On ophthalmic examination, which findings differentiate glaucoma from cataracts, and what is a first-line therapy to lower intraocular pressure?

• A. Glaucoma shows elevated intraocular pressure with optic nerve cupping; cataracts are lens opacities with normal IOP; first-line therapy: topical timolol or dorzolamide
• B. Cataracts cause optic nerve cupping; glaucoma causes lens opacity; first-line therapy: atropine
• C. Glaucoma shows decreased IOP with optic nerve atrophy; cataracts show lens opacities with increased IOP; first-line therapy: prednisone
• D. Cataracts have optic nerve cupping; glaucoma are lens opacities; first-line therapy: pilocarpine

Answer: (D)

Glaucoma is defined by elevated intraocular pressure with progressive optic nerve changes (cupping), whereas cataracts are lens opacities with the intraocular pressure typically normal. A first-line way to lower IOP is a topical medication that reduces aqueous humor production or increases outflow, such as timolol (a beta-blocker) or dorzolamide (a carbonic anhydrase inhibitor). The described option that swaps these findings—cataracts with optic nerve cupping and glaucoma with lens opacities—and lists pilocarpine as first-line does not fit current understanding, since pilocarpine is not typically used as the primary first-line therapy for chronic IOP reduction.