glaucoma
DESCRIPTION
Glaucoma. A lecture from Dr. Lee from Penang Medical CollegeTRANSCRIPT
GlaucomaGlaucoma
Dr Lee Ming YuehDr Lee Ming Yueh
Ophthalmology UnitOphthalmology Unit
Penang HospitalPenang Hospital
Glaucoma is a sight threatening disease Glaucoma is a sight threatening disease which can cause irreversible visual losswhich can cause irreversible visual loss
Baltimore Eye Survey:Baltimore Eye Survey:
- - by the year 2000 by the year 2000 > 66.8 million primary glaucoma > 66.8 million primary glaucoma
> 6.7 million bilateral > 6.7 million bilateral blindness blindness
DefinitionDefinition
A spectrum of disease characterized byA spectrum of disease characterized by
- progressive optic neuropathy- progressive optic neuropathy
- visual field loss- visual field loss
** IOP is an important risk factor. IOP is an important risk factor.
Optic NeuropathyOptic Neuropathy
Progression of
Glaucomatous
Optic Neuropathy
Visual Field Visual Field LossLoss
Classification:Classification:
Open Angle GlaucomaOpen Angle Glaucoma
Close Angle GlaucomaClose Angle Glaucoma
Congenital GlaucomaCongenital Glaucoma
Trabecular meshwork acts like a sieve…Trabecular meshwork acts like a sieve…
Angle StructureAngle Structure
Open Angle GlaucomaOpen Angle Glaucoma
PrimaryPrimaryRisk factors :Risk factors : Age > 60Age > 60
Race – negro, darkRace – negro, darkFamily history – siblings 4xFamily history – siblings 4x
- parents 2x- parents 2xOcular ds – myopia, Retinitis Ocular ds – myopia, Retinitis
PigmentosaPigmentosaCardiovascular ds, DM, SAS, Cardiovascular ds, DM, SAS,
migraine ?migraine ?SecondarySecondarya.a. Pretrabecular – neovascular/inflammatory membranePretrabecular – neovascular/inflammatory membraneb. b. Trabecular- RBC, pseudoexfoliation, pigmentTrabecular- RBC, pseudoexfoliation, pigmentc.c. Post Trabecular- TED, Carotid-cavernous fistulaPost Trabecular- TED, Carotid-cavernous fistula
Primary Open Angle GlaucomaPrimary Open Angle Glaucoma
Traumatic Hyphaema with Traumatic Hyphaema with secondary open angle glaucomasecondary open angle glaucoma
Pseudoexfoliative SyndromePseudoexfoliative Syndrome
Open Angle GlaucomaOpen Angle Glaucoma
Clinical features:Clinical features:
- ‘silent thief of sight’- ‘silent thief of sight’
- Painless gradual loss of vision; loss - Painless gradual loss of vision; loss of visual field follows by impairment of visual field follows by impairment of visual acuity.of visual acuity.
- Intraocular pressure (IOP) rise - Intraocular pressure (IOP) rise gradually, usually asymptomatic, till gradually, usually asymptomatic, till significant visual impairment occurs.significant visual impairment occurs.
This is what a glaucoma patient This is what a glaucoma patient sees….sees….
ExaminationExamination
1.1. Visual acuityVisual acuity
2.2. Pupil – afferent pupillary defectPupil – afferent pupillary defect
3.3. Intra-ocular Pressure (IOP)Intra-ocular Pressure (IOP)
- IOP > 21 mmHg- IOP > 21 mmHg
- IOP asymmetry > 3 mmHg- IOP asymmetry > 3 mmHg
4.4. Optic nerve head & retinal nerve fibre layer Optic nerve head & retinal nerve fibre layer assessmentassessment
- vertical cup-disc ratio (CDR) > 0.7- vertical cup-disc ratio (CDR) > 0.7
- Asymmetry of CDR > 0.2- Asymmetry of CDR > 0.2
- thinning & notching of neuroretinal rim, - thinning & notching of neuroretinal rim, nasalization & bayonetting of retinal vessels.. nasalization & bayonetting of retinal vessels..
(Normal NRR follow ‘ISNT rule’).(Normal NRR follow ‘ISNT rule’).
- Laminar dots sign- Laminar dots sign
- optic disc haemorrhage- optic disc haemorrhage
5. Evaluation of the angle5. Evaluation of the angle
GonioscopyGonioscopy
- open or close ?- open or close ?
