Ординатура / Офтальмология / Английские материалы / Glaucoma Medical Therapy Principles and Management_Netland_2008
.pdf268 Self-Study Examination
8.The recommended dosing regimen for latanoprost is
a.Daily in the morning
b.Daily in the evening
c.Twice daily
d.Three times daily
9.Latanoprost has an additive ocular hypotensive effect with
a.Timolol
b.Acetazolamide
c.Pilocarpine
d.All of the above
Chapter 3
10.All the following are nonselective ocular beta blockers except
a.Levobunolol
b.Timolol in gellan gum
c.Betaxolol
d.Carteolol
11.A patient with a hypersensitivity to benzalkonium chloride might best tolerate which of the following beta blockers?
a.Levobunolol
b.Timolol in gellan gum
c.Betaxolol
d.Carteolol
12.Which of the following beta blockers does not exacerbate reactive airway disease?
a.Timolol maleate
b.Betaxolol
c.Carteolol
d.None of the above
Chapter 4
13.The most common systemic side effect of topical clonidine is
a.Tachycardia
b.Bronchospasm
c.Hypotension
d.Headache
14.Brimonidine is an
a.Alpha-2 agonist
b.Alpha-1 and alpha-2 agonist
c.Alpha-2 antagonist
d.Alpha-1 agonist
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15.The most common ocular side effect of apraclonidine is
a.Cataract
b.Allergy
c.Corneal edema
d.Iritis
Chapter 5
16.The major mechanism by which cholinergic drugs reduce intraocular pressure is enhancement of
a.Unconventional or uveoscleral outflow
b.Trabecular outflow by a direct effect on the trabecular meshwork
c.Trabecular outflow as a result of ciliary muscle contraction, which expands the trabecular meshwork
d.Trabecular outflow as a result of iris contraction
17.Indirect cholinomimetics initiate their effect by
a.Binding directly to muscarinic receptors
b.Suppressing enzymes that inactivate acetylcholine
c.Suppressing acetylcholine release from nerve terminals
d.Increasing the sensitivity of postsynaptic nerve terminals to acetylcholine
18.High doses of cholinomimetics are not indicated for
a.Acute angle-closure glaucoma
b.Open-angle glaucoma
c.Dark-eyed individuals
d.Light-eyed individuals
Chapter 6
19.(For this question, more than one answer may be selected.) Which of the following are available as topical ophthalmic formulations?
a.Acetazolamide
b.Brinzolamide
c.Methazolamide
d.Dorzolamide
20.Side effects associated with systemic administration of carbonic anhydrase inhibitors include
a.Anorexia
b.Malaise
c.Depression
d.All of the above
21.(For this question, more than one answer may be selected.) Patients with which of the following conditions may be at risk for severe adverse effects following therapy with systemic carbonic anhydrase inhibitors?
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a.Diabetes
b.Hepatic insufficiency
c.Chronic obstructive pulmonary disease
d.Pseudotumor cerebri
Chapter 7
22.Advantage(s) of fixed combination drugs include
a.Reduced number of drops per day
b.Reduced ‘‘washout’’ effect
c.Reduced amount of preservative dose
d.All of the above
23.Compared with concomitant dosing with the individual components, fixed combination drugs are likely to
a.Have reduced side effects and similar efficacy
b.Have similar efficacy and side effects
c.Have increased efficacy and similar side effects
d.Have reduced side effects and efficacy
24.Compared with either individual component, fixed combination products should be associated with
a.Less reduction of intraocular pressure
b.The same reduction of intraocular pressure
c.Greater reduction of intraocular pressure
d.Varying effects on intraocular pressure
Chapter 8
25.The most commonly used intravenous osmotic drug is
a.Urea
b.Sodium ascorbate
c.Mannitol
d.Glycerol
26.(For this question, more than one answer may be selected.) In diabetic patients, the preferred osmotic drugs are
a.Glycerol
b.Isosorbide
c.Ethyl alcohol
d.Mannitol
27.Osmotic drugs may be useful in all of the following situations except
a.Angle-closure glaucoma
b.Secondary glaucoma with acute and highly elevated intraocular pressure
c.Chronic primary open-angle glaucoma
d.Perioperative treatment
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Chapter 9
28.Which of the following medications can lower intraocular pressure when administered systemically?
