Free Treatment and Management of Ocular Disease (TMOD) Practice Questions

Sample Practice Questions

Try these 10 sample questions from the Treatment and Management of Ocular Disease (TMOD) practice bank. Each includes the answer and explanation. Continue with the interactive practice above to review the full question set.

1. 1A 64-year-old patient with primary open-angle glaucoma is started on latanoprost 0.005% once nightly. Through which principal mechanism is this prostaglandin F2-alpha analogue believed to lower intraocular pressure?

   1. A. Increasing aqueous outflow through the trabecular meshwork
   2. B. Increasing aqueous outflow through the uveoscleral pathway
   3. C. Decreasing aqueous production by the ciliary body epithelium
   4. D. Decreasing episcleral venous pressure in the outflow veins

   Answer: B

   Explanation: The XALATAN label states: "Latanoprost is a prostaglandin F2α analogue that is believed to reduce the IOP by increasing the outflow of aqueous humor. Studies in animals and man suggest that the main mechanism of action is increased uveoscleral outflow." Trabecular outflow enhancement is the primary action of other classes, and reduced aqueous production is the mechanism of beta-blockers, alpha-2 agonists and carbonic anhydrase inhibitors.

   Reference: XALATAN (latanoprost ophthalmic solution) Prescribing Information — Section 12.1 Mechanism of Action

2. 2A 27-year-old soft contact lens wearer was diagnosed with herpes simplex keratitis 3 weeks ago but has not improved on antiviral therapy. She reports severe pain that seems out of proportion to the modest corneal findings. What is the most likely diagnosis?

   1. A. Recurrent herpes simplex epithelial keratitis
   2. B. Acanthamoeba keratitis
   3. C. Pseudomonas bacterial keratitis
   4. D. Contact lens-related sterile infiltrates

   Answer: B

   Explanation: The CDC clinical overview states: "A classic feature of the infection is pain that is disproportionate to clinical findings." It stresses a high degree of suspicion, "especially important when treating a contact lens wearer with a recent diagnosis of another form of keratitis, such as herpes simplex virus keratitis, who is not responding to therapy." Acanthamoeba keratitis can mimic viral, fungal or bacterial keratitis.

   Reference: CDC: Clinical Overview of Acanthamoeba Keratitis — Symptoms section

3. 3A 63-year-old's acute angle-closure crisis in the right eye has been broken with medical therapy followed by laser peripheral iridotomy. The left eye is phakic with a similarly narrow angle. What does the AAO PACD PPP recommend for the fellow eye?

   1. A. Observation with gonioscopy repeated in 1 year
   2. B. Prompt laser peripheral iridotomy
   3. C. Long-term pilocarpine 2% four times daily
   4. D. Selective laser trabeculoplasty

   Answer: B

   Explanation: The AAO Primary Angle-Closure Disease PPP states: "After addressing the episode of AACC, a phakic fellow eye should generally undergo prompt LPI due to a high risk of developing AACC without prophylactic treatment." Observation leaves the fellow eye at high risk, and trabeculoplasty does not relieve pupillary block.

   Reference: AAO Primary Angle-Closure Disease Preferred Practice Pattern (2025) — Highlighted Findings and Recommendations for Care

4. 4A 61-year-old patient with ocular hypertension who developed eyelid darkening on a prostaglandin analog is switched to brimonidine tartrate 0.1% three times daily. Fluorophotometric studies indicate that brimonidine lowers intraocular pressure through which combination of effects?

   1. A. Reducing aqueous humor production and increasing trabecular outflow
   2. B. Increasing trabecular outflow and lowering episcleral venous pressure
   3. C. Reducing aqueous humor production and increasing uveoscleral outflow
   4. D. Reducing aqueous humor production by inhibiting carbonic anhydrase

   Answer: C

   Explanation: The ALPHAGAN P label states that it is "a relatively selective alpha-2 adrenergic receptor agonist" and that "Fluorophotometric studies in animals and humans suggest that brimonidine tartrate has a dual mechanism of action by reducing aqueous humor production and increasing uveoscleral outflow." Trabecular outflow enhancement with lowered episcleral venous pressure describes rho kinase inhibition, and carbonic anhydrase inhibition is the mechanism of dorzolamide and brinzolamide, not of an alpha-2 agonist.

   Reference: ALPHAGAN P (brimonidine tartrate ophthalmic solution) Prescribing Information — Section 12.1 Mechanism of Action

5. 5A 66-year-old hyperopic woman comes from a dark movie theater with severe right eye pain, headache, vomiting and halos around lights. The right cornea is hazy, the conjunctiva is congested and the pupil is mid-dilated and poorly reactive. What is the most likely diagnosis?

   1. A. Acute anterior uveitis with secondary pressure rise
   2. B. Herpes simplex stromal keratitis with endotheliitis
   3. C. Acute angle-closure crisis
   4. D. Migraine with ocular aura

   Answer: C

   Explanation: The AAO Primary Angle-Closure Disease PPP states: "Symptoms of AACC include eye pain, headache, nausea/vomiting, and blurred vision with halos. Clinical signs of AACC are markedly elevated IOP, corneal edema, conjunctival and episcleral vascular congestion, and/or a mid-dilated pupil." Dim light and hyperopia favor pupillary block in predisposed eyes; uveitis typically produces a small pupil.

