Chapter 2 Glaucoma



10.1055/b-0039-173408

Chapter 2 Glaucoma

Veena Rao


2.1 Questions













Easy


Medium


Hard


1. (Easy) A patient is sent for evaluation for possible narrow-angle glaucoma. The view of the inferior angle with indirect gonioscopy appears as in the first figure. The second figure was acquired after which of the following?




  1. Asking the patient to look up or tilting the mirror up



  2. Asking the patient to look up or tilting the mirror down



  3. Asking the patient to look down or tilting the mirror up



  4. Asking the patient to look down or tilting the mirror down


2. (Hard) The image below was most likely taken from the autopsy of which of the following patients?




  1. A patient who has an extensive family history of glaucoma



  2. patient who was a poorly controlled diabetic who eventually went blind in this eye



  3. A patient who has a history of episodic eye pain



  4. A patient who was hit by a baseball in the eye at age 10 years


3. (Hard) The secondary open-angle glaucoma shown here and caused by mutations in LOXL1 demonstrates characteristic histologic changes in each of the following tissues except which one?




  1. Lens epithelium



  2. Iris stroma



  3. Iris blood vessels



  4. Conjunctival blood vessels


4. (Easy) What is the most common complication of selective laser trabeculoplasty (SLT)?




  1. Transient intraocular pressure increase



  2. Iritis



  3. Synechiae



  4. Pain


5. (Medium) A 55-year-old man underwent uncomplicated trabeculectomy in his left eye. On postoperative day 4, the intraocular pressure is 45 mm Hg. The anterior chamber is noted to be shallow and the bleb appears elevated. Which of the following is the next best intervention?




  1. Start timolol eye drops in this eye.



  2. Start acetazolamide pills.



  3. Perform laser suture lysis.



  4. Start atropine eye drops in this eye.


6. (Medium) Which of the following options is most likely for the the patient whose gonioscopy is shown below?




  1. Experienced recent blunt trauma to the eye



  2. Has an intraocular pressure of 8 mm Hg



  3. Has a refraction of −4.00 diopters



  4. Has a history of of juvenile idiopathic arthritis–associated uveitis treated with steroids


7. (Easy) An 85-year-old man with a history of severe primary open-angle glaucoma in both eyes presents to the clinic with an intraocular pressure of 21 mm Hg in the right eye and 35 mm Hg in the left eye. His visual field shows severe constriction in both eyes due to advanced glaucoma. He reports difficulty in taking his eye drops regularly, due to his arthritis, and he lives alone. You discuss treatment options with him. Which of the following options should likely be avoided in this patient?




  1. Glaucoma drainage device



  2. Trabeculectomy with mitomycin C



  3. Selective laser trabeculoplasty



  4. Transscleral diode cyclophotocoagulation


8. (Medium) Glaucoma is __× as prevelant in the black population versus the white population.




  1. 2



  2. 4



  3. 8



  4. 16


9. (Easy) Which of the following components is less plentiful in aqueous humor versus plasma?




  1. Hydrogen



  2. Chloride



  3. Bicarbonate



  4. Ascorbic acid


10. (Medium) A 79-year-old woman presents to your clinic with elevated intraocular pressure. She reports intolerance to several eye drops in the past. You review your treatment options and start her on a medication she has not tried previously, which works by decreasing uveoscleral outflow. Which drug class does this drop belong to?




  1. Miotic drugs



  2. Cycloplegic drugs



  3. Beta blockers



  4. Trauma


11. (Hard) A 50-year-old male patient with a past medical history significant for hypothyroidism and alcohol abuse is undergoing strabismus surgery under general anesthesia. He begins to exhibit symptoms of malignant hyperthermia. Which of the following does not contribute to an increase in intraocular pressure?




  1. Ketamine



  2. Elevated body temperature



  3. Alcohol



  4. Hypothyroidism


12. (Hard) What percentage of glaucoma patients may develop nerve fiber layer hemorrhages?




  1. 10%



  2. 33%



  3. 50%



  4. 60%


13. (Easy) A 35-year-old man presents for a second opinion on a recent diagnosis of glaucoma. He has no known history of elevated intraocular pressure on his routine annual eye examinations. The patient presents with the below testing and a normal visual field. On dilated fundoscopy, the optic nerves appear symmetrical and tilted. Which of the following would be the next best step in his care?




