Glaucoma MCQs: 40 Questions From Basics to Surgery

This is revision material for ophthalmology examinations, not a protocol for managing an individual eye. Before choosing an answer, place the stem in one of four bins: angle and mechanism; pressure and aqueous route; optic-nerve structure; or visual function. That ordering prevents the common error of calling an eye “glaucoma” from one pressure reading or one red OCT sector alone.¹

The questions deliberately move from definitions to procedures. Try each answer first, then read the explanation as an error-log entry. A useful second pass is to tag every miss as mechanism, sign, test or intervention; revise that gap in the glaucoma topic guide before doing another mixed set.

1. Foundations: what is actually being tested?

1. Which finding is most central to a diagnosis of glaucoma?
   Answer: Characteristic glaucomatous optic neuropathy, supported by structural and/or functional evidence.
   Why: Raised IOP is an important risk factor and treatment target, but it is not itself the definition. Typical damage can occur with IOP measurements in the conventional reference range.¹

2. An IOP of 28 mmHg with a normal disc, field and angle proves primary open-angle glaucoma (POAG). True or false?
   Answer: False.
   Why: It establishes neither characteristic damage nor the mechanism. In an exam answer, call this ocular hypertension or a glaucoma-suspect scenario pending the full assessment.

3. What investigation establishes angle anatomy?
   Answer: Gonioscopy.
   Why: Van Herick assessment can screen peripheral chamber depth, but it does not replace gonioscopy for identifying angle structures, iridotrabecular contact or peripheral anterior synechiae.²

4. In POAG, the angle is usually what on gonioscopy?
   Answer: Open.
   Why: “Open” describes angle configuration, not absence of outflow resistance. The conventional pathway can still have increased resistance at the trabecular meshwork.

5. What are the two major aqueous outflow routes?
   Answer: Conventional trabecular outflow and uveoscleral outflow.
   Why: For the conventional route, say trabecular meshwork → Schlemm canal → collector channels/episcleral veins. It makes drug and laser questions easier to reason through.

6. Goldmann applanation tonometry is classically based on which principle?
   Answer: Imbert–Fick.
   Why: In practice, the cornea is not an ideal thin, dry sphere. Corneal thickness and biomechanics influence interpretation, so a fixed numerical “correction” is not a complete answer.³

7. Normal-tension glaucoma means there is no pressure-related issue. True or false?
   Answer: False.
   Why: It is the label for typical glaucomatous damage with IOP measurements in the statistically conventional range. It does not abolish the need to interpret measurements, angle, disc and differential diagnoses.

8. Which is the safer glaucoma-suspect follow-up comparison: one cup:disc ratio or serial structure-function evidence?
   Answer: Serial structure-function evidence.
   Why: Disc size, rim contour, RNFL, IOP, angle and repeatable field change are interpreted together. A large cup alone may be physiological.

2. Angle and secondary-mechanism questions

9. Shaffer grade 0 means what?
   Answer: No angle structures are visible; the angle is closed.
   Why: Learn the two ends: grade 4 is very wide open, grade 0 is closed. Intermediate grades are descriptive, not a substitute for the whole clinical context.

10. Iris bombe is the characteristic anatomical result of which mechanism?
    Answer: Pupillary block.
    Why: Pressure behind the iris pushes its peripheral part forward. In a mechanism question, name the pressure gradient rather than just saying “angle closure.”

11. A patent peripheral iridotomy is present but the angle remains narrow. What mechanism should the stem make you consider?
    Answer: A non-pupillary-block component, classically plateau iris configuration.
    Why: Iridotomy relieves relative pupillary block; it does not change an anteriorly positioned ciliary body.²

12. A painful red eye with haloes, nausea and a mid-dilated sluggish pupil should be treated in an MCQ as which pattern?
    Answer: Acute angle closure.
    Why: This is an urgent clinical pattern, not an invitation to write a treatment prescription in an examination answer. First identify the angle-closure mechanism and urgency.