a.Beta blockers
b.Calcium channel blockers
c.Central sympatholytics
d.All of the above
29.Consumption of beverages containing which of the following may lead to unexpectedly low measurements of intraocular pressure?
a.Tea
b.Coffee
c.Alcohol
d.Orange juice
30.Which of the following psychoactive substances can lower intraocular pressure?
a.Lysergic acid diethylamide (LSD)
b.Amphetamines
c.Heroin
d.Marijuana
Chapter 10
31.All of the following are major risk factors associated with the development and progression of glaucoma except
a.Elevated intraocular pressure
b.Migraine headache
c.Family history of glaucoma
d.Age
32.All of the following statements regarding the Collaborative Normal-Tension Glaucoma Study are true except
a.It was a randomized treatment of patients with normal-tension glaucoma.
b.Target intraocular pressure was defined as 20% reduction from the baseline intraocular pressure.
c.Cataract formation was significantly less than in the control group.
d.Visual field loss was significantly reduced in the treated group.
33.The condition least likely to be of concern when selecting a medical regimen for a patient beginning medical therapy is
a.A childhood history of asthma
b.Elevated serum high-density lipoprotein (HDL)
c.A clinical history of depression
d.High myopia
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Chapter 11
34.When considering the addition of a beta-blocking topical agent to a patient’s medical regimen, the clinician should take into account the patient’s
a.Pulmonary history
b.Cardiac history
c.Current systemic medications
d.All of the above
35.Maximum medical therapy is
a.The therapy that the patient can tolerate, even if only one or no drug
b.At least three glaucoma medications
c.A level of medical therapy best determined by the physician
d.Not considered when deciding to perform laser trabeculoplasty
36.The classes of topical medications that are additive are
a.Prostaglandins
b.Alpha agonists
c.Beta blockers
d.All of the above
37.The decision to advance medical therapy is best based on
a.A change in intraocular pressure
b.A single visual field
c.The appearance of the optic nerve
d.Change or expected change over time in optic nerve structure or function
Chapter 12
38.The differential diagnosis of pigmentation on the trabecular meshwork includes all of the following except
a.Pigment dispersion syndrome
b.Exfoliation syndrome
c.Steroid-induced glaucoma
d.Angle recession
39.Which of the following conditions can respond paradoxically to pilocarpine with worsening of angle-closure glaucoma?
a.Pupillary block
b.Plateau iris syndrome
c.Aqueous misdirection
d.Pupillary block and aqueous misdirection
40.Miotic treatment may prevent progression of the process leading to glaucoma by interfering with the mechanism leading to trabecular damage in all of the following conditions except
a.Pigment dispersion syndrome
b.Creeping angle closure
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c.Neovascular glaucoma
d.Exfoliation syndrome
41.The appropriate initial therapy for congenital glaucoma is
a.Trabeculectomy
b.Goniotomy
c.Trabeculotomy
d.Either goniotomy or trabeculotomy
Chapter 13
42.According to the Food and Drug Administration, drugs with an established safety record with human testing done proving safety are classified as
a.Class A
b.Class B
c.Class C
d.Class X
43.In lactating women, the concentration of timolol in breast milk may be
a.Lower than serum level
b.The same as serum level
c.Higher than serum level
d.Not detectable
44.In pediatric patients treated with glaucoma medications, responder rates are typically
a.Zero (no patients respond)
b.Higher compared with adults
c.The same compared with adults
d.Lower compared with adults
Chapter 14
45.Compliance is best correlated with patients’
a.Socioeconomic status
b.Age
c.Perception of their disease
d.Sex
46.All of the following factors are associated with increased compliance with glaucoma medications except
a.Simplification of the regimen
b.Knowledge of the pathophysiology of glaucoma
c.Severity of glaucoma
d.Enhancement of the patient–physician relationship
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Answers and Discussions
Chapter 1
1.Answer—b. The main route of topical ocular drug delivery into the anterior chamber of the eye is through the cornea. Drugs may also be absorbed from the cul-de-sac across the conjunctiva and enter the eye through the sclera, but this is a minor route of drug delivery into the anterior chamber.
2.Answer—d. The eye is relatively isolated from the systemic circulation by the blood–retina, blood–vitreous, and blood–aqueous barriers. These types of junctions prevent large molecules, such as plasma proteins, from entering the eye through the blood circulation.
