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Grand Ward Round

Grand Ward Round. 31st January 2008 Boey Pui Yi Medical Officer. Case 1. Mr GKH 35/Chinese/male No past medical history Poor vision RE since childhood ?amblyopia Can only count fingers RE No trauma. Presented with…. RE pain & redness 1 day 1st episode No trauma. Van Herick

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Grand Ward Round

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  1. Grand Ward Round 31st January 2008 Boey Pui Yi Medical Officer

  2. Case 1 • Mr GKH 35/Chinese/male • No past medical history • Poor vision RE since childhood • ?amblyopia • Can only count fingers RE • No trauma

  3. Presented with… • RE pain & redness 1 day • 1st episode • No trauma

  4. Van Herick • 1 (<25%) - high • 2 (25%) - possible • 3 (25-50%) - unlikely • 4 (>50%) - rare

  5. RE CF closely Cornea hazy Pupil mid-dilated No RAPD AC shallow Glaucomflecken + IOP 52 LE 6/6 Cornea clear AC shallow Lens clear IOP 12 CD 0.4 Examination

  6. RE - No view LE 0 0-1 0-1 0-1 Gonioscopy

  7. Gonioscopy - correct conditions: • Dark room • High magnification • Small light beam 1-2mm height, as narrow as possible • Avoid pupil • +/- offset illumination column 10 deg • Superior and inferior angles first

  8. Open angle Primary OAG - rare Secondary OAG Pretrabecular Neovascular Trabecular Uveitic - Any severe AAU, Fuch’s HI, Possner-Schlossman, Herpetic (HZV,VZV) Pigment dispersion Traumatic - hyphaema, angle recession Post-trabecular Raised episcleral pressure - CCF, Sturge-weber Closed angle Primary ACG - rare Secondary ACG Anterior pulling forces Neovascular Peripheral anterior synechiae Posterior pushing forces Posterior synechiae eg. Seclusio pupillae Lens-related eg. Subluxation Tumour eg. CB mass Angle crowding Plateau iris Rare causes a/w ocular pathology Ant segment dysgenesis Aniridia Iridocorneal-endothelial syndrome (ICE) Phakomatoses (open or closed) Sturge-Weber, NF Acute glaucoma in young male – DDx?

  9. Anterior segment OCT RE • B scan RE • No RD • No mass displacing CB forward • Axial length • 24.67mm LE

  10. Diagnosis? • Acute primary angle closure (APAC) attack RE • PACS LE • Management…

  11. Key phrases for exams… • Acute sight-threatening ocular emergency • Aim to break attack and lower IOP • Medical Rx • Other eg. Laser peripheral iridoplasty • Definitive treatment is laser PI

  12. 52(2130hr) 28 (1600hr) Laser PI BE 21 (1800hr) IV diamox 500mg PO diamox 250mg tds G T 0.5% G pilo 4% q15min x 1hr G alphagan G xalatan G PF hrly G alphagan G PF 2H Attempted laser PI - failed Repeat laser iridoplasty 40(2330hr) 48 (1220hr) 14(1000hr) Laser iridoplasty IV mannitol 130ml (20%) over 30min 30 (0200hr) 48 (1000hr) Overnight…

  13. RE IOP 14 CD 0.3 Re-attached RD with pseudo-RP picture LE IOP 19 2-3 2-3 0 2-3 2 1-2 2 2 Review 1/52 post-PI Plan: TCU 2/52, HVF

  14. Mechanism of APAC

  15. Patient factors Elderly Female Race - Chinese, Eskimos Family history Ocular factors Anatomical Shallow AC, narrow angles Anterior iris-lens diaphragm Hypermetropia Thick lens Small corneal diameter Physiological Semi-dark lighting Relative pupil block Is our patient the typical APAC pt?

  16. Pathogenesis of APAC • Incompletely understood • Physiological conditions • Iris rests posteriorly on anterior lens capsule • Some degree of resistance at pupil • Pressure in posterior chamber exceeds that in anterior chamber • Dilator muscle theory • Contraction of dilator pupillae exerts a posterior vector •  apposition between iris and lens,  pupil block • Dilated pupil  peripheral iris more flaccid  bombe • Sphincter muscle theory • Pupillary blocking force of sphincter greatest at 4mm

