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Clinical Ophthalmology Finalised Past Paper Answers
Glaucoma
i) What is the definition of glaucoma?
Glaucoma refers to the group of disorders in which there is eventual development of optic neuropathy with
characteristics of changes in the optic nerve head. These changes are likely to lead to a depression of visual
function and eventual loss of visual field. Raised IOP often represents to be a significant factor in its
development. It is associated with systemic and ocular syndromes.
Incidence – 2nd commonest cause of visual impairment in the UK (MD is number one), account for 10% of
blind registrants in the UK, 200 cases per 100,000 annually at the age of 80. FH- 6x increase in 1st degree
relative affected.
ii) What are the 3 main types of glaucoma? (8)
Primary open angle – no symptoms seen. The patient presents with optic nerve damage, VF defect, raised
IOP and an open angle. In this category, we can also get NTG this is the same as POAG except the pressure
are normal (under 21). NTG is less aggressive then POAG.
Primary angle closure- this is when the angle between the iris and the trabecular meshwork comes in full
contact and the angle is then referred to as closed. There are three different types of PACG. This includes
Chronic, Intermittent and Acute.
Secondary open angle- when the angle closes or becomes in contact with the iris due to a secondary reason.
(pathology) Secondary glaucoma refers to any form of glaucoma in which there is an identifiable cause of
increased eye pressure, resulting in optic nerve damage and vision loss. As with
primary glaucoma, secondary glaucoma can be of the open-angle or angle-closure type and it can occur in
one or both eyes
List 10 features of a glaucomatous disc (5)
Disc changes include:
1. Notching- focal loss of tissue, usually nasally or superiorly
2. Peripapillary atrophy-
a. Alpha zone – superficial RPE changes, larger and more common in glaucoma
b. Beta zone – chorioretinal atrophy, the zone is larger and more common in glaucoma. A sign
of progression. Location can indicate orientation of vision loss.
3. C: D ratio enlargement (0.5/0.6)
4. Blood vessel position
a. Boyoneting- double angulation of BV, with NRR loss.
b. Baring of circumlinear BV, early signing of NRR thinning characterized by a space between
the NRR and superficial BV
5. Rim thinning- loss of ISNT rule
6. Pallor
7. APON (acquired pit optic neuropath)
8. Haemorrhage – more common in NTG then POAG. Indicates a defect in the nerve supply or start of
one
9. Nerve fibre layer defects
10. Laminar dots- grey dot like fenestrations in the lamina cribosa that are exposed when NRR recedes
11. Translucency of the NRR
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12. Asymmetry of cupping between the patients eyes.
b) Describe the different types of closed angle glaucoma, including their underlying mechanisms.
Use diagrams as appropriate. (15)
The 2 main sub categories of closed angle glaucoma, these include Primary closed angle Glaucoma and
secondary closed angle glaucoma.
PACG- This occurs in anatomically predisposed eyes, without any other pathology, in which vision is
threatened by elevation of IOP because of obstruction of aqueous outflow by occlusion of the trabecular
meshwork by the peripheral iris. PACG term can only be used when the result of the above process has
resulted in optic nerve damage and visual field loss. The causes of this type of glaucoma include:
• Hypermetropia (+) – more chances of angle closure
• Shallow AC
• Small eyes
• Anteriorly inserted iris
• Increase in lens size
• Dilation of the pupil
Classification of PACG:
Acute – end-point closure. Emergency. Dilation of the pupil results to the angle becoming closed.
Signs
• Red eye
• Fixed mid dilated pupil
• Hazy blue/green cornea
• Iritis – inflammation of the iris
• IOP higher then 40mmHg
Symptoms
• Blurred vision/haloes
• Brow ache/headache
• Nausea
Intermittent – the angle is narrow- but still open, however certain physiological states (producing dilation)
lead to transient rises in IOP which resolves over variable periods of time. – this can give us transient
symptoms of acute angle closure.
Signs
• Narrow Angle
• Raised or normal IOP
• Shallow AC
• ITC on gonioscopy
• Hypermetropia
• +/- Abnormal optic disc cupping
• +/- Abnormal visual field
Symptoms
• Intermittent brow ache
• Haloes
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Chronic- more common, can often be referred to as POAG (no symptoms). The iris slowly meets an
increasing area of the TM, resulting in dysfunction and a gradual increase in IOP.
o Raised/normal IOP
o Shallow AC
o Hypermetropia
o Abnormal VF
o ITC on gonioscopy
o Abnormal optic disc cupping
• Plateau iris syndrome –
o Anatomical iris configuration – anteriorly displaced ciliary body position or anteriorly
inserted/thicker iris. This pushes the iris forward.
o Angle appears narrow and crowded, gonioscopy shows a ‘double hump” sign
o They often have a normal and modern size of AC but they get due to ciliary body is rotated
forward and there is narrow recess to get into the angle.
o Patient may be given pilocarpine, and if IOP still increases the lens may need to be taken
out.