3.Answer—a. Iris color is determined by the amount of melanin in the iris stroma. The onset and duration of the drug action after topical application are correlated with the retention of the drug in the melanin-containing iris. Many liposoluble drugs are bound by the melanin and slowly released later.
4.Answer—b. The human cul-de-sac has a volume of about 7 mL, which can expand momentarily and variably to 30 mL. A normal blink eliminates about 2 mL of excess fluid from the cul-de-sac.
5.Answer—d. Nasolacrimal occlusion may allow a reduction in the dosage and frequency of administration of various topically applied drugs. The benefit of nasolacrimal occlusion should be determined individually for each patient. It is important to train the patient on the proper performance of punctal occlusion for its benefit to be fully realized. Simple eyelid closure may also reduce nasolacrimal drainage of topically applied drugs.
Chapter 2
6.Answer—d. Prostaglandins primarily act by increasing uveoscleral outflow and outflow facility. They have not been shown to reduce aqueous production or episcleral venous pressure.
7.Answer—a. Latanoprost can cause darkening of iris color and increased pigmentation of eyelashes in some patients. There have been reports of uveitis and cystoid macular edema in some patients using latanoprost. These patients generally have had other risk factors for these conditions, and latanoprost itself has not been proven to cause either of these conditions. Latanoprost is not known to cause any systemic side effects.
8.Answer—b. Although latanoprost may be used once daily at any time of day, there is conflicting evidence that evening dosing is most effective.
9.Answer—d. Latanoprost has been shown to have an additive effect on the reduction of intraocular pressure when used in combination with any of the various classes of hypotensive medications.
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Chapter 3
10.Answer—c. Betaxolol is a relatively selective beta-1 adrenergic antagonist. The other drugs are nonselective.
11.Answer—b. The preservative for the timolol in gellan gum is benzododecinium bromide. The preservative in the other preparations is benzalkonium chloride. Timolol maleate is available in a preservative-free preparation.
12.Answer—d. No ocular beta blocker is without risk for exacerbating reactive airway disease. The selectivity of betaxolol is only relative.
Chapter 4
13.Answer—c. Topical clonidine may cause significant systemic hypotension. For this reason, topical clonidine is not available for clinical use in the United States.
14.Answer—a. Brimonidine is a highly selective lipophilic alpha-2 agonist. Apraclonidine is more hydrophilic and has alpha-1 and alpha-2 agonist activity.
15.Answer—b. Hyperemia and allergy are commonly encountered ocular side effects associated with the use of apraclonidine. The allergic reaction may be delayed and may produce a follicular conjunctivitis.
Chapter 5
16.Answer—c. Although there is some evidence in organ culture systems for enhancement of trabecular outflow by an effect directly on the trabecular meshwork, the main mechanism is via ciliary muscle contraction. When the muscle contracts, tendons and connecting fibrils inserting into the trabecular meshwork and the inner wall of Schlemm’s canal cause an unfolding of the meshwork and a widening of the canal to facilitate aqueous flow. Ciliary muscle contraction decreases uveoscleral outflow.
17.Answer—b. Indirect cholinomimetics act by suppressing cholinesterase activity, thereby decreasing acetylcholine inactivation, so that the neurotransmitter can act at muscarinic receptors to initiate a response.
18.Answer—a. High doses of cholinomimetics can create or increase pupillary block, further complicating angle-closure glaucoma. Moderate doses, such as pilocarpine 2%, induce adequate miosis, in most instances, to help reverse acute angle-closure glaucoma.
Chapter 6
19.Answer—b,d. Brinzolamide (Azopt) and dorzolamide (Trusopt) are available in the United States as topical ophthalmic formulations. Acetazolamide is available in oral and intravenous preparations. Methazolamide is an orally administered carbonic anhydrase inhibitor.
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20.Answer—d. The side effects of systemic carbonic anhydrase inhibitors are legion and troublesome for patients. Anorexia, malaise, and depression are frequently encountered. In addition, aplastic anemia is a rare idiosyncratic adverse effect.
