epiphora, photophobia, blepharospasm, and cloudy enlarged corneas (diameter 13 mm) in both eyes. The most likely diagnosis is:
  4. Goldmann applanation tonometry measures intraocular pressure by applying a flat surface to the cornea. According to Imbert-Fick principle, IOP is correctly calculated when the applanation area has a diameter of:
  5. A 45-year-old man with POAG is prescribed a topical prostaglandin analogue. Which of the following is a recognised ocular side effect specific to this class of drugs?
  6. A 52-year-old woman is found on routine examination to have an intraocular pressure of 26 mmHg bilaterally, a cup-to-disc ratio of 0.7, and gonioscopy showing open angles. Automated visual fields reveal an arcuate scotoma in the superior field of the left eye. Central corneal thickness (CCT) is 490 µm. Regarding interpretation of this IOP in the context of CCT, which statement is most accurate?
  7. In gonioscopy of a suspected angle-closure patient, the clinician uses the Shaffer grading system. A grade 2 angle is described as:
  8. A 55-year-old patient on maximum tolerated topical therapy (prostaglandin + beta-blocker + CAI) still has IOP of 22 mmHg with progressive optic nerve damage. She has a history of recurrent bleb-related infections. The surgeon considers a tube-shunt procedure (Baerveldt or Ahmed). What is the advantage of a non-valved (Baerveldt) over a valved (Ahmed) glaucoma drainage device?
  9. A patient with pseudoexfoliation syndrome is noted to have scattered white flaky deposits on the anterior lens capsule, pupillary margin, and trabecular meshwork. What is the mechanism by which pseudoexfoliation leads to elevated IOP?
  10. Which of the following is the preferred initial surgical treatment for primary congenital glaucoma (trabeculodysgenesis) in an infant?
  11. A 58-year-old woman with primary angle closure glaucoma (PACG) has an IOP of 42 mmHg despite maximum topical therapy. She has a shallow anterior chamber with a patent peripheral iridotomy. Gonioscopy reveals more than 180 degrees of peripheral anterior synechiae (PAS). Plateau iris configuration is suspected on UBM. Which of the following mechanisms BEST explains the persistent angle closure despite a patent iridotomy?
  12. In the UKGTS (United Kingdom Glaucoma Treatment Study), the primary outcome measure used to demonstrate that latanoprost significantly reduces glaucoma progression compared to placebo was:
  13. A patient with primary open-angle glaucoma (POAG) on latanoprost monotherapy has insufficient IOP control. The treating physician adds brimonidine. What is the mechanism of brimonidine that makes it useful as an add-on therapy in POAG beyond IOP reduction?
  14. A neonate presents with buphthalmos, excessive tearing, and photophobia. IOP is 28 mmHg in both eyes. The preferred initial surgical treatment for primary congenital glaucoma (PCG) is:
  15. The OHTS (Ocular Hypertension Treatment Study) identified several baseline predictors of conversion from ocular hypertension to glaucoma. Which parameter had the HIGHEST predictive value for development of POAG in the OHTS?
  16. In the EMGT (Early Manifest Glaucoma Trial), the target IOP reduction achieved by treatment versus observation was approximately what percentage, and this was associated with a risk reduction in progression of approximately what percentage?
  17. A 62-year-old patient with POAG on maximum medical therapy (prostaglandin analog + beta-blocker + carbonic anhydrase inhibitor) still has IOP of 22 mmHg with progressive visual field loss. According to current guidelines, which surgical option has the highest evidence for long-term IOP control compared to trabeculectomy in terms of fewer serious complications?
  18. The mechanism by which selective laser trabeculoplasty (SLT) lowers IOP differs from argon laser trabeculoplasty (ALT) in that SLT:
  19. In primary angle-closure glaucoma (PACG), the 'plateau iris configuration' is best characterized by which mechanism leading to angle closure even after patent peripheral iridotomy?
  20. A neonate is noted to have epiphora, photophobia, and blepharospasm. Examination under anesthesia shows corneal diameter of 14 mm bilaterally with Haab's striae. Which statement about the genetic basis of this condition is most accurate?
  21. In the UKGTS (UK Glaucoma Treatment Study), the primary endpoint demonstrating neuroprotective benefit beyond IOP reduction was assessed by which method?