Secondary closed angle glaucoma is due to the reason that pathology has resulted in the angle to close such
as
• Phacomorphic – the lens gets bigger
• Post vitreoretinal or post corneal graft surgery- the retina gets pushed forward after surgery due to
gas and silicon oil residue.
• Post segment tumours- can be benign or malignant
• Uveitis- inflammation
• Trauma- can cause angle to close
• Melanoma- tumour of the melanin forming cells. Malignant tumour associated with cancer
• Ectopia lentis – genetic condition, patients who have weak zonules- with time it breaks away and
the lens will shift its position. If the lens moves, the iris will push forward- eventually closing the
angle.
• Rubeosis iridis: when there is ischemia in the retina, diabetics get ischemia in the retina, it can
cause neovascularisation on retina and the iris
• Aqueous misdirection syndrome- rare condition which can happen to patient who have undergone
any type of ocular surgery. Surgery fluid that is used and produced by the ciliary body chooses an
alternative route and goes behind the ciliary body and pushes the iris forward increasing IOP.
You refer a healthy 50-year-old male who is not taking any systemic medication. The
ophthalmologist confirms your diagnosis of POAG.
i) List 5 clinical characteristics of POAG. (5)
1. Open angle
2. High pressures (21 or above)
3. Optic nerve damage
4. VF Defect
5. There may be no symptoms until advanced or a paracentral defect is present
st nd rd
ii) State the order of choice of medication type prescribed for POAG (i.e. 1 line, 2 line, 3
th
line and 4 line). (4)
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The order of prescribing:
1. 1st line = prostaglandin analogue or beta blocker (uniocular trials= so you would do one eye and
then wait to see if it works; if it does then do the other eye)
2. 2nd line= prostaglandin analogue or beta blocker
3. 3rd line= carbonic anhydrase or alpha 2 antagonist
4. 4th line- rarely as three above pilocarpine
iii) For the two most commonly prescribed first line glaucoma medications, briefly state
their mechanism of action. (4)
Prostaglandin: These increase analogue, increased uveoscleral outflow by the ciliary muscle relaxation-
decreases IOP by roughly 30-35%. For example- Latanoprost (Xalatan). Side effects include
Side effects:
• Mild conjunctival hyperaemia
• Mild punctate keratopathy
• Foreign body sensation/ ocular irritation
• Increased iris pigmentation 20%
• Lengthening of the eyelashes
Beta-blocker: Topical beta-blockers reduce the intraocular pressure (IOP) by blockade of sympathetic nerve
endings in the ciliary epithelium causing a fall in aqueous humour production.
Beta blocker Side effects: OCULAR
• Punctate keratopathy
• Dry eye syndromes
• Burning/stinging
• Corneal hypaesthesia
A patient attends for a routine eye examination. The patient does not attend the hospital for any
reason and has no history of any eye problems. On examination, her intra-ocular pressure
measures 28mmHg in both eyes using Goldmann tonometry. On Van Hericks her anterior chamber
angles appear open.
b) What is your management of the conditions described in part a), above? (3)
Since the pressures are over 21 and the angle appear open it may be OHT. I would conduct other tests to see
if there is any other glaucomatous changes such as optic nerve damage or visual filed loss. If there is no
damage i would manage this as a routine referral.
For future management, it can be advised to eat reducing IOP foods such as CHOCOLATEEEE and grapes.
They may be prescribed with topical hypotensive.
b) Describe the main surgical treatments of glaucoma (trabeculoplasty, iridotomy,
trabeculectomy), mentioning the general indications of use. (6)
YAG iridotomy: this is used for angle closure glaucoma. A small hole is made in the superior iris and it
relives pupil block. This may reduce intraocular pressure in angle closure cases. This has a low risk- the main
risk of this treatment is inflammation or bleeding. It may make the Gonio angle wider and patient may
rarely experience glare. The main aim of this is to re-establish communication between the posterior and
anterior chambers by making an opening in the peripheral iris.
Main indications:
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Clinical Ophthalmology Finalised Past Paper Answers
Glaucoma
i) What is the definition of glaucoma?
