MCQ Quiz: Management of Glaucoma

Glaucoma, a group of eye conditions leading to progressive optic nerve damage, is a leading cause of irreversible blindness worldwide. The management of this chronic disease is a cornerstone of pharmacy practice, particularly when caring for geriatric patients. As detailed in the Patient Care VII curriculum’s “Management of Glaucoma” unit, the primary goal of therapy is to lower intraocular pressure (IOP) to prevent further vision loss. This requires a thorough understanding of aqueous humor dynamics, the pharmacology of various topical and systemic medications, and the crucial role of patient counseling on proper administration and adherence. This quiz will test your knowledge of the comprehensive management of glaucoma, from first-line therapies to side effect profiles and patient care considerations.

1. What is the primary therapeutic goal in the management of open-angle glaucoma?

• a) Reversing existing optic nerve damage
• b) Curing the disease with a single course of treatment
• c) Lowering intraocular pressure (IOP) to prevent further vision loss
• d) Improving the patient’s color vision Answer: c) Lowering intraocular pressure (IOP) to prevent further vision loss

2. Prostaglandin analogs, such as latanoprost and travoprost, are considered first-line therapy for open-angle glaucoma. What is their primary mechanism of action?

• a) They decrease the production of aqueous humor.
• b) They increase aqueous humor outflow through the trabecular meshwork.
• c) They increase aqueous humor outflow through the uveoscleral pathway.
• d) They are miotic agents that constrict the pupil. Answer: c) They increase aqueous humor outflow through the uveoscleral pathway.

3. A common and notable side effect of prostaglandin analogs that pharmacists should counsel patients on is:

• a) Temporary stinging and burning upon instillation.
• b) Permanent darkening of the iris color and eyelash growth.
• c) Severe bradycardia and hypotension.
• d) A metallic taste in the mouth. Answer: b) Permanent darkening of the iris color and eyelash growth.

4. Topical beta-blockers, like timolol, lower IOP by which mechanism?

• a) Increasing uveoscleral outflow
• b) Increasing trabecular outflow
• c) Decreasing the production of aqueous humor by the ciliary body
• d) Constricting the pupil to open the trabecular meshwork Answer: c) Decreasing the production of aqueous humor by the ciliary body

5. The use of a non-selective beta-blocker like timolol is relatively contraindicated in patients with which comorbid conditions?

• a) Hypertension and diabetes
• b) Asthma, COPD, and bradycardia
• c) Osteoarthritis and hyperlipidemia
• d) Gout and kidney stones Answer: b) Asthma, COPD, and bradycardia

6. Which topical beta-blocker is beta-1 selective, making it a potentially safer option for a glaucoma patient with mild asthma?

• a) Timolol
• b) Levobunolol
• c) Carteolol
• d) Betaxolol Answer: d) Betaxolol

7. Brimonidine, an alpha-adrenergic agonist, has a dual mechanism of action for lowering IOP. What are the two mechanisms?

• a) It increases aqueous production and decreases uveoscleral outflow.
• b) It decreases aqueous humor production and increases uveoscleral outflow.
• c) It increases trabecular outflow and constricts the pupil.
• d) It blocks beta receptors and inhibits carbonic anhydrase. Answer: b) It decreases aqueous humor production and increases uveoscleral outflow.

8. A common side effect that can limit the use of brimonidine is:

• a) Iris darkening
• b) Allergic conjunctivitis
• c) Severe hypertension
• d) Hypokalemia Answer: b) Allergic conjunctivitis

9. Topical carbonic anhydrase inhibitors, such as dorzolamide and brinzolamide, lower IOP by:

• a) Increasing aqueous outflow.
• b) Decreasing aqueous humor production.
• c) Constricting the ciliary muscle.
• d) Acting as a prostaglandin analog. Answer: b) Decreasing aqueous humor production.

10. A patient prescribed a topical carbonic anhydrase inhibitor who has a known allergy to what class of drugs should use it with caution?

