4 - glaukoma
TRANSCRIPT
![Page 1: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/1.jpg)
Aqueous Humor
![Page 2: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/2.jpg)
Sekresi Aqueous humor
• 80% disekresi oleh epitel badan silier yang tidak berpigmen melalui proses metabolik aktifs yang tergantung pada jumlah enzim (carbonic anhydrase enzyme),
• 20% diproduksi oleh proses pasif melalui ultrafiltrasi dan difusi
![Page 3: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/3.jpg)
Anatomi Jaringan Trabekular
![Page 4: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/4.jpg)
Jaringan Trabekular
• Jaringan trabekular terletak di sudut bilik mata depan yang terdiri dari : – Membran Descemet Garis Schwalbe– Sklera tonjolan sklera– Iris tonjolan iris– Badan Siliar angle recess
![Page 5: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/5.jpg)
Jaringan Trabekular
• The TM is devided into three portions:– Uveal meshwork, large spaces, resistance «,– Corneoscleral meshwork, smaller space,– Endothelial meshwork, major proportion of
normal resistance to aqueous outflow.
• Obstruction of aqueous flow usually at trabecular meshwork high IOP.
![Page 6: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/6.jpg)
Jaringan Trabekular
a. Jaringan Uveab. Jaringan
Korneosclerac. Garis Schwalbed. Kanal Schlemme. Saluran
pengumpulf. Badan Siliarg. Tonjolan Sclera
![Page 7: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/7.jpg)
Aliran Aqueous
Aliran normal cairan aqueous :
a. Jalur trabekular konvensional
b. Jalur Uveoskleral
c. melalui iris
![Page 8: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/8.jpg)
Aliran Aqueous
• AH mengisi bilik mata belakang (BMB) pupil bilik mata depan (BMD) keluar dari dalam mata melalui 2 cara :– 90% melalui jalur trabekular kanalis
Schlemm’s vena episklera keluar mata– 10% melalui jalur uveosklera: melewati badan
silier ronga suprachoroidal sistim vena dalam badan silier
![Page 9: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/9.jpg)
Aliran Aqueous
AH mengisi BMB pupil
Jalur trabekular BMD
Kanalis Schlemm jalur uveosklera (10%)
rongga suprakoroid badan silier Keluar mataMelalui vena episklera sistim vena dalam badan silier
90 %
![Page 10: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/10.jpg)
Aliran Aqueous, dipengaruhi oleh:
• Tekanan intra okular (TIO) yg tinggi
• Tekanan episklera yg tinggi
• Kekentalan Aqueous : eksudat, sel darah
• Blok Siliar, blok pupil, sinekia posterior
• Sudut bilik mata depan sempit/tertutup
• Penyempitan pori-pori jaringan trabekula• Macrofag, sel lensa di jaringan trabekula
![Page 11: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/11.jpg)
Tekanan Intra Okular (TIO)
• Normal 15 - 21 mm Hg,• TIO > 21 mm Hg diduga glaukoma• Perubahan Diurnal TIO selama 24 jam :
– TIO lebih tinggi pada pagi hari– TIO lebih rendah pada sore & malam hari
• Hipertensi Okular : TIO > 21 mmHg tanpa kerusakan serabut saraf
• Glaukona tensi normal : normal TIO, ada gejala glaukoma
![Page 12: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/12.jpg)
Glaukoma
![Page 13: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/13.jpg)
Definisi Glaukoma
• Neuropati diskus optikus yg ditandai dengan :– TIO tinggi > 21 mHg– Kematian serabut saraf optik kerusakan
diskus optik– Kerusakan lapang pandang progresif
• Penyebab kebutaan permanen ketiga terbanyak
![Page 14: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/14.jpg)
Incidence
• Congenital glaucoma age 0 - 2 years
• Infantile glaucoma age > 2 years
• Juvenile glaucoma age > 15 year
• Secondary glaucoma: glaucoma as a complication from other eye disease
![Page 15: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/15.jpg)
Pathogenesis of Glaucomatous Damage
• There are two current theories:– The indirect ischaemic theory: IOP » -- nerve
fiber death + interfering of micro circulation of the optic disc,
– Direct mechanical theory: IOP » -- damage retinal nerve fiber at the optic disc.
![Page 16: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/16.jpg)
Classification of the glaucomas
• According to:– Outflow impairment: open angle and angle
closure glaucoma,– Factor contributing IOP » : primary and
secondary glaucoma,– Age: congenital, infantile, juvenile, adult.