Glaucoma refers to the group of disorders in which there is eventual development of optic neuropathy with
characteristics of changes in the optic nerve head. These changes are likely to lead to a depression of visual
function and eventual loss of visual field. Raised IOP often represents to be a significant factor in its
development. It is associated with systemic and ocular syndromes.
Incidence – 2nd commonest cause of visual impairment in the UK (MD is number one), account for 10% of
blind registrants in the UK, 200 cases per 100,000 annually at the age of 80. FH- 6x increase in 1st degree
relative affected.
ii) What are the 3 main types of glaucoma? (8)
Primary open angle – no symptoms seen. The patient presents with optic nerve damage, VF defect, raised
IOP and an open angle. In this category, we can also get NTG this is the same as POAG except the pressure
are normal (under 21). NTG is less aggressive then POAG.
Primary angle closure- this is when the angle between the iris and the trabecular meshwork comes in full
contact and the angle is then referred to as closed. There are three different types of PACG. This includes
Chronic, Intermittent and Acute.
Secondary open angle- when the angle closes or becomes in contact with the iris due to a secondary reason.
(pathology) Secondary glaucoma refers to any form of glaucoma in which there is an identifiable cause of
increased eye pressure, resulting in optic nerve damage and vision loss. As with
primary glaucoma, secondary glaucoma can be of the open-angle or angle-closure type and it can occur in
one or both eyes
List 10 features of a glaucomatous disc (5)
Disc changes include:
1. Notching- focal loss of tissue, usually nasally or superiorly
2. Peripapillary atrophy-
a. Alpha zone – superficial RPE changes, larger and more common in glaucoma
b. Beta zone – chorioretinal atrophy, the zone is larger and more common in glaucoma. A sign
of progression. Location can indicate orientation of vision loss.
3. C: D ratio enlargement (0.5/0.6)
4. Blood vessel position
a. Boyoneting- double angulation of BV, with NRR loss.
b. Baring of circumlinear BV, early signing of NRR thinning characterized by a space between
the NRR and superficial BV
5. Rim thinning- loss of ISNT rule
6. Pallor
7. APON (acquired pit optic neuropath)
8. Haemorrhage – more common in NTG then POAG. Indicates a defect in the nerve supply or start of
one
9. Nerve fibre layer defects
10. Laminar dots- grey dot like fenestrations in the lamina cribosa that are exposed when NRR recedes
11. Translucency of the NRR
Downloaded by Sylvester Kanyi ()
, lOMoARcPSD|13728229
12. Asymmetry of cupping between the patients eyes.
b) Describe the different types of closed angle glaucoma, including their underlying mechanisms.
Use diagrams as appropriate. (15)
The 2 main sub categories of closed angle glaucoma, these include Primary closed angle Glaucoma and
secondary closed angle glaucoma.
PACG- This occurs in anatomically predisposed eyes, without any other pathology, in which vision is
threatened by elevation of IOP because of obstruction of aqueous outflow by occlusion of the trabecular
meshwork by the peripheral iris. PACG term can only be used when the result of the above process has
resulted in optic nerve damage and visual field loss. The causes of this type of glaucoma include:
• Hypermetropia (+) – more chances of angle closure
• Shallow AC
• Small eyes
• Anteriorly inserted iris
• Increase in lens size
• Dilation of the pupil
Classification of PACG:
Acute – end-point closure. Emergency. Dilation of the pupil results to the angle becoming closed.
Signs
• Red eye
• Fixed mid dilated pupil
• Hazy blue/green cornea
• Iritis – inflammation of the iris
• IOP higher then 40mmHg
Symptoms
• Blurred vision/haloes
• Brow ache/headache
• Nausea
Intermittent – the angle is narrow- but still open, however certain physiological states (producing dilation)
lead to transient rises in IOP which resolves over variable periods of time. – this can give us transient
symptoms of acute angle closure.
Signs
• Narrow Angle
• Raised or normal IOP
• Shallow AC
• ITC on gonioscopy
• Hypermetropia
• +/- Abnormal optic disc cupping
• +/- Abnormal visual field
Symptoms
• Intermittent brow ache
• Haloes
Downloaded by Sylvester Kanyi ()
, lOMoARcPSD|13728229
Chronic- more common, can often be referred to as POAG (no symptoms). The iris slowly meets an
increasing area of the TM, resulting in dysfunction and a gradual increase in IOP.
o Raised/normal IOP
o Shallow AC
o Hypermetropia
o Abnormal VF
o ITC on gonioscopy
o Abnormal optic disc cupping
• Plateau iris syndrome –
o Anatomical iris configuration – anteriorly displaced ciliary body position or anteriorly
inserted/thicker iris. This pushes the iris forward.
o Angle appears narrow and crowded, gonioscopy shows a ‘double hump” sign
o They often have a normal and modern size of AC but they get due to ciliary body is rotated
forward and there is narrow recess to get into the angle.
o Patient may be given pilocarpine, and if IOP still increases the lens may need to be taken
out.