  1. Plan laser trabeculoplasty to lower his intraocular pressure.



  2. Obtain neuroimaging.



  3. Careful observation with repeat visual field testing.



  4. Initiation of latanoprost.


14. (Hard) A patient with 20/25 vision in both eyes and intraocular pressure of 24 mm Hg presents with the following clinical appearance. Which treatment plan is least appropriate?




  1. Laser peripheral iridotomy alone



  2. Phacoemulsification with intraocular lens implantation



  3. Initiation of timolol



  4. A series of two laser procedures for each eye


15. (Medium) A 69-year-old woman with a history of asthma, hypertension, and open-angle glaucoma treated with latanoprost has the following visual fields (in the figure below—top visual field from 1 year ago and bottom visual field from today). Her intraocular pressure readings in this eye over this time period have ranged between 8 and 9 mm Hg, and her optic disc shows a cup to disc ratio of 0.8 with inferior thinning. Which further evaluation is best indicated at this time?




  1. Referral to a neurologist for possible neuroimaging



  2. Referral to her cardiologist to ensure adequate blood pressure control



  3. Referral to her pulmonologist to see if timolol would be an appropriate agent for her glaucoma



  4. Referral to a retina specialist for evaluation of possible occult macular degeneration


16. (Medium) A patient undergoes valved glaucoma drainage device implanation. At postoperative week 8, the patient’s intraocular pressure is noted to have increased to 28 mm Hg in the operative eye. This increase in eye pressure is most likely due to which of the following?




  1. Steroid-related intraocular pressure rise



  2. Prolonged intraocular inflammation leading to scarring of the trabecular meshwork



  3. Encapsulation of the extraocular reservoir surrounding the implant



  4. Progressive glaucoma


17. (Medium) An 85-year-old man with uncontrolled eye pressure despite good compliance with his maximally tolerated eye drops refuses surgery to better control his glaucoma. You compromise on trying oral acetazolamide. In counseling the patient on acetazolamide use, you discuss potential side effects. Which of the following is not a potential adverse reaction?




  1. Parasthesias



  2. Aplastic anemia



  3. Loss of libido



  4. Fatty liver disease


18. (Easy) A 63-year-old man with a history of brimonidine use for 8 years presents to your clinic with bilateral red, irritated, itchy eyes. You suspect an allergy to brimonidine. Which of the following is the incidence of blepharoconjunctivitis with chronic use of brimonidine tartrate?




  1. 5%



  2. 10%



  3. 20%



  4. 40%


19. (Medium) A 72-year-old retired male physician is very cautious about interactions between his glaucoma drops and his systemic health. He has a history of high cholesterol, for which he takes an oral statin drug. He should be counseled about which of the following for the use of topical timolol?




  1. Increases high-density lipoprotein (HDL) cholesterol levels.



  2. Decreases HDL cholesterol levels.



  3. Has no effect on serum cholesterol levels.



  4. Decreases overall serum cholesterol levels.


20. (Easy) A 9-month-old female infant with primary congential glaucoma requires surgery to control her eye pressure. The cornea has diffuse edema leading to a cloudy view of the iris and optic nerve on examination under anesthesia. Which of the following would be the best surgical approach in this setting?




  1. Goniotomy



  2. Trabeculotomy ab externo



  3. Glaucoma drainage device



  4. Transscleral diode cyclophotocoagulation


21. (Hard) Concerned parents of a newborn infant present to your clinic for an evaluation of their baby, who has an extensive family history of glaucoma. They are concerned he may have glaucoma because he is tearing, which the parents heard can be a sign of glaucoma in infants. You measure the intraocular pressure of the baby and reassure the parents that his eye pressure is normal. What is the most likely measurement obtained?




  1. Less than 10 mm Hg



  2. Low teens



  3. Mid teens



  4. Upper teens


22. (Hard) A 35-year-old female patient with the clinical appearance below presents to your clinic. What is the most common cause of glaucoma in her condition?




