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DR.K.SUDHAMATHI CONSULTANT EYEQ SUPERSPECIALITY HOSPITALS

GLAUCOMA BASICS. VISION. DR.K.SUDHAMATHI CONSULTANT EYEQ SUPERSPECIALITY HOSPITALS. Magnitude. Second major cause of blindness Often asymptomatic in early stage. Damage is irreversible. Effective treatment is available. DEFINITION.

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DR.K.SUDHAMATHI CONSULTANT EYEQ SUPERSPECIALITY HOSPITALS

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  1. GLAUCOMA BASICS VISION DR.K.SUDHAMATHI CONSULTANT EYEQ SUPERSPECIALITY HOSPITALS

  2. Magnitude Second major cause of blindness Often asymptomatic in early stage. Damage is irreversible. Effective treatment is available

  3. DEFINITION It is a heterogenous group of diseases in which damage to the optic nerve(optic neuropathy) is usually caused by raised ocular pressure IOP: Depends on the balance between production and removal of aqueous humour

  4. Aqueous Humor Dynamics • Produced by non-pigmented epithelia of pars plicata • Secretion • Ultrafiltration • Diffusion • Aqueous production rate - 2µL/min • Facility of outflow – 0.22µL/min/mm of Hg

  5. Aqueous outflow Anatomy Physiology a - Uveal meshwork a - Conventional outflow-90% b - Corneoscleral meshwork b - Uveoscleral outflow c - Schwalbe line c - Iris outflow d - Schlemm canal e - Collector channels f - Longitudinal muscle of ciliary body g - Scleral spur

  6. Goldmann EquationPo = (F/C) + Pv

  7. NORMAL IOPMean= 15.9mmHg ± 2 SDIOP > 21.7 is abnormal.Factor affect IOP*Age *Sex *Race *Heredity*Diurnal & Seasonal variation*Blood pressure *Obesity *Drugs*Posture *Exercise *Neural *Hormone*Refractive error *Eye movement *Eyelid closure*Inflammation *Surgery INTERNAL

  8. STEPWISE DIAGNOSIS • IOP with Applanationtonometry with Corneal Pachymetry • Good S/L exam/. & Stereoscopic DialatedOphtalmoscopic examination*AFTER AC DEPTH • Gonioscopy • Formal visual-field testing(WWP) • Imaging

  9. Tonometers Goldmann Schiotz Perkins Contact applanation Portable contact applanation Contact indentation Pulsair 2000 (Keeler) Tono-Pen Air-puff Portable non-contact applanation portable contact applanation Non-contact indentation

  10. VON HERRICKS ANGLE GRADING- SIMPLIFIED VAN HERRICKS

  11. Primary Glaucoma Is the iris: NOT covering the Trabecular meshwork Covering the Trabecular meshwork CLOSED angle glaucoma OPEN angle glaucoma

  12. Indentation gonioscopy in iridocorneal contact Before indentation During indentation • Complete angle closure • Part of angle is forced open Apex of corneal wedge not visible Part of angle remains closed by PAS

  13. Optic Nerve Head • Optic Disc 1.5 mm dia • 1.2 million axons/1000 fascicles • Normal loss 5000 axons/year • Optic Nerve • Surface nerve fibre layer • Prelaminar • Laminar • Retrolaminar

  14. Anatomy of retinal nerve fibres Horizontal raphe Papillomacular bundle Normal Slit Defect Wedge defect Total atrophy

  15. Theories of damage • Mechanical theory • Compression of axons leads to axonal death • Vascular theory • Ischemia causes axonal necrosis Direct damage due to Pr. Capillary Occlusion Interference to Axoplasmic flow

  16. Glaucomatous Damage • Axonal necrosis leading to cupping • Loss of supporting glial tissue • Normally leads to disc pallor Histology of Normal and Glaucomatous Optic nerve

  17. Glaucomatous Damage

  18. Types of physiological excavation Cup with sloping temporal wall Larger and deeper punched-out central cup Small dimple central cup

  19. Pallor and cupping Pallor - maximal area of colour contrast Cupping - bending of small blood vessels crossing disc Cupping and pallor correspond Cupping is greater than pallor

  20. GLAUCOMA Optic nerve signs of glaucoma progression • Increasing C:D ratio • Development of disk pallor • Disc hemorrhage (60% will show progression of VF damage) • Vessel displacement • Increased visibility of lamina cribosa

  21. STRUCTURE /FUNCTION EVALUATION

  22. CLASSIFICATION ACORDING TO AETIOLOGY *Primary *Secondary *Congenital-present at birth. Infantile, present in first year of life. Juvenile, present in late childhood. ACCORDING TO APPERANCE OF THE ANGLE *Open angle glaucoma. *Closed angle glaucoma. *Combined mechanism glaucoma

  23. GLAUCOMA CLASSIFICATION PRIMARY VERSUS SECONDRY *PRIMARY No detectable ocular or systemic abnormality. Often bilateral. Often familial *SECONDARY Predisposing ocular or systemic abnormality. Often unilateral. Often sporadic

  24. Primary OPEN angle glaucoma • It is the most common type of glaucoma • It is the 2nd cause of blindness in the India • It is also called chronic open angle glaucoma. • It causes SLOW damage to the optic nerve, causing gradual loss of vision.