![Page 17: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/17.jpg)
Primary glaucomas
• High IOP is not associated with any ocular disorder– Open angle– Angle closure– Congenital (developmental)
![Page 18: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/18.jpg)
Secondary glaucomas
• Aqueous outflow alters by ocular / non ocular disorders IOP » :– Secondary open angle glaucoma: pretrabecular,
trabecular and post-trabecular,– Secondary angle closure glaucoma caused by
apposition between the peripheral iris and trabeculum,
– Pathogenesis: anterior forces / posterior forces
![Page 19: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/19.jpg)
Secondary Glaucoma
Mechanism of obstruction in secondary glaucoma:
a. Pre-trabecular obstruction (membrane)
b. Trabecular obstruction (pigment granules)
c. Secondary angle closure by pupil block
d. Secondary angle closure without pupil block
![Page 20: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/20.jpg)
Tonometry
• Two main methods of measuring IOP:– applanation force to flatten the cornea– indentation force to indent the cornea
• The main types of tonometer:– The Schiotz tonometer uses a plunger with a
preset weight to indent the cornea. The amount of indentation is converted into mmHg by use of Friedenwald tables.
![Page 21: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/21.jpg)
Tonometry
• The main types of tonometer:
– Goldmann tonometer consists of double prism with 3.06 mm in diameter, applanation, more accurate,
– Perkins tonometer, hand held, applanation,
– The air puff tonometer, non contact, applanation, jet of air to flatten the cornea.
– Tono-pen
– Gas Tonometer
– Electrical Tonometer
![Page 22: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/22.jpg)
Schiotz Tonometer
Portable, simple, low cost, Measure the depth of indentation of
cornea by a plunger with specific weight,
5 mm indentation represent as each scale of Schiotz which converted into mmHg by Freidenwald table,
Low accuracy because it is influenced by ocular rigidity (high myop, DM, corneal leucoma).
![Page 23: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/23.jpg)
Goldmann’s Applanation Tonometer
• More accurate, not influenced by ocular rigidity,• The foot plate of the plunger is smaller (3.06 mm),• Disadvantages: cannot be applied to
– Corneal edema
– Keratitis, corneal ulcer
– Keratokonus
– High astigmatic
![Page 24: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/24.jpg)
Tonography
• To estimate outflow facility of HA,• Principal: to express fluid from the eye by
continuous pressing to the eye, maximal flows,
• Placing Schiotz type tonometer 2-4 minutes, • Compare IOP at 0 and after 4 minutes
outflow facility (C),• Normal C > 0.18.
![Page 25: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/25.jpg)
Provocation Test
• Water drinking test, dark room test, midriatic test, steroid test,
• Positive if IOP at the end of the tests are more than 8 mmHg,
• Indications:– Narrow / closed angle glaucoma– Normal tension glaucoma– Bias IOP
![Page 26: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/26.jpg)
Gonioscopy
• Three main purposes of gonioscopy:– Identification of abnormal angle structure,– Estimating the width of the chamber angle,– Visualization of the angle during this following
procedures: goniotomy, laser trabeculoplasty.
![Page 27: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/27.jpg)
Indentation Gonioscopy
![Page 28: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/28.jpg)
Identification of angle structures
• Schwalbe’s line as an opaque line is a peripheral termination of Descemet membrane,
![Page 29: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/29.jpg)
Identification of angle structures
• Trabecular meshwork has a ground glass appearance, stretches from Schwalbe’s line to scleral spur.Consists of two part:– The anterior, nonfunctional, non pigmented
part, whitish color,– The posterior, functional, pigmented part,
greyish-blue translucent.
![Page 30: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/30.jpg)
Identification of angle structures
• Schlemm’s canal, slightly darker line, deep to the posterior trabeculum,
• Scleral spurs, most anterior of sclera, narrow, dense, often shiny, whitish band. As a landmark for laser trabeculoplasty.
![Page 31: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/31.jpg)
Identification of angle structures
• Ciliary body stands behind the scleral spur as dull brown band. The width depends on iris insertion.– Curve of the corner at the margin of the ciliary body– Iris processes
• The angle recess dipping of the iris, it inserts into the ciliary body.
• Iris processes, small extension of the anterior surface of the iris, inserted at the level of scleral spur.
![Page 32: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/32.jpg)
Identification of angle
structures
![Page 33: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/33.jpg)
Identification of angle structures
![Page 34: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/34.jpg)
Angle classification by Shaffer
• Grade IV : 45 degrees angle
III : 20 - 25 degrees angle
II : 20 degrees angle closed
I : 10 degrees angle closed• Slit angle : less than 10 degrees,• Grade 0 : closed angle, iridocorneal
contact.