  1. Rotation of the iris stump toward the angle, leading to synechial angle closure



  2. Abnormal development of the trabecular meshwork



  3. Abnormally high level of resistance in the trabecular meshwork



  4. Overproduction of aqueous fluid


23. (Medium) When performing trabeculectomy on a patient with this condition, what is the most concerning potential complication?




  1. Choroidal hemorrhage



  2. Hyphema



  3. Neovascularization of the iris



  4. Prolonged inflammation


24. (Hard) A 64-year-old myopic man presents to your clinic. While traveling abroad several weeks ago, he recalls several days of flashing lights in his right eye, followed by slowly decreasing vision in that eye. On examination, his vision is counting fingers at his face with a dilated examination remarkable for a chronic-appearing retinal detachment with three peripheral retinal tears. What is the mechanism behind elevated intraocular pressure in this clinical scenario?




  1. Decreased outflow due to perturbation of the retinal pigment epithelium



  2. Increased pigment floating in the vitreous and anterior chamber, clogging the trabecular meshwork



  3. Photoreceptor segments clogging the trabecular meshwork



  4. Secondary angle closure from the retinal detachment rotating the iris anteriorly


25. (Medium) A 29-year-old woman with congenital glaucoma typically controlled on latanoprost once daily in both eyes presents to your clinic for a routine check up. She tells you she is planning on becoming pregnant this year and asks which medication would be best for her if she does become pregnant?




  1. Brimonidine



  2. Timolol



  3. Dorzolamide



  4. Latanoprost


26. (Easy) Among which group is the prevalence of primary angle closure highest?




  1. Chinese



  2. Inuit



  3. Scandinavian



  4. East African


27. (Hard) Of the four scenarios presented below, in which case is the gene responsible located on chromosome 1?




  1. An 85-year-old woman with scleral spur identified on gonioscopy 360 degrees and history of maximal intraocular pressure of 35 mm Hg OU



  2. A 33-year-old woman with history of open-angle glaucoma and elevated intraocular pressures, now controlled by trabeculectomy in both eyes



  3. A 65-year-old woman with history of elevated intraocular pressure and moth-eaten pupillary border



  4. A 54-year-old man with posterior embryotoxon and history of elevated intraocular pressure


28. (Hard) Which structure is responsible for aqueous humor production?




  1. Capillaries within ciliary processes



  2. Stroma of ciliary processes



  3. Inner nonpigmented epithelial cells of ciliary processes



  4. Outer pigmented epithelial cells of ciliary processes


29. (Medium) What method measures the rate of aqueous humor formation?




  1. Tonometry



  2. Tonography



  3. Fluorophotometry



  4. Angiography


30. (Medium) What is the area of greatest resistance in the trabecular outflow system?




  1. Uveal meshwork



  2. Corneoscleral meshwork



  3. Scleral spur



  4. Juxtacanalicular meshwork


31. (Medium) What percentage of aqueous outflow is attributable to the uveoscleral pathway?




  1. 2%



  2. 15%



  3. 25%



  4. 35%


32. (Easy) When using the Goldmann tonometry to measure intraocular pressure, corneal edema can cause a falsely ____ pressure reading, and an excess of fluorescein can cause a falsely ____ pressure reading.




  1. Low; high



  2. Low; low



  3. High; high



  4. High; low


33. (Easy) A 55-year-old woman presents to your clinic for a glaucoma suspect evaluation. She has visual acuity of 20/20 OU, intraocular pressure 21 mm Hg OD and 20 mm Hg OS, central corneal thickness of 600 µm OU. She mentions her optometrist told her she has “thick corneas” and that was a reassuring sign against glaucoma. Which clinical trial is her optometrist referring to?




  1. Blue Mountain Eye Study



  2. Collaborative Initial Glaucoma Treatment Study



  3. Ocular Hypertension Treatment Study



  4. Early Manifest Glaucoma Trial


34. (Medium) You present to a new eye clinic and observe each of the four technicians cleans the Goldmann applanation prism using a different technique. You note one technician did not perform an adequate job cleaning the prism. Which technique did he or she use?