• a) Penicillins
• b) Sulfonamides (“sulfa” drugs)
• c) Tetracyclines
• d) Macrolides Answer: b) Sulfonamides (“sulfa” drugs)

11. Pilocarpine is a cholinergic (miotic) agent that lowers IOP by:

• a) Decreasing aqueous humor production.
• b) Increasing uveoscleral outflow.
• c) Constricting the ciliary muscle, which pulls open the trabecular meshwork to increase outflow.
• d) Relaxing the ciliary muscle to decrease outflow. Answer: c) Constricting the ciliary muscle, which pulls open the trabecular meshwork to increase outflow.

12. The Rho kinase inhibitor, netarsudil, represents a newer class of glaucoma medication that works by:

• a) Primarily decreasing aqueous humor production.
• b) Increasing outflow through the trabecular meshwork.
• c) Exclusively increasing uveoscleral outflow.
• d) Blocking beta-adrenergic receptors. Answer: b) Increasing outflow through the trabecular meshwork.

13. Which type of glaucoma is considered a medical emergency requiring immediate treatment to prevent blindness?

• a) Open-angle glaucoma
• b) Pigmentary glaucoma
• c) Normal-tension glaucoma
• d) Acute angle-closure glaucoma Answer: d) Acute angle-closure glaucoma

14. Cosopt® is a popular combination eye drop product. It contains which two active ingredients?

• a) Latanoprost and timolol
• b) Brimonidine and timolol
• c) Dorzolamide and timolol
• d) Brinzolamide and brimonidine Answer: c) Dorzolamide and timolol

15. To minimize systemic absorption of a topical eye drop, patients should be counseled to perform which technique after instillation?

• a) Blink rapidly for 30 seconds.
• b) Apply a warm compress.
• c) Nasolacrimal occlusion (closing the eye and pressing on the corner near the nose).
• d) Rub their eyes vigorously. Answer: c) Nasolacrimal occlusion (closing the eye and pressing on the corner near the nose).

16. If a patient needs to instill more than one type of eye drop, what is the recommended waiting period between each drop?

• a) No waiting period is necessary.
• b) At least 5 minutes.
• c) Exactly 60 seconds.
• d) At least 30 minutes. Answer: b) At least 5 minutes.

17. Benzalkonium chloride (BAK) is a common preservative in ophthalmic formulations. What is a key counseling point for soft contact lens wearers?

• a) BAK helps clean the contact lenses.
• b) Lenses should be removed before instilling drops with BAK and kept out for at least 15 minutes.
• c) BAK has no effect on soft contact lenses.
• d) Drops with BAK should be instilled directly onto the contact lens. Answer: b) Lenses should be removed before instilling drops with BAK and kept out for at least 15 minutes.

18. Aqueous humor is produced by the ________ and primarily drains through the ________.

• a) Iris; uveoscleral pathway
• b) Ciliary body; trabecular meshwork
• c) Retina; Schlemm’s canal
• d) Cornea; ciliary muscle Answer: b) Ciliary body; trabecular meshwork

19. A patient is prescribed a glaucoma eye drop that is a suspension. What is a crucial instruction for this type of formulation?

• a) The bottle must be shaken well before each use.
• b) The bottle should never be shaken.
• c) The drop should be stored in the freezer.
• d) The suspension can be instilled with contact lenses in. Answer: a) The bottle must be shaken well before each use.

20. The primary difference between open-angle and angle-closure glaucoma relates to the:

• a) Color of the patient’s iris.
• b) Age of the patient at diagnosis.
• c) Physical space and access to the drainage angle of the eye.
• d) Level of intraocular pressure. Answer: c) The physical space and access to the drainage angle of the eye.

21. Systemic oral carbonic anhydrase inhibitors like acetazolamide are typically reserved for acute situations or refractory glaucoma due to:

• a) Their low cost.
• b) Their favorable systemic side effect profile.
• c) Their significant systemic side effects (e.g., paresthesias, metabolic acidosis).
• d) Their lack of efficacy. Answer: c) Their significant systemic side effects (e.g., paresthesias, metabolic acidosis).