  25. Primary OPEN angle glaucoma • Pathogenesis: • Resistance of drainage of aqueous through the Trabecular meshwok, due to: • Thickening of Trabecular lamellae (reduces pore size). • Reduction in number of lining Trabecular cells. • Increased extracellular material in the Trabecular meshwork spaces.

  26. Open Angle Glaucoma • Risk Factors • Age • Race • Family History • Diabetes • Myopia • Hypertension • Smoking Signs & symptoms • “Silent thief of sight” • Frequent change of presbyopic glasses

  27. Low-tension Glaucoma • IOP<21 • Mostly elderly people • Vasospastic disease – Migraine, Raynaud’s phenomena, Autoimmune disease • Systemic hypotension 1.TRUE LTG 2.Non Progressive LTG 3.Pseudo LTG

  28. SECONDARY OPEN ANGLE GLAUCOMA PreTrabecular-Membrane on T.M. *Epithelial *Endothelial *Fibrous *Fibrovascular *Inflamatory Trauma, Toxicity toTM • Edema • Tears • Toxins • Laser TRABECULAR-Particle obstruct T.M. *RBC-Haem *WBC-Imflammation *NEOPLASTIC CELLS *PIGMENTS *PXF MATERIAL Posttrabecular-Increased Episcleral VP SUPERIOR VENA CAVA OBSTRUCTION THYROID EYE DISEASE A/V FISTULA STURGE WEBER SYNDROME *VISCOUS MATERIAL-SILICONE OIL *HEALON *LENS PARTICLE *VITREOUS *FIBRIN

  29. Pigmentary Glaucoma • Young, white, male myopes • Pigment dispersion due to zonular contact with iris • Krukenberg spindle • Radial transillumination defects • Trabecular meshwork pigmentation

  30. Pseudoexfoliation Glaucoma • Elderly white women • Fibrillar material deposited on trabecular meshwork • Moth-eaten iris transillumination defects • Pigment on trabecular meshwork

  31. STEROID INDUCED GLAUCOMA • Risk Factors • POAG • Diabetes • Myopia • Stronger the steroid more the elevation

  32. Primary Angle ClosureGlaucomas PRIMARY ANGLE-CLOSURE GLAUCOMA A. INTERMITENT ANGLE-CLOSURE GLAUCOMA B. SUBACUTE ANGLE-CLOSURE GLAUCOMA C. ACUTE ANGLE-CLOSURE GLAUCOMA D. CHRONIC ANGLE-CLOSURE GLAUCOMA E. ABSOLUTE GLAUCOMA PRIMARY ANGLE-CLOSURE GLAUCOMA ANATOMIC FEATURES: • SMALL CORNEAL DIAMETER • SHALLOW ANTERIOR CHAMBER • THICKER LENS • SMALL RADIUS OF THE ANTERIOR LENS CURVATURE • ANTERIOR LENS POSITION • SHORT AXIAL LENGTH • HYPEROPIC EYES

  33. Classification of primary angle closure (PAC)

  34. Primary Angle Closure Glaucoma • Risk factors • Elderly • Hypermetropic • Emotionally unstable women

  35. Glaucomflecken Iris Atrophy

  36. Primary Angle Closure Glaucoma-Acute congestive attack-EMERGENCY!!! • Symptoms • Sudden pain • Loss of vision • Coloured halos • Signs • High IOP • Shallow Ac • Oedematous cornea • Pupil mid-dilated & fixed

  37. Narrow Angle Glaucoma Treatment: Peripheral Iridotomy

  38. Secondary Angle Closure • Anterior iris pulling mechanism • NVG • ICE syndromes------------ • Posterior pushing mechanism • Plateau iris • Malignant glaucoma 1-Progressive iris atrophy 2-Chandler syndrome 3-Cogan-reese syndrome With pupil block - seclusio pupillae and iris bombé . Without pupil block - peripheral anterior synechiae

  39. Plateau Iris Syndrome • Younger patients, uncommon • Ac appears to be normal but gonioscopy demonstrates relatively flat iris • Plateau iris syndrome – high IOP despite LI • Plateau iris configuration – normal IOP after LI • Laser Iridoplasty to shrink peripheral iris

  40. Neovascular Galucoma • Causes • Diabetes • CRVO • Carotid vascular disease • CRAO • Eales’ Disease • Sickle cell anemia • Coats disease • Signs & symptoms • Rubeosis iridis • Ectropion uveae • NV of angle

  41. Malignant Glaucoma • Aqueous misdirected posteriorly behind vitreous • Vitreous moves forward, collapses iris & lens into AC • Typically after intraocular surgery particularly cataract & glaucoma

  42. Lens related Glaucoma Intumescence Dislocation and Subluxation Phacolytic Lens particle

  43. Primary Congenital Glaucoma • From birth till 3 years of age • Autosomal recessive • Photophobia • Blephrospasm • Epiphora • Hazy cornea • Haab’s Striae • Deep AC

  44. MANAGEMENT OF CONGENITAL GLAUCOMA GONIOTOMY TRABECULOTOMY

  45. Medical Treatment of GLAUCOMA • Beta-blockers • Carbonic anhydrase inhibitors • Prostaglandin analogues • Miotics • Alpha-2 agonists

  46. Surgical treatment of GLAUCOMA • Argon laser trabeculoplasty • Trabeculectomy/Filtering Sx • Cyclocryotherapy • Cyclolaser ablation • Iridotomy

  47. Thank you

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