  1. Wiping the prism with an alcohol pad



  2. Soaking the prism in 70% isopropyl alcohol



  3. Soaking the prism in 1:10 sodium hypochlorite



  4. Wiping the prism with 1:10 sodium hypochlorite


35. (Medium) An optic nerve is measured as 1.5 mm in height on ophthalmoscopy with a 90 D lens. What is the actual height of the nerve?




  1. 1.15 mm



  2. 1.5 mm



  3. 1.65 mm



  4. 1.95 mm


36. (Hard) You are examining a 49-year-old man for a glaucoma suspect evaluation. You find the right eye has a cup to disc ratio of 0.3 and the left eye has a cup to disc ratio of 0.65. You discuss the assymmetry with your patient, who asks you what is the chance that this is just normal asymmetry. You answer that asymmetry to this degree is present in __% of normal individuals.




  1. 0%



  2. 1%



  3. 5%



  4. 10%


37. (Hard) The accuracy of visual field testing may decrease with pupil sizes smaller than which of the following option?




  1. 2.0 mm



  2. 2.5 mm



  3. 1.5 mm



  4. 3.0 mm


38. (Hard) Frequency doubling technology (FDT) perimetry can be especially useful in patients with ____ glaucoma, possibly due to its emphasis on __ cells.




  1. Late glaucoma, M cells



  2. Early glaucoma, M cells



  3. Late glaucoma, P cells



  4. Early glaucoma, P cells


39. (Medium) A 60-year-old woman presents for a new patient evaluation. This is her first eye examination in 10 years. Her best corrected visual acuity is 20/20 in the right eye and 20/80 in the left eye. The intraocular pressure is 15 mm Hg in the right eye and 38 in the left eye. There is no afferent pupillary defect. The optic nerve is notable for a cup to disc ratio of 0.2 in the right eye with a healthy rim and near total loss of the optic nerve rim tissue in the left eye. Which of the following glaucomas is most likely in this scenario?




  1. Primary open angle



  2. Pigmentary



  3. Pseudoexfoliation



  4. Iridocorneal endothelial syndrome


40. (Medium) For a patient with pigmentary glaucoma compared to a patient with primary open-angle glaucoma, selective laser trabeculoplasty would be expected to have an effect lasting a _____ duration and require ____ energy settings:




  1. Longer, higher



  2. Longer, lower



  3. Shorter, higher



  4. Shorter, lower


41. (Medium) A 90-year-old woman who is pseudophakic OD presents with a 4+ nuclear sclerotic cataract OS and intraocular pressure of 12 mm Hg OD and 48 mm Hg OS. She reports pain in the left eye and denies trauma. On slit lamp examination, you note microcystic corneal edema, 3+ anterior chamber cell, keratoprecipitates, and an open-angle OS. Which of the following cell types is uniquely seen in this subtype of glaucoma?




  1. Basophils



  2. Neutrophils



  3. Eosinophils



  4. Macrophages


42. (Easy) A 49-year-old man presents with unilateral blurry vision, light sensitivity, and elevated intraocular pressure. You note anterior-chamber inflammation on his examination. Which of the following ocular inflammatory conditions is least likely in this scenario?




  1. Herpes simplex uveitis



  2. Toxoplasmosis uveitis



  3. Fuchs’ heterochromic iridocyclitis



  4. HLA B27-associated uveitis


43. (Medium) A 56-year-old man presents with decreased vision and a “red” right eye. He is found to have elevated episcleral venous pressure. Which comorbidity is most likely to be present?




  1. Superior vena cava syndrome



  2. Aortic regurgitation



  3. Uncontrolled hypertension



  4. Diastolic heart failure


44. (Easy) What is normal episcleral venous pressure?




  1. 4–6 mm Hg



  2. 6–8 mm Hg



  3. 8–10 mm Hg



  4. 10–12 mm Hg


45. (Medium) Four patients present to your emergency room on Sunday afternoon with eye trauma. Which patient is least likely to develop glaucoma?




  1. Man hit in eye with baseball



  2. Girl hit by tree branch leading to corneal abrasion



  3. Woman with metal grinding injury



  4. Man with bleach to eye


46. (Medium) Which medication should be avoided in this patient?




  1. Rosuvastatin



  2. Amiodarone



  3. Oxybutynin



  4. Fluticasone


47. (Medium) Which of the following options is most likely the patient shown in the figure?