13. Pseudoexfoliative material is classically sought at which two sites?
    Answer: The pupillary margin and anterior lens capsule.
    Why: Pseudoexfoliation is a secondary open-angle glaucoma association. Marked trabecular pigmentation and pressure variation are useful supporting clues, not standalone diagnostic criteria.

14. A Krukenberg spindle is pigment deposited where?
    Answer: On the corneal endothelium.
    Why: It points toward pigment dispersion when read with iris transillumination defects and dense angle pigmentation. The mechanism is pigment loading of the trabecular meshwork.

15. What feature makes neovascular glaucoma a secondary angle-closure process at a later stage?
    Answer: Contraction of a fibrovascular membrane causes synechial angle closure.
    Why: The early clue is iris or angle neovascularisation; the stem is usually testing the transition from new vessels to tractional closure.

16. Steroid response is generally classified as what form of glaucoma mechanism?
    Answer: Secondary open-angle glaucoma.
    Why: The high-yield association is corticosteroid exposure with impaired trabecular outflow. Do not infer the route or duration of exposure from an MCQ unless supplied.

17. A widened ciliary-body band after blunt trauma suggests what?
    Answer: Angle recession.
    Why: It represents structural angle injury and may be associated with later outflow dysfunction. The examiner is testing recognition of a traumatic secondary-glaucoma mechanism.

18. In uveitic glaucoma, can inflammation coexist with more than one pressure mechanism?
    Answer: Yes.
    Why: Trabeculitis, inflammatory debris, synechiae and treatment effects can all matter. Avoid the simplistic claim that every inflamed eye has high IOP from one route.

3. Disc, OCT and field correlation

19. Which is a classic early glaucomatous field pattern: nasal step or homonymous hemianopia?
    Answer: Nasal step.
    Why: A homonymous defect localises behind the chiasm. Nasal steps, paracentral defects and arcuate defects are the useful glaucoma pattern family.

20. A Bjerrum scotoma follows what anatomy?
    Answer: The arcuate retinal nerve-fibre bundles.
    Why: The word “arcuate” should make you correlate field loss with RNFL anatomy and disc-rim change rather than with a lesion behind the chiasm.

21. Does an OCT printout with a red sector diagnose glaucoma by itself?
    Answer: No.
    Why: Check scan quality, segmentation, disc anatomy, refractive context and concordance with examination and field. Database colour coding is a comparison tool, not a diagnosis.¹

22. What optic-disc change is more concerning than a large cup alone?
    Answer: Progressive focal rim thinning or notching in the appropriate context.
    Why: Large discs can have large physiological cups. The question is asking for pattern and progression, not a single cup:disc cut-off.

23. A disc haemorrhage should be interpreted how in a glaucoma question?
    Answer: As a clinically important progression/risk clue requiring structural and functional correlation.
    Why: It is not synonymous with a diagnosis, but it makes a casual “stable physiological cup” answer less convincing.

24. A single abnormal field should establish progression. True or false?
    Answer: False.
    Why: Reliability indices, learning effect, media opacity, pattern and serial correlation matter. A repeatable change that agrees with disc/RNFL evidence is stronger.³

25. Why can a relative afferent pupillary defect be absent in mild, symmetric POAG?
    Answer: RAPD reflects asymmetric afferent dysfunction; mild symmetric damage may not create enough inter-eye difference.
    Why: A normal RAPD does not exclude glaucoma.

26. The ISNT rule is best described as what?
    Answer: A screening heuristic for rim configuration.
    Why: It can be violated in normal discs and may look preserved in glaucoma. Do not elevate it to a diagnostic rule.

4. Drops and laser: reason from the aqueous route

27. Which topical class classically increases uveoscleral outflow?
    Answer: Prostaglandin analogues.
    Why: This is a mechanism question. Specific treatment choice is individualised clinically; for revision, connect the class to the outflow route.