- to exclude secondary cause of glaucoma- to exclude secondary cause of glaucoma
Angle StructureAngle Structure
Grading for Gonioscopy findingGrading for Gonioscopy finding
GradeGrade 00 II IIII IIIIII IVIV
ShafferShaffer closedclosed 1010°° 2020°° 3030°° 4040°°
ModifieModifie
ShafferShaffer
Schwalbe Schwalbe lineline
Not seenNot seen
SchwalbeSchwalbe
Line Line
visiblevisible
TrabTrab
MeshworkMeshwork
visiblevisible
Scleral Scleral spurspur
visiblevisible
Ciliary Ciliary
Body Body
visiblevisible
Shaffer Gonioscopic ClassificationShaffer Gonioscopic Classification
Eclipse SignEclipse Sign
6.6. Visual Field TestVisual Field Test
- Humphrey visual field is gold standard- Humphrey visual field is gold standard
- classical VF defects are - classical VF defects are
: : paracentral scotomaparacentral scotoma
nasal stepnasal step
Arcuate scotomaArcuate scotoma
Temporal wedgeTemporal wedge
Humprey Humprey Visual FieldVisual Field
Optic disc photographOptic disc photograph showing thinning of the inferior showing thinning of the inferior neuroretinal rim and increased cupping, consistent with neuroretinal rim and increased cupping, consistent with
glaucoma.glaucoma.Humphrey visual fieldHumphrey visual field showing showing superior arcuatesuperior arcuate defect defect and and nasal stepnasal step corresponding to the glaucomatous optic corresponding to the glaucomatous optic
nerve changes on the left.nerve changes on the left.
Management:Management:MedicalMedicaltopical anti-glaucoma topical anti-glaucoma - B-blocker eg Timolol, Betoptic- B-blocker eg Timolol, Betoptic- prostaglandin analog - prostaglandin analog - carbonic anhydrace inhibitor- carbonic anhydrace inhibitor- - αα agonist agonist Laser TreatmentLaser Treatment- Argon laser trabeculoplasty /Selective LT- Argon laser trabeculoplasty /Selective LTSurgicalSurgical- Trabeculectomy/augmented trabeculectomy- Trabeculectomy/augmented trabeculectomy- Shunt/valve surgery- Shunt/valve surgery
ConservativeConservative- asymptomatic poor visual prognosis- asymptomatic poor visual prognosis
Indications for surgery:Indications for surgery:
1.1. Failed medical therapyFailed medical therapy
2.2. Disease progression despite maximun Disease progression despite maximun medical therapymedical therapy
3.3. Anticipated fast progressionAnticipated fast progression
4.4. Combined cataract & trabeculectomy Combined cataract & trabeculectomy surgerysurgery
Primary Angle Closure Primary Angle Closure GlaucomaGlaucoma
Risk Factors:Risk Factors:
- - age, average 60 y-oldage, average 60 y-old
- female more common 4:1- female more common 4:1
- race: more common in SEA, Chinese, - race: more common in SEA, Chinese, Eskimos.Eskimos.
- Family: 1- Family: 1stst degree relatives increased risk . degree relatives increased risk .
Anatomical predisposing factorsAnatomical predisposing factors
1.1. Relatively anterior location of iris-lens Relatively anterior location of iris-lens diaphragm.diaphragm.
2.2. Shallow anterior chamberShallow anterior chamber3.3. Narrow entrance to the chamber angleNarrow entrance to the chamber angle
Eyes with PACGEyes with PACG have have-corneal diameter 0.25mm smaller than normal -corneal diameter 0.25mm smaller than normal eyeseyes- shallower anterior chamber (1.8mm)- shallower anterior chamber (1.8mm)- hypermetropic eyes- hypermetropic eyes
Secondary- Pupillary Block Secondary- Pupillary Block GlaucomaGlaucoma
Inflammatory with occlusio or seclusio Inflammatory with occlusio or seclusio pupillaepupillae
PhacomorphicPhacomorphic
Vitreous blocVitreous bloc
Silicone oilSilicone oil
Secondary-NonPupillary Block Secondary-NonPupillary Block GlaucomaGlaucoma
NeovascularNeovascular
Iridocorneal endothelial syndromIridocorneal endothelial syndrom
Ciliary tumour, iris cystCiliary tumour, iris cyst
Suprachoroidal haemorrhageSuprachoroidal haemorrhage
Iatrogenic- tight scleral buckling, post PRPIatrogenic- tight scleral buckling, post PRP
Clinical Features:Clinical Features:
Rapidly progressive blurring of visionRapidly progressive blurring of visionPeriocular pain and congestionPeriocular pain and congestionNausea and vomiting in severe cases.Nausea and vomiting in severe cases.
