A laser peripheral iridotomy would most likely relieve angle-closure glaucoma in which of

the following conditions?

Pseudophakic pupillary block
Angle-closure glaucoma scleritis
Neovascular glaucoma
Iridocorneal endothelial syndrome

Feedback: A laser peripheral iridotomy is indicated in cases with primary and secondary
angle-closure glaucoma with relative or complete papillary block. This includes eyes with
acute, subacute, and chronic closure glaucoma, all with a relative pupillary block, and in eyes
with phakic, aphakic, or pseudophakic pupillary-block glaucoma. Angle-closure mechanisms
that operate by pulling the iris into the angle, such as occurs with neovascular glaucoma or
iridocorneal endothelial syndrome, would not be expected to benefit from a laser peripheral
iridotomy. During angle closure from scleritis, the peripheral iris is anteriorly displaced by
rotation of the ciliary body from the thickened and edematous sclera. This mechanism of
glaucoma may respond to topical cycloplegic therapy and systemic corticosteroid therapy;
however, if laser therapy is needed, a peripheral iridoplasty would be more beneficial than an
iridotomy

A miotic agent would be least effective in a patient with glaucoma and which one of the
following?
Aphakia
Aniridia with open angle
Angle recession
Severe secondary angle closure

Please select an answer Feedback: In the absence of substantial secondary angle closure,
aniridia does not reduce the effectiveness of topical miotic (cholinergic) therapy. The effect
of miotic agents is mediated through the ciliary muscle and not the pupillary sphincter, which
is absent in patients with aniridia. Surgical aphakia does not alter the effectiveness of miotic
therapy. Angle trauma and angle recession can decrease the effectiveness of miotic therapy.
Eyes with severe synechial angle closure would be the least likely to respond to cholinergic
agents and may have a paradoxical rise of intraocular pressure from miotic therapy because
of a reduction of nonconventional uveoscleral outflow.

Which of the following increases the risk of aqueous misdirection (malignant glaucoma)?
High myopia Chronic angle-closure glaucoma Pseudophakia Prior pars plana vitrectomy
Please select an answer Feedback: Aqueous misdirection is a rare form of glaucoma that
typically presents following ocular surgery. The condition results from a misdirection of
aqueous humor posteriorly. Increased fluid volume in the vitreous cavity pushes the lens-iris
diaphragm forward causing secondary angle-closure glaucoma. Axial shallowing of the
anterior chamber is present in this condition. Patients with a history of angle-closure
glaucoma (acute and chronic) are at increased risk of aqueous misdirection. Prior pars plana
vitrectomy does not increase the risk of this complication, and vitrectomy may actually be
used to treat aqeuous misdirection that is refractory to medical and laser therapy. High
myopia and pseudophakia are not risk factors for aqueous misdirection.
Which medication has been reported to cause secondary angle-closure glaucoma in rare
cases?
Metoprolol (Toprol)
Prednisone
Topiramate (Topamax)
Azithromycin (Zithromax)

Please select an answer Feedback: Topiramate (Topamax) is a sulfa medication that has been
reported to induce angle-closure glaucoma in rare instances. The underlying mechanism
involves ciliary body congestion and development of a ciliochoroidal effusion that causes
anterior rotation of the ciilary body and angle closure. Systemic corticosteroid therapy can
also cause secondary glaucoma, but this occurs via an open-angle mechanism. Azithromycin
and metoprolol have not been reported to cause secondary angle-closure glaucoma.

Which of the following has been reported to cause secondary angle-closure glaucoma
secondary to congestion of the ciliary body and ciliochoroidal detachment?
azithromycin(Zithromax)
acetaminophen(Tylenol)
valium
topiramate (Topamax)

Please select an answer Feedback: Topiramate (Topamax) is an oral sulfa medication that is
used to treat epilepsy, migraines, and depression. There have been reports of acute bilateral
angle-closure glaucoma associated with this medication. Ocular findings of this syndrome
include axial shallowing of the anterior chamber with a forward shift of the lens-iris
diaphragm, induced myopia, markedly elevated intraocular pressure, and a closed angle. The
syndrome appears to result from swelling of the ciliary body with the development of a
ciliochoroidal effusion/detachment allowing the lensiris diaphragm to shift foward.
Azithromycin, valium, and acetaminophen have not been reported to produce secondary
angle-closure glaucoma.