![Page 35: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/35.jpg)
Shaffer Grading
![Page 36: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/36.jpg)
Ophthalmoscopy of the optic disc
• 1.2 million axons pass across the retina and enter the optic disc,
• Fibers from the macula papillomacular bundle, straight to the optic disc, most resistant,
• Fibers from temporal of macula an arcuate path around the papillomacular bundle supero and inferotemporal of the optic disc, vulnerable to glaucomatous damage.
![Page 37: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/37.jpg)
Ophthalmoscopy of the optic disc
Nerve fiber layer anatomy
![Page 38: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/38.jpg)
Ophthalmoscopy of the optic disc
Normal nerve fiber layer
![Page 39: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/39.jpg)
Ophthalmoscopy of the optic disc
Diffuse nerve fiber atrophyNormal nerve fiber layer
![Page 40: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/40.jpg)
Ophthalmoscopy of the optic disc
• Scleral canal, the opening of 1.2 million nerve fiber leaves the eye, oval, vertical, 1.75 mm in diameter,
• The lamina cribrosa, plate of collagenous connective tissue, 200-400 pore, containing retinal nerve fiber bundles,
• The large pores have thin connective tissue supports, and large nerve fibers, vulnerable to glaucomatous damage.
![Page 41: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/41.jpg)
Ophthalmoscopy of the optic disc
• The optic cup, pale depression in the center of the optic cup, absent of nerve fiber,
• The neuroretinal rim, tissue between outer edge of the cup and the outer margin of the disc, the color is pink orange, uniform width, contains nerve fibers,
• Nerve fibers death thinning of retinal rim,• High IOP posterior bowing of lamina cribrosa,
nasalisation of central retinal vessels.
![Page 42: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/42.jpg)
Ophthalmoscopy of the optic disc
• The cup-disc ratio: fraction of vertical and horizontal diameter cup and diameter of the disc, normal c/d ratio is 0.3 or less.
![Page 43: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/43.jpg)
Optic disc changes in glaucoma
Normal disc with small cup
![Page 44: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/44.jpg)
Optic disc changes in glaucoma
Large physiological cups
![Page 45: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/45.jpg)
Optic disc changes in glaucoma
• Progressive loss of the retinal nerve fibers notching / thinning of neuroretinal rim (NRR)
• The cup is enlarged :– concentrically diffuse thinning of NRR
– localized expansion notching of NRR
• Double angulation of the blood vessel bayoneting sign,
• Arterial and vein nasalisation,
![Page 46: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/46.jpg)
Optic disc changes in glaucoma
• Cup and disc ratio > 0.6,
• Peripapillary atrophy at temporal region,• Splinter-shaped hemorrhage on the disc
margin.
![Page 47: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/47.jpg)
Optic disc changes in glaucoma
![Page 48: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/48.jpg)
Normal Visual Field Examination
• Nasally 60 degrees• Temporally 95 degrees• Superiorly 50 degrees• Inferiorly 70 degrees• The blind spot is located temporally 10-20 degrees• Visual field is an island of vision surrounded by
sea of darkness, the sharpest is at the top of island.
![Page 49: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/49.jpg)
Visual Fields in Glaucoma
• Baring of the blind spot
• Localized paracentral scotoma at 10 - 20 degrees of fixation at superior and inferior quadrant extension to the blind spot Byerrum scotoma ring scotoma with nasal step of Roenne,
![Page 50: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/50.jpg)
Visual Fields in Glaucoma
• Peripheral scotoma that spreads and coalesce to the paracentral scotoma
• Leaving central island and accompanying temporal island, even if the central vision is still normal
• Temporal island total blindness
![Page 51: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/51.jpg)
Visual Fields in Glaucoma
![Page 52: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/52.jpg)
Classification
• Primary open-angle glaucoma
• Secondary open-angle glaucoma
• Primary closed-angle glaucoma
• Secondary closed-angle glaucoma
• Primary congenital glaucoma
• Secondary congenital glaucoma
![Page 53: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/53.jpg)
Primary Open-Angle Glaucoma(Simple Glaucoma)
• Bilaterally, not necessarily symmetrical, absence of secondary causes of high IOP,
• Glaucomatous optic nerve damage,• Open and normal angle, IOP > 21 mmHg,• Adult onset, hereditary, steroid responsiveness,• Glaucomatous visual field defects, central tunnel
vision,• Minimal clinical signs.