  22. A 35-year-old patient is found to have elevated IOP of 26 mmHg bilaterally, open angles, normal visual fields, and a cup-to-disc ratio of 0.6. The clinician wishes to calculate the absolute risk of conversion to glaucoma over 5 years. According to the Ocular Hypertension Treatment Study (OHTS), which TWO factors carry the highest predictive weight in the OHTS risk calculator?
  23. Rho-kinase (ROCK) inhibitors such as netarsudil lower IOP primarily through which mechanism distinct from all other current glaucoma drug classes?
  24. In a patient with primary angle-closure glaucoma undergoing laser peripheral iridotomy, the procedure fails to deepen the anterior chamber angle. Subsequent gonioscopy reveals plateau iris syndrome. The most appropriate next management step is:
  25. The AGIS (Advanced Glaucoma Intervention Study) demonstrated that the optimal sequence of interventions to slow visual field loss in Black patients with advanced POAG was:
  26. In primary angle-closure glaucoma, which of the following mechanisms is responsible for the relative pupillary block leading to iris bombe?
  27. The OHTS (Ocular Hypertension Treatment Study) demonstrated that topical ocular hypotensive therapy reduced the 5-year risk of developing POAG by approximately:
  28. In congenital glaucoma, the histopathological finding of Barkan's membrane refers to:
  29. The Collaborative Normal Tension Glaucoma Study (CNTGS) showed that a 30% reduction in IOP in normal tension glaucoma led to:
  30. A patient with POAG on maximal medical therapy has persistent IOP of 22 mmHg. According to the AGIS (Advanced Glaucoma Intervention Study), the target IOP to prevent visual field progression should be:
  31. The AGIS (Advanced Glaucoma Intervention Study) demonstrated that in patients with open-angle glaucoma, long-term visual field preservation is best achieved when mean IOP is maintained below which threshold?
  32. A 55-year-old patient with POAG has progressive field loss despite IOP of 16 mmHg on maximal tolerated medical therapy. The next most appropriate step, per current guidelines, is:
  33. In the mechanism of aqueous outflow, uveoscleral pathway accounts for approximately what percentage of total aqueous drainage in young healthy adults?
  34. The Ocular Hypertension Treatment Study (OHTS) identified which of the following as the strongest independent predictor of conversion from ocular hypertension to POAG?
  35. Sturge-Weber syndrome associated glaucoma is mechanistically distinct from other developmental glaucomas because it involves:
  36. A 60-year-old woman with primary open-angle glaucoma (POAG) has target IOP of 15 mmHg. Despite maximum tolerated medical therapy (timolol + dorzolamide + latanoprost), IOP remains 20 mmHg. The Advanced Glaucoma Intervention Study (AGIS) demonstrated that IOP consistently below which threshold was associated with no visual field progression?
  37. In the Collaborative Initial Glaucoma Treatment Study (CIGTS), which treatment arm showed better preservation of quality of life in the long term?
  38. The mechanism by which rho-kinase (ROCK) inhibitors such as netarsudil lower intraocular pressure differs from prostaglandin analogues in that they act primarily on which pathway?
  39. A newborn has epiphora, photophobia, and blepharospasm with corneal diameter of 13 mm. Examination under anesthesia reveals IOP of 30 mmHg. The primary definitive surgical treatment is:
  40. In the Ocular Hypertension Treatment Study (OHTS), the most important baseline risk factor predicting conversion from ocular hypertension to POAG was:
  41. The AGIS (Advanced Glaucoma Intervention Study) demonstrated that in patients with open-angle glaucoma, the IOP level most strongly associated with halting visual field progression was:
  42. In the selective laser trabeculoplasty (SLT) mechanism, the 532 nm Q-switched Nd:YAG laser selectively targets which cells in the trabecular meshwork?
  43. A 60-year-old patient with POAG on maximum tolerated medical therapy shows continued progression. On gonioscopy, the angle is open to grade 4 in all quadrants. The Collaborative Initial Glaucoma Treatment Study (CIGTS) found that comparing initial medical vs. surgical treatment, which outcome was observed?