  1. Has symmetrical clinical findings in both eyes



  2. Is a woman



  3. Is 70 years old



  4. Has experienced ocular trauma


48. (Medium) What is the most appropriate next step in treatment for a patient with intraocular pressure of 40 mm Hg on maximal tolerated medical therapy in an eye with with 20/100 vision following treatment for ocular melanoma?




  1. Continue to observe on maximal medical therapy



  2. Trabeculectomy with mitomycin C



  3. Glaucoma drainage device



  4. Transscleral diode cyclophotocoagulation


49. (Hard) Which of the following conditions is not associated with glaucoma?




  1. Sturge–Weber syndrome



  2. Neurofibromatosis type 1



  3. von Hippel–Lindau syndrome



  4. Tuberous sclerosis


50. (Easy) Two teenage parents bring their 6-month old male infant in for an examination, as they’ve noticed the baby makes strange “grimacing” facial movements. They also note that the baby’s eyes tear up and he cries when being taken outside into the daylight. Which of the following is most often true for the condition the baby presents with here?




  1. Occurs in males



  2. Occurs within the first 3 years of life



  3. Occurs in one eye



  4. Has a better prognosis if diagnosed as a newborn infant


51. (Medium) This finding is thought to develop due to which of the following reasons?




  1. Chronic inflammation



  2. Iris pigment deposition



  3. Ischemia



  4. Regressed neovascularization


52. (Hard) A 58-year-old hyperopic woman presents to the emergency room with decreased vision, nausea, vomiting, and unilateral eye pain. Which of the following medical treatments are indicated for her most likely condition?




  1. Brimonidine and pilocarpine 2%



  2. Brimonidine and pilocarpine 4%



  3. Apraclonidine and pilocarpine 2%



  4. Apraclonidine and pilocarpine 4%


53. (Hard) The patient shown below presents with unilateral eye pain and elevated eye pressure. The lens appears tilted on slit lamp examination and there are limited angle structures seen on gonioscopy. Which of the following is the least appropriate treatment?




  1. Laser iridotomy



  2. Atropine



  3. Pilocarpine



  4. Acetazolamide


54. (Easy) A 60-year-old woman complains of decreased visual acuity OD. Her vision is 20/60 OD. Her IOP is 36 mm Hg OD. Slit lamp examination is significant for a mid-dilated, fixed pupil associated with a mix of prominent and fine abnormal blood vessels in the anterior-chamber angle. Which answer would you least likely elicit upon taking further history?




  1. Sudden onset of diffusely decreased vision



  2. History of panretinal photocoagulation



  3. Sudden onset of decreased vision in the upper half of the visual field



  4. Episodes of dark vision that self-resolve


55. (Medium) A 65-year-old woman with a history of central retinal vein occlusion presents several months after her initial diagnosis with eye pain and decreased vision in the affected eye. On gonioscopy, you note synechiae and abnormal blood vessels. The patient asks what percentage of patients like her develop this condition, and you answer as below:




  1. 5%



  2. 10%



  3. 25%



  4. 33%


56. (Hard) A recently postoperative cataract surgery patient presents with a diffusely shallow anterior chamber and elevated intraocular pressure. Examination of the posterior segment appears within normal limits. Which of the following is the most appropriate treatment for the likely condition?




  1. Nd:YAG laser treatment



  2. Pilocarpine



  3. Bandage contact lens



  4. Suturing of the main cataract surgery wound


57. (Hard) Which of the following is a diagnostic tool helpful in this condition?




  1. Ultrasound biomicroscopy



  2. CT scan



  3. Argon laser



  4. Pachymetry


58. (Medium) A small child is noted to have a white pupillary reflex. On further examination, a retrolental membrane is noted. Which of the following would be the most likely subtype of glaucoma to develop in this patient?




  1. Inflammatory or uveitic



  2. Chronic angle closure



  3. Open angle



  4. Steroid induced


59. (Easy) A 26-year-old woman with a history of migraine and seasonal allergies presents to your clinic with bilateral eye pain and elevated eye pressure. She is currently using topiramate and fluticasone nasal spray for her medical conditions. What should not be used to treat the most likely etiology of her elevated intracranial pressure?