![Page 54: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/54.jpg)
Management of Primary Open Angle Glaucoma
• Initial therapy is usually medical, except in advanced cases,
• Argon laser trabeculoplasty (ALT) if IOP is uncontrolled despite maximal tolerated medical therapy,
• Trabeculectomy with / without antimetabolic drug in refractory glaucoma,
• Artificial filtering shunt: Achmed valve, Molteno tube, Krupin- Denver valve.
![Page 55: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/55.jpg)
Surgical Indications forSimple Glaucoma
• Uncontrolled IOP by maximal medical treatment
• Progressive disc damage and visual field defect
• Drugs intolerance• Unable to buy the drugs• Poor compliance• Unable to do the regular control
![Page 56: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/56.jpg)
Primary Closed-Angle Glaucoma
• Obstruction of aqueous outflow as a result of closure of the angle by the peripheral iris
• Anatomically predisposed, bilateral,• Predisposition:
– Crowded anterior segment– Relatively anterior location iris lens diaphragm,– Shallow anterior chamber,– Narrow entrance to the chamber angle.
![Page 57: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/57.jpg)
PACG stage
• Five overlapping stage:– Latent– Intermittent (sub acute)– Acute (congestive and post congestive)– Chronic– Absolute
![Page 58: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/58.jpg)
Latent angle-closure glaucoma
• Shallow anterior chamber, convex-shape iris lens diaphragm, close iris to cornea, normal IOP, occludable angle,
• Treatment: – Good fellow eye without treatment, follow
up,– PACG fellow eye laser iridotomy.
![Page 59: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/59.jpg)
Intermittent angle-closure glaucoma
• Rapid partial closure anterior chamber angle and reopening of the angle after some rest,
• Precipitating factors: physiological mydriasis, watching TV in dark room, prone position, reading, sewing, emotion, stress,
• Transient blurring of vision, halo, headache,• Recovery after some rest.
![Page 60: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/60.jpg)
Acute congestiveangle-closure glaucoma
• Presentation:
– Rapidly progressive impairment of vision, sometimes the vision 1/300 – 0,
– Eye ache and frontal headache,
– Congestion, nausea, vomiting.
![Page 61: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/61.jpg)
Acute congestiveangle-closure glaucoma
• Examination– Ciliary and conjunctival injection– IOP > 50 mmHg, dilated pupil,
unreactive.
– Cornea: epithelial edema, KP(+), vesicle– Ant chamber: shallow PAS, flare /
cell (+),
![Page 62: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/62.jpg)
Acute congestiveangle-closure glaucoma
• Wide pupil, slow / negative light reflex,
• Papilla edema, retinal edema,
![Page 63: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/63.jpg)
Acute congestive angle-closure glaucoma
![Page 64: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/64.jpg)
Acute congestiveangle-closure glaucoma
• Differential diagnosis:– Red eyes:
• acute glaucoma, conjunctivitis, iridocyclitis
– Silent eyes:• simple glaucoma, ocular hypertension
– Glaucomatous visual field defect:• anomaly of the optic nerve and retina
– Papillary atrophy:• anomaly at optic nerve
– Congenital megalocornea without high IOP
![Page 65: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/65.jpg)
Acute congestiveangle-closure glaucoma
• Treatment:– Immediately decrease IOP with maximal drugs,– Wait for 24 hours evaluation,– Normal IOP, deep AC, open angle
iridectomy,– High IOP, permanent AC closure > 50%
trabeculectomy,– The fellow eye: preventive iridectomy.
![Page 66: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/66.jpg)
Postcongestiveangle-closure glaucoma
![Page 67: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/67.jpg)
Chronic closed-angle glaucoma
• Clinical features of chronic CAG are similar as POAG except gonioscopy of the angle is closed,
• There are three mechanism of CCAG:
– Creeping PAS laser iridotomy / trabeculectomy
– After intermittent and laser iridotomy drug >
– Combination of POAG with narrow angle laser iridotomy + medical trabeculectomy
![Page 68: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/68.jpg)
Chronic closed-angle glaucoma
• Signs and therapy are similar as simple glaucoma:– Trabeculectomy,– Laser gonioplasty to make an angle,– Argon Laser Trabeculopasty (ALT)
![Page 69: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/69.jpg)
Primary Congenital Glaucoma
• 65% of patients are male, 1: 10.000,
• Inheritance is autosomal recessive, bilateral,
• Maldevelopment of the trabeculum and iridotrabecular junction, abscent of angle recess, trabeculodysgenesis,
• The iris insertion can be flat or concave,
• Poorly prognosis.