Slit-lamp exam:Slit-lamp exam:- ciliary flush/circumcornea injection- ciliary flush/circumcornea injection- high IOP (50 -100mmHg)- high IOP (50 -100mmHg)- cornea oedema w epithelial cysts- cornea oedema w epithelial cysts- shallow anterior chamber.- shallow anterior chamber.
Acute Management ofAcute Management of Angle Closure Angle Closure GlaucomaGlaucoma
To lower the IOP fastTo lower the IOP fast
- IV Diamox 500mg /IV Mannitol- IV Diamox 500mg /IV Mannitol
- Topical antiglaucoma- Topical antiglaucoma > pilocarpine 2%> pilocarpine 2%
> timolol 0.5%> timolol 0.5%
> prostaglandin > prostaglandin analog analog
Definitive treatmentDefinitive treatment
- laser peripheral iridectomy/ surgical - laser peripheral iridectomy/ surgical
Further managementFurther management
To To control IOPcontrol IOP to to stop disease stop disease progressionprogression
- IOP, optic nerve changes, visual field- IOP, optic nerve changes, visual field
MedicalMedical
- - ββ blocker, prostaglandin analog carbonic blocker, prostaglandin analog carbonic anhydrace inhibitor, anhydrace inhibitor, αα agonist agonist
SurgicalSurgical- Trabeculectomy- Trabeculectomy
- Shunt/valve surgery- Shunt/valve surgery
TrabeculotomyTrabeculotomy
Aquoues OutflowAquoues Outflow
Congenital GlaucomaCongenital Glaucoma
Congenital GlaucomaCongenital Glaucoma
Primary Primary SecondarySecondary - Anterior segment dysgenesis- Anterior segment dysgenesis- Ocular ds- Ocular ds- Phakomatoses eg. Neurofibromatosis- Phakomatoses eg. Neurofibromatosis- Metabolic ds eg. Lowe’s, Homocysteinuria- Metabolic ds eg. Lowe’s, Homocysteinuria- Congenital rubella- Congenital rubella- chromosomal abn eg. Down’s- chromosomal abn eg. Down’s- Ocular tumour- Ocular tumour- inflammatory eg. Seronegative arthritis- inflammatory eg. Seronegative arthritis
Clinical Features:Clinical Features:
May manifest at birth or develop laterMay manifest at birth or develop later
Signs & SymptomsSigns & Symptoms lacrimationlacrimation PhotophobiaPhotophobia Hazy corneaHazy cornea buphthalmosbuphthalmos rapidly progressive myopiarapidly progressive myopia
BuphthalmosBuphthalmos
Examination under anaesthesiaExamination under anaesthesia
Intraocular pressureIntraocular pressureAnterior segment examinationAnterior segment examination- cornea opacity, Haab’s striae- cornea opacity, Haab’s striae- anterior segment dysgenesis- anterior segment dysgenesisGonioscopyGonioscopy- Thicken trabecular meshwork, Barkhan’s - Thicken trabecular meshwork, Barkhan’s membranemembraneFundus examinationFundus examination- optic cup-disc ratio- optic cup-disc ratio
Management of Congenital GlaucomaManagement of Congenital Glaucoma
Congenital glaucoma is a surgical disease!Congenital glaucoma is a surgical disease!
SurgerySurgery goniotomy goniotomy trabeculotomytrabeculotomy trabeculectomytrabeculectomy
MedicalMedical topical eye drops ie. topical eye drops ie. ΒΒ-blocker, carbonic anhydrace -blocker, carbonic anhydrace
inhibitor, prostaglandin analoginhibitor, prostaglandin analog Alfa-2 agonist contraindicated due to sedative effectAlfa-2 agonist contraindicated due to sedative effect
GoniotomyGoniotomy
Barkhan Goniotomy lens & Swan goniotomy knife
Thank YouThank You