  1. Acetazolamide



  2. Immediate discontinuation of topiramate



  3. Immediate laser peripheral iridotomy



  4. Atropine


60. (Easy) Which layer of the cornea is affected in this external photograph?




  1. Epithelium



  2. Bowman’s layer



  3. Descemet’s membrane



  4. Endothelium


61. (Medium) What is the most common inheritance pattern of this condition?




  1. Autosomal recessive



  2. Autosomal dominant



  3. X-linked recessive



  4. Sporadic


62. (Easy) This infant would mostly benefit from a referral to which of the following specialists?




  1. Cardiologist



  2. Nephrologist



  3. Gastroenterologist



  4. Dermatologist


63. (Hard) An infant is diagnosed with bilateral cataracts by her pediatrician. She subsequently undergoes cataract surgery in both eyes within the first few months of birth. Which factors may increase her risks of developing glaucoma?




  1. Cataract surgery at the age of 2 years



  2. Small corneal diameter



  3. Uncomplicated cataract surgery



  4. Density of cataract


64. (Easy) What is the normal corneal diameter in a newborn infant?




  1. 8 mm



  2. 9 mm



  3. 10 mm



  4. 11 mm


65. (Easy) At the normal rate of aqueous production, how long would it take for the eye to reaccumulate the volume removed in a 100-µL anterior-chamber paracentesis?




  1. 30 minutes



  2. 40 minutes



  3. 50 minutes



  4. 60 minutes


66. (Medium) Diurnal variation in intraocular pressure greater than ___ mm Hg is suggestive of glaucoma.




  1. 4



  2. 8



  3. 10



  4. 12


67. (Medium) Which factor is least likely to increase intraocular pressure?




  1. Playing a trombone



  2. Yoga



  3. Chronic constipation



  4. Pregnancy


68. (Medium) A 32-year-old African American man presents with intraocular pressure of 25 mm Hg OU and cup to disc ratio of 0.7 OU. Which factor is least likely to promote progression of his glaucoma?




  1. Younger age



  2. Larger cup to disc ratio



  3. Higher intraocular pressure



  4. Race


69. (Easy) A 32-year-old man presents with intraocular pressure of 34 mm Hg OD and 38 mm Hg OS. His cup to disc ratio is 0.9 OD and 0.95 OS. His visual field testing is revealing for superior and inferior arcuate scotomas OS worse than OD. Which gene is associated with his glaucoma diagnosis?




  1. GLC1A



  2. GLC1B



  3. GLC1C



  4. GLC1E


70. (Easy) A patient presents for evaluation of progressive glaucoma. Her visual fields are shown below. Which of the following is the best course for the next step in management?




  1. Start brimonidine in both eyes 2×/d



  2. Observe closely



  3. Obtain neuroimaging



  4. External ocular examination


71. (Medium) An 83-year-old woman with primary open-angle glaucoma controlled after trabeculectomy OU performed 10 years ago presents to your clinic with 1 day of right-sided eye pain and decreased vision. Your examination is notable for injection surrounding the trabeculectomy and 1-mm hypopyon. Which of the following is a risk factor for the development of this condition?




  1. Wearing an eye shield at night



  2. Moderate weight lifting



  3. Swimming with watertight goggles



  4. Thin, avascular bleb


72. (Hard) A 45-year-old man who is undergoing trabeculectomy with mitomcyin C for his right eye due to progressive pigmentary glaucoma. What should be specifically considered during his postoperative period?




  1. Wearing an eye shield at night indefinitely



  2. Prolonged topical antibiotic course



  3. Regular use of ocular lubrication



  4. Delayed laser suture lysis


73. (Medium) Which of the following is most likely the mechanism of action of selective laser trabeculoplasty?




  1. Increased aqueous humor outflow due to small openings created in the trabecular meshwork



  2. Increased aqueous humor outflow due to distortion of the junctions between cells in the trabecular meshwork



  3. Increased aqueous humor outflow mediated by thermal changes to the trabecular meshwork



  4. Increased aqueous humor outflow due to changes in matrix metalloproteinases in the trabecular meshwork


74. (Hard) An 85-year-old man with elevated intraocular pressure that is not resposive to antihypertensive eye drops or acetazolamide. You discuss the risks and benefits of a trial of mannitol with the patient and his family. You should discuss all of the following potential side effects except which one?