![Page 70: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/70.jpg)
Primary Congenital Glaucoma
• Clinical signs:– Depends on the age of onset and the level of
IOP,– According to age of onset there are 3 types:
• True congenital glaucoma (40%). IOP elevated intrauterine buphthalmos,
• Infantile glaucoma (55%) manifest after birth,
• Juvenile glaucoma: IOP » at 2-16 years of age, with clinical manifestation the same as POAG.
![Page 71: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/71.jpg)
Primary Congenital Glaucoma
• Examinations:– Corneal haze, lacrimation, photophobia and
blepharospasm,– Buphthalmos if IOP » before the age of 3
usually associated with axial myop, subluxated lens,
– Break of Descemet membrane, endothelial decompensation permanent stromal edema,
– Reversible glaucomatous cupping.
![Page 72: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/72.jpg)
Primary Congenital Glaucoma
• Treatment:– Initial drug treatment,– Goniotomy if cornea is still clear,– Trabeculotomy at corneal clouding,– Trabeculectomy and trabeculotomy,– Trabeculectomy with antimetabolic agent,– Outcome of the operation is poor.
![Page 73: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/73.jpg)
Secondary Glaucoma
• Inflammation and residual inflammation of the uveal tissue: iridocyclitis, posterior synechia,
• Immature cataract, hipermature cataract,• Lens luxation, lens subluxation,• Ischemic retina,• Sub choroidal bleeding,• Congenital anomaly of the eye
![Page 74: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/74.jpg)
Secondary Glaucoma
• Pigmentary gl. - Neovascular gl.• Inflammatory gl. - Phacolytic glaucoma• Red cell gl. - Ghost cell glaucoma• Angle recession glaucoma• Iridocorneal endothelial syndrome• Pseudoexfoliative glaucoma
![Page 75: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/75.jpg)
Therapy
• Nerve fiber damage caused by glaucoma is irreversible,
• Principal of therapy is to decrease IOP medically or surgically to maintain the current condition,
• The purposes of decreasing the IOP is to reduce progressivity of the nerve fiber damage and visual field defect,
• Early finding.
![Page 76: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/76.jpg)
Indications of Medical Treatment
• Simple glaucoma
• Acute / chronic closed angle glaucoma
• Maintain the diurnal IOP
• Lowering IOP before operation
![Page 77: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/77.jpg)
Reducing aqueous production
• Carbonic anhydrase inhibitor – acetazolamide 250 mg qid orally,– dorzolamide eye drop tid,
• Beta-adrenergic antagonist:– beta-blocker (timolol maleat 0.25-0.5%) bid,– betaxolol 0.25% - 0.5% bid.
• Adrenergic agonist:– depefeprine 0.5% - 2% bid.
![Page 78: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/78.jpg)
Other antiglaucoma drugs
• Parasympathomimetic agents:
– pilocarpin eye drop 2-4%, 2-6 x / day
– carbachol 0.75% used after cataract operation
• Increase the latanoprost uveoscleral flow• Hyperosmotic fluid
– glycerol 50% 1-2 ml/kg body weight, drink all at once,
– manitol 20% swift infusion preoperative, 1.5-3 ml/kg body weight.
![Page 79: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/79.jpg)
Surgical treatment
• Peripheral iridectomy:– Acute attack glaucoma, with good trabecular
meshwork,– Preventive treatment from acute attack for the fellow
eye.
• Trabeculectomy for all types of glaucoma,• Goniotomy for congenital glaucoma if the cornea
is still clear,• Trabeculotomy for congenital glaucoma if the
cornea is edema.
![Page 80: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/80.jpg)
Surgical treatment
• Treatment for absolute glaucoma:– cyclocryo coagulation destroys the ciliary body
to decrease HA production,– enucleation if all treatment is not successfull.
• Laser treatment:– iridotomy– gonioplasty– trabeculoplasty
![Page 81: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/81.jpg)
Good Prognosis
• Early and right diagnosis,
• Adequate control of IOP by medical / surgical treatment,
• Compliance of the patients for checking their IOP and use medical treatment,
• Case finding among glaucoma family.
![Page 82: 4 - Glaukoma](https://reader036.vdocuments.mx/reader036/viewer/2022081416/551619464979591a4d8b4633/html5/thumbnails/82.jpg)
Thank You