Test 42
(Matching Paper: Glaucoma)

1. Match the history (a-d ) with the most suitable medication given (A-H):

A. bromonidine B. pilocarpine C. iodipine D. latanoprost

E. timolol F. oral acetazolamide G. dorzolamide H. dipivefrine

 

a.	A 78 year-old woman has been taking an anti-glaucoma eyedrop for the past 20 years. The pressures in both eyes measure 18mmHg.  Examination reveals the presence of black deposits in the lower tarsal  conjunctiva of both eyes. What medication is she likely to be on?    Answer H. Dipivefrine is the prodrug of adrenaline. It is seldom used nowadays. Adrenaline is oxidized to adrenochrome and can cause black conjunctival  deposits.
b.	A 54 year-old woman with a past history of ophthalmic shingle develops a right uveitis and raised intraocular pressure measuring 30mmHg. There is  also mild corneal oedema. She is on tricyclic antidepressant for post-herpetic neuralgia. Which anti-glaucoma medication is preferable? Answer E. Timolol is the treatment of choice as the patient has no history of  shortness of breath. Pilocarpine and latanoprost can exacerbate the inflammation. In the presence of corneal decompensation, carbonic anhydrase inhibitor is contraindicated. Bromonidine is contraindicated in patients taking tricyclic antidepressant as it can cause hypertensive crisis.
c.	A 78 year-old asthmatic man has bilateral mild ptosis and early glaucoma with raised intraocular pressures of RE 25 and LE 28. He was given an anti-glaucoma treatment. On review four weeks later, the pressures in both eyes are controlled and the ptosis improves. Which anti-glaucoma medication  might have been given in this patient? Answer A. Bromonidine can cause eyelid retraction and may explain the reduction of the ptosis. Dipivefrine is also a possibility but it is rarely prescribed nowadays.
d.	A 29 year-old woman has bilateral pigment dispersion syndrome and raised intraocular pressures measuring RE 39 and LE38. She is a keen sport woman and trains regularly for long-distance running. Which anti-glaucoma medication is preferable? Answer D. Latanoprost is the drug of choice. Timolol is contraindicated as it may affect the physical activity of the patient. Pilocarpine is not suitable for  young patients as it can induce myopia and headache. For the pressures  of this patient, latanoprost (reduction of 35% of IOP from baseline) is more effective than dorzolamide (13-21% reduction from baseline) or brominidine (27% reduction of IOP from baseline) in lowering the pressure. In addition, there is less side effects with latanoprost and the patient only needs to apply it once a day.

 
2. Match the following history and clinical signs (a-d) with the most likely diagnosis
    (A-N) listed below. 

A. Schwartz's syndrome B. carotid-cavernous fistula C. phacomorphic glaucoma D. phacoanaphylactic glaucoma E. phacolytic glaucoma F. iridocorneal endothelial syndrome G. iridoschisis

H. posterior polymorphous dystrophy I.  bulphthalmos J.  malignant glaucoma K. epithelial ingrowth L.  neurofibromatosis M. Peter's anomaly N.  Axenfeld's syndrome

 

a.	A 28 year-old patient has bilateral prominent Schwalbe's line with peripheral anterior  synechiae. The pressures in both eyes measure R29 and L28. The cornea in both eyes appear normal. Answer N. Axenfeld's syndrome has iris abnormalities such as hypoplasia of the anterior layer of the iris stroma. In some cases, the pupil may be situated abnormally  (corectopia) or is abnormal in shape (slit pupil). Multiple pupils (polycoria) and false pupils (pseudocoria) also occur. Prominence and anterior displacement of  Schwalbe's line into the clear portion of the cornea, termed posterior embryotoxon is a common feature. Just over 50% of patients have glaucoma.
b.	A 46 year-old man has bilateral glaucoma. Examination reveals peripheral anterior  synechiae, corectopia and iris atrophy in both eyes. In additions, there are band like  lesions and islands of endothelial changes at the level of Descemet's membrane. Answer H. Posterior polymorphous dystrophy may be confused with ICE syndrome.  Less than 15% develop glaucoma. Unlike ICE, it is a bilateral condition and has  an autosomal dominant inheritance. Findings on examination show posterior cornea with single or groups of blisters/vesicles, band like lesions with scalloped edges, or islands with endothelial changes at level of Descemet's membrane. Some have  peripheral anterior synechiae, corectopia, iris atrophy and it is these features that make it resemble ICE syndrome. However, the majority of the patients are asymptomatic.
c.	A 70 year-old woman underwent a right trabeculectomy for primary open angle  glaucoma. 24 hours after the operation the anterior chamber is noted to be shallow and the intraocular pressure measures 43mmHg. The iridectomy appears patent. Answer J. Malignant glaucoma also calls ciliary block glaucoma or aqueous misdirection. The characteristic findings are elevated IOP after filtering surgery, with central  shallowing of the anterior chamber, a patent iridotomy or iridectomy, and the absence of suprachoroidal effusion or haemorrhage. This occurs in 0.6 to 4% of  acute angle-closure glaucoma undergoing intraocular surgery.
d.	A 54 year-old man has a red right eye and decreased vision. On examination, he has  a superior retinal detachment and a mild anterior chamber inflammation. The intraocular  pressure measures 32mmHg and responded poorly to anti-glaucoma eyedrops.  Post-operatively, the intraocular pressure returns to normal spontaneously without  further treatment. Answer A. Schwartz's syndrome is open-angle glaucoma associated rhegmatogenous retinal  detachment. There is usually mild anterior chamber reaction. The cause of the glaucoma is not known but has been attributed to iridocyclitis or blockage of the trabecular  meshwork by retinal pigment epithelium cells or photoreceptors. The glaucoma typically resolves following retinal detachment operation.

 

More MCQs