   Reference: AAO Primary Angle-Closure Disease Preferred Practice Pattern (2025) — Highlighted Findings and Recommendations for Care

6. 6A 68-year-old with primary angle-closure glaucoma, a visually insignificant early cataract and markedly elevated IOP despite a patent iridotomy is being counseled about definitive treatment. Which intervention does the AAO PACD PPP highlight as effective for PACG and PAC with markedly elevated IOP?

   1. A. Laser iridoplasty repeated every 6 months
   2. B. Lens extraction
   3. C. Long-term topical atropine
   4. D. Repeat laser iridotomy

   Answer: B

   Explanation: The AAO Primary Angle-Closure Disease PPP states: "Lens extraction is an effective treatment for patients with PACG and PAC with markedly elevated IOP." Removing the thick crystalline lens deepens the anterior chamber and widens the angle; atropine is not a long-term treatment for primary angle closure.

   Reference: AAO Primary Angle-Closure Disease Preferred Practice Pattern (2025) — Highlighted Findings and Recommendations for Care

7. 7A 70-year-old patient with primary open-angle glaucoma and a history of bronchial asthma is being considered for timolol maleate 0.5% drops. Which pharmacologic property of timolol accounts for the risk of bronchospasm in this patient?

   1. A. Intrinsic sympathomimetic activity at the beta-adrenergic receptors
   2. B. Membrane-stabilizing local anesthetic activity at airway nerve fibers
   3. C. Direct myocardial depressant activity independent of receptor blockade
   4. D. Non-selective blockade of both beta-1 and beta-2 adrenergic receptors

   Answer: D

   Explanation: The TIMOPTIC label describes timolol as "a beta1 and beta2 (non-selective) adrenergic receptor blocking agent that does not have significant intrinsic sympathomimetic, direct myocardial depressant, or local anesthetic (membrane-stabilizing) activity." It adds: "Beta-adrenergic receptor blockade in the bronchi and bronchioles results in increased airway resistance from unopposed parasympathetic activity. Such an effect in patients with asthma or other bronchospastic conditions is potentially dangerous." The other three options are properties that the label states timolol lacks.

   Reference: TIMOPTIC (timolol maleate ophthalmic solution) Prescribing Information — Clinical Pharmacology, Mechanism of Action

8. 8A 78-year-old has sudden painless severe vision loss in both eyes on the same day, with posterior pole whitening and cherry red spots bilaterally. Which underlying cause should be suspected first?

   1. A. A vasculitic process such as giant cell arteritis
   2. B. Cholesterol emboli from a single carotid plaque
   3. C. Bilateral posterior vitreous detachment
   4. D. Bilateral central serous chorioretinopathy

   Answer: A

   Explanation: The AAO Retinal and Ophthalmic Artery Occlusions PPP states that in CRAO, "In 1% to 2% of cases, occurrence is bilateral, which should raise the suspicion of a vasculitic process, such as GCA." In patients over 50, GCA should be suspected and urgent corticosteroids considered.

   Reference: AAO Retinal and Ophthalmic Artery Occlusions Preferred Practice Pattern (2024) — Clinical Findings Characteristic of Retinal and Ophthalmic Artery Occlusion

9. 9A newly diagnosed POAG patient has an untreated IOP of 28 mmHg with moderate field loss. When setting an initial target pressure, by how much has lowering the pretreatment IOP been shown to slow progression, according to the AAO POAG PPP?

   1. A. By 25% or more
   2. B. By 5% or more
   3. C. By 10% or more
   4. D. By 60% or more

   Answer: A

   Explanation: The AAO POAG PPP states: "Lowering the pretreatment IOP by 25% or more has been shown to slow the progression of POAG." A lower target can be justified with more severe or rapidly progressing damage or other risk factors.

   Reference: AAO Primary Open-Angle Glaucoma Preferred Practice Pattern (2025) — Management, Target Intraocular Pressure

10. 10A patient with open-angle glaucoma whose pressure remains above target on a prostaglandin analog has netarsudil 0.02% added once nightly. Netarsudil, a rho kinase inhibitor, is believed to lower intraocular pressure mainly by which action?

    1. A. Enhancing conventional aqueous outflow through the trabecular meshwork
    2. B. Enhancing unconventional aqueous outflow across the ciliary muscle
    3. C. Suppressing aqueous formation through alpha-2 receptor stimulation
    4. D. Suppressing aqueous formation through beta-adrenergic receptor blockade

    Answer: A

    Explanation: The RHOPRESSA label states: "Netarsudil is a rho kinase inhibitor, which is believed to reduce IOP by increasing the outflow of aqueous humor through the trabecular meshwork. The exact mechanism is unknown." Unconventional (uveoscleral) outflow is the main route enhanced by prostaglandin analogs, while alpha-2 stimulation and beta blockade lower pressure by reducing aqueous formation.

    Reference: RHOPRESSA (netarsudil ophthalmic solution) 0.02% Prescribing Information — Section 12.1 Mechanism of Action