21.Answer—a,b,c. The metabolic acidosis associated with systemic administration of carbonic anhydrase inhibitors may cause serious problems in diabetic patients susceptible to ketoacidosis; in patients with hepatic insufficiency, because they are unable to tolerate the obligatory increase in serum ammonia; and in patients with respiratory acidosis and chronic obstructive pulmonary disease. Patients with pseudotumor cerebri may benefit from systemic administration of carbonic anhydrase inhibitors.
Chapter 7
22.Answer—d. Fixed combination drugs may reduce the total number of drops administered per day, reduce the amount of preservative instilled in the eye. In addition, they may reduce the ‘‘washout’’ effect by avoiding the rapid-sequence administration of the components when given separately. Cost savings is a potential advantage.
23.Answer—b. A useful fixed combination drug should have similar efficacy and side effects compared with the individual components administered in separate bottles. Other advantages of fixed combination products are attractive to patients and clinicians, including convenience and avoidance of ‘‘washout’’ effect.
24.Answer—c. Useful fixed combination products should have greater efficacy compared with any individual component. If the efficacy is the same as a single component administered as monotherapy, it would be preferable to treat with the single drug.
Chapter 8
25.Answer—c. Urea and sodium ascorbate are distributed in total body water and have a less pronounced osmotic effect compared with mannitol. Also, there are significant practical problems in the preparation and administration of urea and sodium ascorbate. Glycerol is an oral osmotic agent.
26.Answer—b,d. Glycerol and ethyl alcohol are metabolized and cause increased caloric load after ingestion, which may be a problem, particularly in diabetic patients.
27.Answer—c. Osmotic drugs are not useful in the long-term medical management of chronic glaucoma. They are, however, useful in the therapy of acutely elevated intraocular pressure and in the perioperative treatment of certain glaucoma patients.
Chapter 9
28.Answer—d. Medications prescribed by physicians for systemic disorders may affect intraocular pressure. Clinical measurement of intraocular pressure
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should be interpreted after considering the patient’s topical and systemic medications.
29.Answer—c. Alcohol has an osmotic effect, which can cause reduction of intraocular pressure. Patients who ingest alcohol-containing beverages prior to their appointments may temporarily lower their intraocular pressure.
30.Answer—d. Marijuana has an ocular hypotensive effect. Ophthalmologists who care for glaucoma patients can better interpret intraocular pressure measurements when they are aware of recent marijuana use by their patients.
Chapter 10
31.Answer—b. All are major risk factors for the development of glaucoma except migraine headache. Although not included as a requirement in the definition of glaucoma, elevated intraocular pressure is one of the greatest single risk factors in the development of glaucoma. Intraocular pressure affects risk in a dosedependent manner. The risk of developing glaucoma is 10 times greater for the individual with intraocular pressure greater than 23 mm Hg compared to one with intraocular pressure less than 16 mm Hg. A positive family history of glaucoma is present in approximately 50% of patients with primary open-angle glaucoma, which is the cause of most glaucoma in the United States. A positive family history increases the risk of developing primary open-angle glaucoma by 4- to 7-fold in first-degree relatives. Glaucoma is uncommon before the age of 40 years, but increases dramatically after the age of 50. In some studies, the prevalence of glaucoma is greater than 10% of individuals older than 70 to 80. Migraine headaches may be a risk factor for normal-tension glaucoma. However, the role of vasospastic disease in the development of most other types of glaucoma is uncertain. Race is another major risk factor, which is not listed in the question. African Americans have a significantly greater risk of developing glaucoma than do whites.
32.Answer—b. The target intraocular pressure in the treated group in this wellexecuted clinical trial was defined as a 30% reduction in intraocular pressure from the baseline value. A significant number of patients developed cataracts after filtration surgery. When this fact was taken into account, progression of visual field loss was significantly reduced in the treated group (80% survival vs. 40% in the control group).
33.Answer—b. Low serum high-density lipoprotein (HDL) is a risk factor for atherosclerotic vascular disease. Carteolol is a beta blocker that is less likely to reduce serum HDLs than are nonselected beta blockers. A history of childhood asthma suggests the possibility of latent reactive airway disease. Patients with a history of asthma or chronic obstructive pulmonary disease are at significantly increased risk of developing reactive airway disease. Beta blockers can aggravate or induce clinical depression in susceptible individuals. Knowledge of a history of clinically treated depression should be obtained prior to initiating beta-blocker therapy. High myopia is a risk factor for retinal