  44. In plateau iris configuration, laser peripheral iridotomy (LPI) fails to prevent recurrent angle closure because the primary mechanism is:
  45. In trabeculectomy with mitomycin C (MMC), the preferred method to reduce endophthalmitis risk from hypotony-related bleb-related infection is:
  46. In primary angle-closure glaucoma (PACG), peripheral iridotomy (PI) relieves pupillary block by:
  47. Selective laser trabeculoplasty (SLT) lowers IOP by a mechanism that differs from argon laser trabeculoplasty (ALT) in that SLT:
  48. Congenital glaucoma (primary infantile glaucoma) differs from adult POAG in all of the following EXCEPT:
  49. The normal IOP diurnal variation is approximately 2–6 mmHg with the highest values typically occurring:
  50. Primary congenital glaucoma (buphthalmos) is caused by trabecular dysgenesis. The pathognomonic triad includes which set of features?
  51. In Goldmann applanation tonometry, which factor in the Imbert-Fick law is PRACTICALLY accounted for by the design of the tonometer prism (using a 3.06 mm applanation diameter)?
  52. A patient with primary angle closure suspect (PACS) is found to have a narrow angle with peripheral anterior synechiae (PAS) in 4 clock hours and IOP of 26 mmHg with normal optic disc. The next step in management is:
  53. A 42-year-old Asian woman presents with IOP of 32 mmHg on Goldmann applanation tonometry. Gonioscopy reveals Shaffer grade 1 angle bilaterally with trabecular meshwork not visible. Pachymetry shows central corneal thickness (CCT) of 510 μm OU. The Shaffer grade 1 angle corresponds to which degree of angle opening?
  54. A patient with primary open-angle glaucoma (POAG) is on maximum tolerated medical therapy (timolol + latanoprost + dorzolamide) with IOP of 21 mmHg, but shows progressive visual field loss. The NEXT most appropriate step is:
  55. An infant presents at 3 months with photophobia, epiphora, and blepharospasm. Examination under anaesthesia (EUA) shows horizontal corneal diameter of 13 mm bilaterally (Haab's striae present), IOP 26 mmHg, and CDR of 0.7. This is primary congenital glaucoma. The DEFINITIVE treatment is:
  56. A 52-year-old woman presents with sudden onset of severe pain in the right eye, headache, nausea, and vomiting. Slit-lamp examination reveals corneal oedema, a mid-dilated fixed pupil, and shallow anterior chamber. IOP measures 58 mmHg. Gonioscopy of the fellow eye shows a Van Herick grade I angle. Which mechanism best explains the acute pressure elevation in this patient?
  57. A patient with POAG is being managed with maximum tolerated medical therapy but continues to progress. He undergoes trabeculectomy. Six weeks post-operatively, the IOP is unexpectedly elevated to 32 mmHg, the bleb is flat and avascular, and gonioscopy shows the ostium is open. What is the most likely cause of surgical failure?
  58. A neonate is noted to have photophobia, epiphora, and blepharospasm. Corneal diameter measures 13 mm bilaterally. Examination under anaesthesia reveals elevated IOP of 30 mmHg, corneal oedema, and Haab's striae running horizontally. Which embryological structure fails to involute in congenital glaucoma?
  59. A patient with POAG on latanoprost monotherapy has an IOP of 22 mmHg. Target IOP is 14 mmHg. The next agent to add should reduce IOP by an additional 20–25%. Which combination is most rational pharmacologically given that latanoprost already maximises uveoscleral outflow?
  60. During gonioscopy, the examiner identifies a structure that is the most anterior landmark of the drainage angle. It appears as a fine, pigmented or non-pigmented line that marks the functional limit of the corneal endothelium. This structure is:
  61. A 60-year-old woman presents to the emergency department with sudden onset of severe right-sided headache, nausea, vomiting, and blurred vision with halos around lights. Examination reveals a mid-dilated, fixed pupil, corneal oedema, and an IOP of 52 mmHg. The most important immediate step is:
  62. A 55-year-old man with well-controlled primary open-angle glaucoma on timolol shows progressive visual field loss on serial Humphrey perimetry despite an IOP of 14 mmHg. Which structural finding on OCT of the optic nerve head would best correlate with this progression?