  1. Subdural hemorrhage



  2. Subarachnoid hemorrhage



  3. Congestive heart failure



  4. Tinnitus


75. (Medium) A postoperative month-1 trabeculectomy patient presents to clinic and you are asked to consent the patient for a 5-fluorouracil (5-FU) injection. What is a potential risk from the medication that should be discussed with the patient?




  1. Progressive cataract formatoin



  2. Retinal tear



  3. Corneal endothelial disease



  4. Blebitis


76. (Medium) In planning for cataract extraction using phacoemulsification in a patient with an anatomic narrow angle and anterior-chamber depth of 1.9 mm, which of the following might be useful?




  1. High-viscosity viscoelastic



  2. Hydrodissection of the nucleus and phacoemulsification above the iris plane



  3. Decreased bottle height



  4. Creation of a larger main incision


77. (Easy) An 88-year-old man referred to your clinic for advanced glaucoma notes good compliance with his three eye drops and eye visits. He has not noted any recent changes in vision. His best corrected visual acuity is 20/40 in the right eye and 20/200 in the left eye; intraocular pressure is 8 mm Hg in both eyes. The patient is pseudophakic in both eyes and has a cup to disc ratio of 0.95 in both eyes. Which of the following would you most recommend?




  1. Discussion of treatment plan with a family member



  2. Discussion of a low-vision evaluation



  3. Discussion of insurance coverage of medication



  4. Assistance with transportation costs to/from the clinic


78. (Hard) Goldmann’s applanation can yield falsely ___ intraocular pressure readings if excessive fluorescein was instilled and falsely ___ intraocular pressure readings in the setting of high myopia.




  1. Low, low



  2. Low, high



  3. High, high



  4. High, low


79. (Medium) Which of the following lenses is not appropriate for performing the procedure seen here?




  1. Koeppe’s lens



  2. Barkan’s lens



  3. Swan–Jacob lens



  4. Posner’s lens


80. (Hard) The following patient would benefit from which of the following options?




  1. Cataract extraction



  2. Laser peripheral iridotomy alone



  3. Brimonidine



  4. Panretinal photocoagulation


81. (Hard) What systemic findings are associated with this condition?




  1. Hypospadias



  2. Enlarged molars



  3. Mottled skin pigmentation



  4. Ataxia


82. (Medium) The lamina cribrosa of the optic nerve is supplied by which of the following?




  1. The circle of Zinn–Haller



  2. Central retinal artery



  3. Retinal capillaries



  4. Cilioretinal artery


83. (Easy) What is the usual visual field stimulus size on a standard automated visual field performed with a Humphrey perimeter?




  1. ¼ mm2



  2. 1 mm2



  3. 4 mm2



  4. 16 mm2


84. (Hard) In which of the following patients malignant glaucoma is most likely to occur?




  1. A patient with history of pigmentary glaucoma



  2. A patient requiring an in-the-bag lens implant +28 diopters for emmetropia



  3. A patient having axial length of 24 mm



  4. A patient having history of requiring three medications to control intraocular pressure


85. (Medium) How large is a Goldmann size III stimulus compared to a Goldmann size I stimulus?




  1. Two times larger



  2. Four times larger



  3. Eight times larger



  4. Sixteen times larger


86. (Medium) A 50-year-old woman has an intraocular pressure of 26 mm Hg both eyes (OU) despite reliable use of dorzolamide–timolol OU twice a day and latanoprost OU before bed. She has an allergy to brimonidine. You discuss starting a trial of pilocarpine. The patient asks about potential side effects. All of the following should be discussed except which one?




  1. Induced myopia



  2. Retinal detachment



  3. Band keratopathy



  4. Iritis


87. (Medium) A patient presents for a routine appointment with the following appearance. Which of the following is not a reasonable treatment course?




  1. Observation



  2. Autologous blood injection



  3. Antibiotic ointment



  4. Timolol


88. (Hard) Which patient would likely benefit from the largest intraocular pressure lowering with selective laser trabeculoplasty?