Secondary closed angle glaucoma is due to the reason that pathology has resulted in the angle to close such
as
• Phacomorphic – the lens gets bigger
• Post vitreoretinal or post corneal graft surgery- the retina gets pushed forward after surgery due to
gas and silicon oil residue.
• Post segment tumours- can be benign or malignant
• Uveitis- inflammation
• Trauma- can cause angle to close
• Melanoma- tumour of the melanin forming cells. Malignant tumour associated with cancer
• Ectopia lentis – genetic condition, patients who have weak zonules- with time it breaks away and
the lens will shift its position. If the lens moves, the iris will push forward- eventually closing the
angle.
• Rubeosis iridis: when there is ischemia in the retina, diabetics get ischemia in the retina, it can
cause neovascularisation on retina and the iris
• Aqueous misdirection syndrome- rare condition which can happen to patient who have undergone
any type of ocular surgery. Surgery fluid that is used and produced by the ciliary body chooses an
alternative route and goes behind the ciliary body and pushes the iris forward increasing IOP.
You refer a healthy 50-year-old male who is not taking any systemic medication. The
ophthalmologist confirms your diagnosis of POAG.
i) List 5 clinical characteristics of POAG. (5)
1. Open angle
2. High pressures (21 or above)
3. Optic nerve damage
4. VF Defect
5. There may be no symptoms until advanced or a paracentral defect is present
st nd rd
ii) State the order of choice of medication type prescribed for POAG (i.e. 1 line, 2 line, 3
th
line and 4 line). (4)
Downloaded by Sylvester Kanyi ()
, lOMoARcPSD|13728229
The order of prescribing:
1. 1st line = prostaglandin analogue or beta blocker (uniocular trials= so you would do one eye and
then wait to see if it works; if it does then do the other eye)
2. 2nd line= prostaglandin analogue or beta blocker
3. 3rd line= carbonic anhydrase or alpha 2 antagonist
4. 4th line- rarely as three above pilocarpine
iii) For the two most commonly prescribed first line glaucoma medications, briefly state
their mechanism of action. (4)
Prostaglandin: These increase analogue, increased uveoscleral outflow by the ciliary muscle relaxation-
decreases IOP by roughly 30-35%. For example- Latanoprost (Xalatan). Side effects include
Side effects:
• Mild conjunctival hyperaemia
• Mild punctate keratopathy
• Foreign body sensation/ ocular irritation
• Increased iris pigmentation 20%
• Lengthening of the eyelashes
Beta-blocker: Topical beta-blockers reduce the intraocular pressure (IOP) by blockade of sympathetic nerve
endings in the ciliary epithelium causing a fall in aqueous humour production.
Beta blocker Side effects: OCULAR
• Punctate keratopathy
• Dry eye syndromes
• Burning/stinging
• Corneal hypaesthesia
A patient attends for a routine eye examination. The patient does not attend the hospital for any
reason and has no history of any eye problems. On examination, her intra-ocular pressure
measures 28mmHg in both eyes using Goldmann tonometry. On Van Hericks her anterior chamber
angles appear open.
b) What is your management of the conditions described in part a), above? (3)
Since the pressures are over 21 and the angle appear open it may be OHT. I would conduct other tests to see
if there is any other glaucomatous changes such as optic nerve damage or visual filed loss. If there is no
damage i would manage this as a routine referral.
For future management, it can be advised to eat reducing IOP foods such as CHOCOLATEEEE and grapes.
They may be prescribed with topical hypotensive.
b) Describe the main surgical treatments of glaucoma (trabeculoplasty, iridotomy,
trabeculectomy), mentioning the general indications of use. (6)
YAG iridotomy: this is used for angle closure glaucoma. A small hole is made in the superior iris and it
relives pupil block. This may reduce intraocular pressure in angle closure cases. This has a low risk- the main
risk of this treatment is inflammation or bleeding. It may make the Gonio angle wider and patient may
rarely experience glare. The main aim of this is to re-establish communication between the posterior and
anterior chambers by making an opening in the peripheral iris.
Main indications:
Downloaded by Sylvester Kanyi ()