  63. Gonioscopy of a patient with elevated IOP reveals a broad iridocorneal apposition with the trabecular meshwork not visible at any quadrant even after indentation. The Shaffer grade of this angle is:
  64. A 40-year-old Scandinavian woman is referred with IOP of 32 mmHg bilaterally. Gonioscopy shows open angles with a grey-white flaky material deposited on the lens equator and anterior lens capsule, trabecular meshwork, and corneal endothelium. The most likely diagnosis is:
  65. A 25-year-old myopic man notices a brown pigmented arc on the corneal endothelium (Krukenberg spindle) and heavy trabecular pigmentation on gonioscopy. He experiences exercise-induced blurring. The mechanism of elevated IOP in this condition is:
  66. A 55-year-old woman with a narrow angle is found to have plateau iris syndrome on ultrasound biomicroscopy (UBM) after a laser peripheral iridotomy has already been performed. The UBM finding that confirms plateau iris (rather than residual pupil block) is:
  67. In congenital glaucoma, Haab's striae are pathognomic horizontal linear opacities in the cornea. The underlying mechanism is:
  68. A patient with POAG is well-controlled on a prostaglandin analogue but has had progressive disc cupping. It is decided to add a second agent. He has asthma and is on salbutamol. The MOST contraindicated class is:
  69. Selective laser trabeculoplasty (SLT) differs from argon laser trabeculoplasty (ALT) in that SLT:
  70. In primary angle-closure glaucoma (PACG), the mechanism of plateau iris configuration differs from pupillary block in which way?
  71. The selective laser trabeculoplasty (SLT) mechanism differs from argon laser trabeculoplasty (ALT) in that SLT:
  72. Congenital glaucoma is most commonly caused by a developmental anomaly in which structure, and what is the pathognomonic clinical sign in infants?
  73. A 60-year-old is diagnosed with primary angle-closure glaucoma (PACG). On gonioscopy, the trabecular meshwork is not visible for 360 degrees with 75% peripheral anterior synechiae (PAS). IOP is 38 mmHg despite maximum topical therapy. The MOST definitive surgical intervention is:
  74. Retinal nerve fibre layer (RNFL) thinning on OCT in glaucoma characteristically occurs FIRST in which sector of the optic nerve head?
  75. In congenital glaucoma, the first-line surgical treatment is:
  76. Non-contact air-puff tonometry (NCT) compared to Goldmann applanation tonometry (GAT) is characterised by all EXCEPT:
  77. In primary congenital glaucoma (PCG), the cardinal triad at presentation includes all of the following EXCEPT:
  78. Selective laser trabeculoplasty (SLT) uses which laser and targets which cells in the trabecular meshwork?
  79. In gonioscopy, the most anteriorly visible structure in the angle is:
  80. In plateau iris syndrome, an acute angle closure attack can occur despite a patent peripheral iridotomy (PI) because:
  81. In primary congenital glaucoma, the classical triad of presentation includes all EXCEPT:
  82. Selective Laser Trabeculoplasty (SLT) reduces IOP in open-angle glaucoma by:
  83. A 65-year-old man with primary open-angle glaucoma (POAG) undergoes selective laser trabeculoplasty (SLT). Which cellular mechanism underpins SLT's IOP-lowering effect?
  84. In congenital glaucoma (buphthalmos), Haab's striae are seen on the cornea. What do Haab's striae represent, and why do they run horizontally?
  85. A patient with acute primary angle-closure crisis (PACG) presents to the emergency department with IOP of 58 mmHg, corneal oedema, mid-dilated fixed pupil, and severe pain. Which drug given FIRST reduces IOP most rapidly in this emergency?
  86. Gonioscopy of a patient shows peripheral anterior synechiae (PAS) at the level of the anterior trabecular meshwork. The remaining angle shows a closed recess with appositional closure on dynamic indentation gonioscopy. According to the ISGEO classification, this is best categorised as:
  87. A 55-year-old woman undergoes gonioscopy after a subacute angle-closure attack. The drainage angle shows peripheral anterior synechiae (PAS) occupying 270° of the trabecular meshwork. Her IOP remains elevated at 32 mmHg despite topical medications and YAG iridotomy. The NEXT step is:
  88. Sussman Scheie classification of the anterior chamber angle uses which method?
  89. A neonate presents with buphthalmos, photophobia, lacrimation, and corneal oedema. IOP is 32 mmHg in both eyes. The definitive surgical treatment is:
  90. In the OHTS (Ocular Hypertension Treatment Study), which baseline factor was identified as the most powerful predictor of conversion from ocular hypertension to glaucoma?
  91. A patient's Goldmann applanation IOP reads 24 mmHg. CCT is 495 µm. The Ehlers correction formula adjusts this to an estimated true IOP of approximately:
  92. A 65-year-old patient with open-angle glaucoma is being considered for trabeculectomy. Which factor from the TVT (Tube Versus Trabeculectomy) study most strongly favours choosing a tube shunt over trabeculectomy?
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