  17. Pathogenesis of APAC Pupil block Iris bombe Irido-trabecular block Acute  IOP

  18. Classification of PACG

  19. Classification of PACG

  20. Revised classification of Primary Angle Closure (PAC) • Foster PJ et al. The definition and classification of glaucoma in prevalence surverys. BJO 2002;86;238-242 • Acute, symptomatic form of angle closure may not have end-organ damage • 65-70% recover without OD or VF damage • Chronic, asymptomatic form of angle closure may have more end-organ damage • Comparison of 18 AACG vs 11 CACG eyes • NFL defect 39% vs 82% • Disc cupping 0% vs 45% • Disc pallor 39% vs 82% • Douglas GR et al. The visual field and nerve head in angle-closure glaucoma. A comparison of the effects of acute and chronic angle closure. Arch Ophthalmol 975;93:409-11

  21. Revised classification of Primary Angle Closure (PAC) • PAC suspect or narrow angles • Appositional contact between peripheral iris and posterior trabecular meshwork is considered possible • Arbitrary defined: 270º of posterior pigmented TM cannot be seen • PAC • Occludable angles, with: • Features indicating that TM obstruction by peripheral iris has occurred • PAS • IOP • Iris whorling (distortion of radially oriented iris fibres) • Glaucomflecken • Excessive TM pigmentation • PACG • PAC, with Glaucomatous disc or VF defect

  22. Laser settings - Iridoplasty • Indications • APAC when corneal oedema precludes laser peripheral iridotomy • Plateau iris • Therapeutic goal • Shrink and flatten peripheral iris • Peripheral iridoplasty • Peripheral iris • Radial iridoplasty • Double row of burns radially on oblique meridians • Dilate pupil to break pupil block

  23. Laser settings - Iridoplasty • Type of laser • Argon • 4-10 per quad, 1 spot size apart • Large, long, low-powered burns • 200-500microns • 0.2-0.5s • 0.2-0.4W • End-point • Non-penetrating contraction burns

  24. Peripheral iridotomy • Indications • Therapeutic • PACG • POAG with narrow angles • Secondary ACG • Prophylactic • Narrow occludable angles

  25. Peripheral iridotomy • Technique • Lens • Abraham • Site • 1, 11 o’clock • Peripheral 1/3, Iris crypt • Type of laser • Argon • Small, short, high-powered burns • 50microns • 0.02-0.05s • 0.8-1.1W • Nd:YAG • 2-3.5mJ • End-point • Plume of pigments • Visualise lens capsule • Transillumination

  26. Case 2 • Mdm LGS, 74/Chinese/lady • DM - OHGA • Seen previously in TTSH Eye 2004-05 • VR 6/7.5 +1.75/-0.75x88 • VL 6/7.5 +2.25/-1.25x105 • NS + cataracts • AC D/Q • No NVI • Dilated fundal exam - No DR, CDR 0.2 OU • Discharged to OPS for yearly DRP

  27. Urgent referral… • LE pain, redness 1 day • Giddy, vomiting • 1st episode • RE no complaints

  28. RE 6/24 -> 6/12 Cornea clear AC shallow NS 2-3 + IOP 26 CD 0.2 LE HM Hazy cornea AC shallow NS 2-3 + IOP 46 No RAPD 0 0 0 0 0 0 0 0 Examination

  29. Diagnosis • LE APAC attack • RE PAC

  30. D1 • 46 (1510hr) • 46 (1730hr) • 31 (2030hr) • 27 (0000hr) • IV diamox 500mg • PO diamox 250mg tds • T 0.5, PF 3H, Pilo 4% LE, Pilo 2% RE • IV mannitol, G alphagan D2 • 16 (0900hr) • 10 (1030hr) • 13 (1630hr) • RE laser PI - through • LE laser PI (1st) - failed - cornea haze + • LE laser PI (2nd) - failed • LE laser PI (3rd) - failed D3 • 18 • LE laser PI (4th) - failed • Options? Laser Iridoplasty? Surgical PI? Watch? D4 • 16 D5 • 16 Discharged with AAC advice • LE laser PI (5th) - through D6 • 12

  31. Thank you

  32. 46 (1510hr) 46 (1730hr) 31 (2030hr) 27 (0000hr) 16 (0900hr) 10 (1030hr) 13 (1630hr) 18 16 16 12 IV diamox 500mg PO diamox 250mg tds T 0.5, PF 3H, Pilo 4% LE, Pilo 2% RE IV mannitol, G alphagan RE laser PI - through LE laser PI (1st) - failed - cornea haze + LE laser PI (2nd) - failed LE laser PI (3rd) - failed LE laser PI (4th) - failed Discharged with AAC advice LE laser PI (5th) - through D1 D2 D3 D4 Options? • Laser iridoplasty • But attack broken • Surgical PI D5 D8

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