22. Which class of glaucoma medications is typically dosed once daily in the evening?

• a) Beta-blockers
• b) Prostaglandin analogs
• c) Alpha-adrenergic agonists
• d) Cholinergic agents Answer: b) Prostaglandin analogs

23. Combigan® is a combination product containing brimonidine and:

• a) Latanoprost
• b) Dorzolamide
• c) Pilocarpine
• d) Timolol Answer: d) Timolol

24. The mechanism of action of autonomic drugs used in glaucoma management is a key topic in which foundational course?

• a) Pathophysiology and Patient Assessment I
• b) Principles of Law & Ethics
• c) Drug Delivery Systems
• d) Population Health Answer: a) Pathophysiology and Patient Assessment I

25. A patient complains of blurry vision and difficulty seeing in the dark shortly after starting his glaucoma drops. He is most likely taking which agent?

• a) Timolol
• b) Latanoprost
• c) Pilocarpine
• d) Brimonidine Answer: c) Pilocarpine

26. Why is adherence a major challenge in glaucoma management?

• a) The medications are very painful to instill.
• b) The disease is often asymptomatic in its early stages, so patients do not feel an immediate benefit.
• c) The eye drops must be administered every hour.
• d) Insurance does not cover any glaucoma medications. Answer: b) The disease is often asymptomatic in its early stages, so patients do not feel an immediate benefit.

27. Laser trabeculoplasty is a non-pharmacological procedure that aims to:

• a) Create a new drainage channel for aqueous humor.
• b) Improve drainage through the existing trabecular meshwork.
• c) Reduce the production of aqueous humor.
• d) Destroy the ciliary body. Answer: b) Improve drainage through the existing trabecular meshwork.

28. A patient using a prostaglandin analog should be advised that the full IOP-lowering effect may take how long to become apparent?

• a) 1 hour
• b) 24 hours
• c) 3-5 days
• d) 2-4 weeks Answer: d) 2-4 weeks

29. Which glaucoma medication class has a side effect profile that includes hyperemia (red eyes)?

• a) Prostaglandin analogs
• b) Alpha-adrenergic agonists
• c) Rho kinase inhibitors
• d) All of the above Answer: d) All of the above

30. The management of glaucoma is a topic specifically covered in the Patient Care VII curriculum as part of which module?

• a) Module 1: Acute Care/Critical Care
• b) Module 5: Transplant and Oncology
• c) Module 9: Special Populations – Geriatrics
• d) Module 3: Complex Infectious Disease Disorders Answer: c) Module 9: Special Populations – Geriatrics

31. The “cap color” of an ophthalmic medication bottle is standardized to help identify the drug class. A teal or turquoise cap typically indicates which class?

• a) Beta-blockers
• b) Prostaglandin analogs
• c) Alpha-adrenergic agonists
• d) Carbonic anhydrase inhibitors Answer: b) Prostaglandin analogs

32. A yellow or blue cap on a glaucoma medication bottle typically indicates which drug class?

• a) Prostaglandin analogs
• b) Beta-blockers
• c) Miotics
• d) Carbonic anhydrase inhibitors Answer: b) Beta-blockers

33. Apraclonidine is an alpha-adrenergic agonist primarily used for:

• a) Long-term, chronic management of open-angle glaucoma.
• b) Prevention or short-term treatment of post-surgical IOP spikes.
• c) Reversing the effects of other glaucoma drops.
• d) Treating dry eye. Answer: b) Prevention or short-term treatment of post-surgical IOP spikes.

34. The pharmacist’s role in glaucoma management includes:

• a) Counseling on proper administration technique.
• b) Educating on the importance of adherence.
• c) Monitoring for side effects and drug interactions.
• d) All of the above. Answer: d) All of the above.

35. A patient with a history of depression taking an MAO inhibitor should use which glaucoma medication with caution due to the risk of a hypertensive crisis?

• a) Timolol
• b) Latanoprost
• c) Brimonidine
• d) Dorzolamide Answer: c) Brimonidine

36. If a patient is using both an eye drop solution and an eye ointment, which should be administered first?

• a) The ointment should be administered first.
• b) The solution (drop) should be administered first, with a waiting period before the ointment.
• c) They can be administered in any order with no waiting period.
• d) The two products should never be used together. Answer: b) The solution (drop) should be administered first, with a waiting period before the ointment.