  1. Image A



  2. Image B



  3. Image C



  4. Image D


Consider the following story while answering the next two questions:


89. (Easy) A 16-year-old African American patient with the examination shown is being treated in your emergency room for an intraocular pressure of 28 mm Hg. He is unsure of his past medical history but states he has been generally healthy.


Which medication should be used with caution in this situation?




  1. Latanoprost



  2. Brimonidine



  3. Timolol



  4. Dorzolamide


90. (Easy) The patient seen in the figure is tested and found to have normal blood work. He would not be recommended surgery in which of the following scenarios?




  1. Corneal blood staining



  2. Intraocular pressure of 35 mm Hg for 3 days



  3. Intraocular pressure of 35 mm Hg for 36 hours and sickle cell trait



  4. Intraocular pressure of 25 mm Hg for 36 hours and sickle cell anemia


91. (Medium) What is the blood supply to the superficial nerve fiber layer of the optic nerve?




  1. Central retinal artery



  2. Short posterior ciliary arteries



  3. Circle of Zinn–Haller



  4. Contributions from both circle of Zinn–Haller and other short posterior ciliary arteries


92. (Easy) A newborn of 1 month old is being treated for elevated intraocular pressure in the setting of congenital glaucoma. Which of the following medications should not be used?




  1. Timolol



  2. Brimonidine



  3. Dorzolamide



  4. Latanoprost


93. (Hard) What is the most common pathogen in this condition?




  1. Streptococcus



  2. Staphylococcus



  3. Haemophilus influenzae



  4. Fungi


94. (Easy) The Ocular Hypertension Treatment Study identified which of the following as a protective factor against glaucoma development?




  1. Central corneal thickness



  2. Increased age



  3. Increased cup to disc ratio



  4. Higher baseline intraocular pressure


95. (Medium) In the Collaborative Initial Glaucoma Treatment Study which of the following was shown?




  1. Quality of life was worse in the surgical group.



  2. Intraocular pressure was lower in the medically treated group.



  3. Visual field outcomes were similar between the surgically and the medically treated groups.



  4. Early visual acuity loss was greater in the medically treated group.


96. (Easy) A 64-year-old woman brought into the operating room for cataract surgery develops an anterior-chamber hemorrhage upon your initial incision. Which of the following conditions is most likely present?




  1. Fuchs’ heterochromic iridocyclitis



  2. Pigmentary glaucoma



  3. Pseudoexfoliation glaucoma



  4. Traumatic glaucoma


97. (Medium) Which of the following is an appropriate management for this patient 5 years status post trabeculectomy?




  1. Brimonidine



  2. Trabeculectomy revision



  3. Frequent lubrication



  4. Careful observation


98. (Easy) Which of the following is a possible cause of elevated episcleral venous pressure?




  1. The Valsalva maneuver



  2. Thyroid eye disease



  3. Iris neovascularization



  4. primary open-angle glaucoma


99. (Medium) A 50-year-old man was hit in the eye with a bottle cap. Subsequently, he developed a hyphema and an intraocular pressure of 5 mm Hg. His hyphema was self-resolved, and the decision was made to monitor his eye pressure. Two weeks later, he returns to the ER with extreme eye pain and an intraocular pressure of 45 mm Hg. What is the most likely diagnosis?




  1. Recurrent hyphema



  2. Late-onset ocular inflammation



  3. Spontaneous closure of a cyclodialysis cleft



  4. Corneal abrasion


100. (Easy) Which of the following descriptions of visual field artifacts is incorrect?




  1. Lens rim artifact—patient’s prescription vision lens is placed too far from her eye.



  2. False positive—patient does not respond to visual field stimulus in an area she previously has seen.



  3. Cloverleaf artifact—patient loses attention and stops responding as the test progresses.



  4. Fixation loss—patient’s eye loses the fixation target and shifts during test.

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Related posts:

  1. Chapter 3 Lens and Cataract
  2. Chapter 4 Neuro-Ophthalmology
  3. Chapter 7 Refractive Management and Optics
  4. Chapter 6 Pediatric Ophthalmology and Strabismus

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May 9, 2020 | Posted by in OPHTHALMOLOGY | Comments Off on Chapter 2 Glaucoma

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