28. What is the core pressure-lowering mechanism of topical carbonic-anhydrase inhibitors?
    Answer: Reduced aqueous humour formation.
    Why: The ciliary epithelium is the production site. This contrasts with drugs or procedures that chiefly alter an outflow route.

29. Beta-blocker drops require particular caution with which broad history?
    Answer: Bronchospastic airway disease and bradyarrhythmia/cardiac conduction concerns.
    Why: In an SBA, choose systemic contraindication awareness rather than a vague “allergy” answer. Real prescribing requires an individual review.

30. Pilocarpine has what two immediately testable effects?
    Answer: Miosis and ciliary-muscle contraction.
    Why: Its anatomical effects explain many older examination stems; do not confuse it with a drug whose main effect is reduced aqueous production.

31. Selective laser trabeculoplasty acts at which tissue?
    Answer: The trabecular meshwork.
    Why: It is an open-angle intervention. A stem asking about a permanently closed synechial angle is testing whether you distinguish accessible trabecular meshwork from closure.

32. Compared with SLT, argon laser trabeculoplasty has more structural thermal effect. True or false?
    Answer: True.
    Why: The comparison tests laser-tissue interaction, not a blanket claim that one procedure is correct for every open-angle patient.

33. Which laser directly addresses relative pupillary block?
    Answer: Laser peripheral iridotomy.
    Why: Its role is to create an alternative aqueous communication through the peripheral iris; it does not reverse established glaucomatous damage.

5. Filtering surgery, tubes and childhood glaucoma

34. After a trabeculectomy, aqueous is intended to drain into what visible reservoir?
    Answer: A subconjunctival filtering bleb.
    Why: The procedure creates a guarded fistula to subconjunctival space. This differs from a tube, which routes aqueous to an end-plate reservoir.

35. Why may mitomycin C be used during filtration surgery?
    Answer: To reduce postoperative subconjunctival scarring.
    Why: The tested concept is wound-modulation and bleb survival. It is not an instruction about dose, concentration or clinical suitability.

36. Name two exam-differential considerations for a shallow anterior chamber after filtration surgery.
    Answer: Overfiltration and aqueous misdirection.
    Why: The aim is differential thinking. A real postoperative eye needs prompt supervised assessment, not an MCQ-derived management step.

37. Where does a glaucoma drainage device ultimately direct aqueous?
    Answer: To a plate/end-plate reservoir beneath the conjunctiva.
    Why: Its tube bypasses the anterior outflow obstruction; do not confuse the plate reservoir with Schlemm canal.

38. Cyclodestructive procedures lower IOP by acting on which structure?
    Answer: The ciliary processes.
    Why: The mechanism is reduced aqueous production, unlike a filtering operation that creates an alternative drainage route.

39. What is the classic triad in primary congenital glaucoma?
    Answer: Epiphora, photophobia and blepharospasm.
    Why: Enlarged cornea/eye and corneal clouding may also appear. The infant eye is distensible, explaining buphthalmos.

40. Haab striae are breaks in which corneal layer?
    Answer: Descemet membrane.
    Why: Pair this with childhood globe distensibility. It is a common way examiners separate congenital glaucoma from adult disease.

A 20-minute second-pass routine

Redo only the questions you missed, but say the answer in a complete sentence: “This is a secondary open-angle mechanism because …”; “this field pattern is glaucomatous because …”; or “this procedure changes production/outflow by …”. That small discipline exposes memorised labels without mechanisms. Then use the site’s free ophthalmology MCQs for an untimed mixed check. If you want a topic-organised revision layer, inspect the published Glaucoma Exam Ready Notes and its sample; verify current product details on the page before purchase.

For source checking, use the European Glaucoma Society guidance and AAO Preferred Practice Pattern rather than treating this set as a clinical manual. Examination rules, guidelines and drug information should be rechecked at final editorial review.