37. Which statement about normal-tension glaucoma is correct?

• a) It is a condition where optic nerve damage occurs despite IOP being in the normal range.
• b) It is not considered a true form of glaucoma.
• c) The goal of treatment is to raise the IOP.
• d) It is always treated with oral medications only. Answer: a) It is a condition where optic nerve damage occurs despite IOP being in the normal range.

38. The primary advantage of combination eye drops for glaucoma is:

• a) They are less effective than single agents.
• b) They increase the number of bottles and instillations per day.
• c) They can improve adherence by simplifying the medication regimen.
• d) They have fewer side effects than monotherapy. Answer: c) They can improve adherence by simplifying the medication regimen.

39. A “washout” period may be required when switching between which two classes of glaucoma medications?

• a) A beta-blocker and a carbonic anhydrase inhibitor
• b) Two different prostaglandin analogs
• c) A prostaglandin analog and a miotic agent
• d) Two different beta-blockers Answer: b) Two different prostaglandin analogs

40. Which of the following is a risk factor for developing open-angle glaucoma?

• a) Young age
• b) Myopia (nearsightedness)
• c) Advanced age, family history, and African ancestry
• d) Male gender Answer: c) Advanced age, family history, and African ancestry

41. The stinging or burning sensation upon instillation of dorzolamide drops is primarily due to its:

• a) High viscosity
• b) Preservative
• c) Acidic pH
• d) Oily formulation Answer: c) Acidic pH

42. A key component of the ophthalmic formulation that affects drug residence time in the eye is its:

• a) Color
• b) Viscosity
• c) Cost
• d) Bottle size Answer: b) Viscosity

43. Which of the following is NOT a first-line treatment option for primary open-angle glaucoma?

• a) Prostaglandin analogs
• b) Beta-blockers
• c) Laser trabeculoplasty
• d) Oral acetazolamide Answer: d) Oral acetazolamide

44. A patient reports that their timolol eye drops are causing fatigue and lightheadedness. This is likely due to:

• a) A local allergic reaction in the eye.
• b) Systemic absorption of the beta-blocker.
• c) The preservative in the formulation.
• d) The patient imagining the side effect. Answer: b) Systemic absorption of the beta-blocker.

45. What is the goal of initial therapy for acute angle-closure glaucoma?

• a) To rapidly lower the acutely high IOP with a combination of topical and systemic agents.
• b) To schedule elective cataract surgery in six months.
• c) To prescribe a new pair of glasses.
• d) To observe the patient without treatment. Answer: a) To rapidly lower the acutely high IOP with a combination of topical and systemic agents.

46. Brinzolamide (Azopt) is formulated as a suspension, whereas dorzolamide (Trusopt) is a solution. This difference in formulation, covered in courses like Drug Delivery Systems, affects:

• a) The drug’s mechanism of action.
• b) The need to shake the bottle before use.
• c) The drug’s therapeutic class.
• d) The drug’s price. Answer: b) The need to shake the bottle before use.

47. A patient with glaucoma should be advised to inform all of their healthcare providers about their condition because:

• a) It is a highly contagious disease.
• b) Systemic medications (like corticosteroids or some antidepressants) can potentially affect IOP.
• c) It allows them to get discounts on other medications.
• d) It is required for all international travel. Answer: b) Systemic medications (like corticosteroids or some antidepressants) can potentially affect IOP.

48. Why is monitoring the appearance of the optic nerve and visual fields just as important as monitoring IOP?

• a) Because glaucoma is ultimately a disease of the optic nerve, and IOP is just a risk factor.
• b) It is not as important as monitoring IOP.
• c) It is easier and cheaper to do.
• d) It is required by all insurance companies. Answer: a) Because glaucoma is ultimately a disease of the optic nerve, and IOP is just a risk factor.

49. Rocklatan® is a combination product containing netarsudil and which other first-line agent?

• a) Timolol
• b) Brimonidine
• c) Latanoprost
• d) Dorzolamide Answer: c) Latanoprost

50. The ultimate goal of lifelong glaucoma management is to:

• a) Cure the disease.
• b) Eliminate the need for eyeglasses.
• c) Preserve the patient’s remaining vision and maintain their quality of life.
• d) Ensure the patient uses the most expensive medications available. Answer: c) Preserve the patient’s remaining vision and maintain their quality of life.