1. Case Report Staphyloma & Secondary Glaucoma
Dwi Permana Putra
Tanjungpura University

2. Definition of Staphyloma
Staphyloma refers to a localised bulging of weak and thin outer tunic of the eyeball (cornea or sclera)  lined by uveal tissue which shines through the thinned out of fibrous coat

3. Types Anatomically: Anterior Equatorial posterior staphyloma
Intercalary
Ciliary
Equatorial
posterior staphyloma

4. Anterior Staphyloma
An ectasia of psuedocornea (the scar formed from organised exudates and fibrous tissue covered with epithelium)
It results after total sloughing of cornea, with iris plastered behind it

5. Intercalary Staphyloma
It is a bulge in limbal area lined by root of iris
It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer.
there may be associated secondary angle closure glaucoma due to the progression of bulge if not treated
Treatment consists of localised staphylectomy under heavy doses of oral steroids.

6. Ciliary staphyloma
it is the bulge of weak sclera lined by ciliary body  occurs about 2-3 mm away from the limbus
Its common causes  thinning of sclera following perforating injury, scleritis and absolute glaucoma

7. Equatorial Staphyloma
It results due to bulge of sclera lined by the choroid in the equatorial region
Its causes are scleritis and degeneration of sclera in pathological myopia
Occurs commonly at the regions of sclera which are perforated by vortex veins

8. Posterior staphyloma
It refers to bulge of weak sclera lined by the choroid behind the equator
common causes are pathological myopia, posterior scleritis and perforating injuries
The area is excavated with retinal vessels dipping in it (just like marked cupping of optic disc in glaucoma)
it is diagnosed on ophthalmoscopy

9. Glaucoma
Glaucoma refers to a group of conditions with heterogeneous causes that results in damage to the optic nerve head and loss of visual field
It is usually associated with an increase in intraocular pressure (IOP) above the normal value usually estimated at 21 mmHg
Primary open angle glaucoma is the most common type of glaucoma, accounting for over 70 % of cases

10. Classification 1. Primary Glaucoma
In open-angle glaucoma, the channel where the flow of aqueous humor is open, but the flow of fluid from the anterior chamber is too slow.
Pressure will gradually
damage to the optic nerve
progressive decline in visual function

11. 2. Primary Closure-Angle Glaucoma
If the iris by the pupil (by the center of the iris) touches the lens too much, the fluid is prevented from traveling through the pupil
Pressure from the flow of the aqueous trying to get through the pupil pushes the iris by the trabecular meshwork forward (called iris bombe)  cause the iris to bow forward too much, resulting in a complete blockage of the drainage meshwork

12. 3. Secondary Glaucoma
Is an increasing of intraocular pressure occurring as one manifestation of some other eye disease
Caused by pigmentation, changes in lens, changes in uveal tract, tumor, trauma, surgery, neovascular and steroid
Treatment involves controlling intraocular pressure by medical and surgical means but also dealing with the underlying disease if possible

13. Patient History Name : Mr. S Sex : Male Age : 28 years old
address : Parit Bugis St.
Occupation : Employee
Ethnic : Bugis
Religion : Moslem
Medical Record Number : -
Hospital Entry Date : March 20th 2014

14. Chief Complaint
Sore in the right eye

15. History of Current illnesses
In 1997
Admitted had an injury to his right eye
Due to exposure of wood
2 until 3 days later, he felt his right eye was swollen  felt there was a black line in front of him
Several days later, the swollen was bigger than before  difficulties to see anything
Taken to the hospital  cant see anymore
In 2011
the patient felt his eye was sore, redness, painful when after he was seeing of the light
the doctor said he suffered from glaucoma and the doctor gave him medications. After several days consumed the drugs  cured
Since a week ago
patient felt sore, redness, pain , and watery of his right eye after he was seeing of light. also, he felt there was something that blocked of his right eye, so that he came to the ophthalmologist to consult of his symptoms

16. Past Medical History
Patient had an eye injury of his right eye when he was at 11 years old. Patient had suffered from typhoid 5 years ago
He ignored when he was asking from experiences of hypertension, diabetes mellitus and consumption of steroid drugs

17. Family History
He admitted his family never suffered the disease like he experienced with. There was no history of hypertension and Diabetes Mellitus of his family

18. Physical Examination
An interview was conducted on 20th March 2014, at a.m
General Condition : Good
Awareness : Compos Mentis
Vital Sign
Blood Pressure : 140/80 mmHg
HR : 64 x/minute
RR : 24 x/minute
Temperature : 36, 8 oC

19. Ophtalmologic Status
Visual Acuity :
OD : 0
OS : 6/7,5

20. Movement (+), spasm (+), pain (+) Palpebra OD OS
exotrophia
Eye ball Position
orthotrophia
Movement (+), spasm (+), pain (+)
Palpebra
Movement (+), spasm (-)  Normal
Redness (+), watery (+)
Conjungtiva
Redness (-). watery (-)  Normal
Cloudy (+), edema (+), fibrous (+)
cornea
Clear, edema (-), fibrous (-)  normal
Cannot be described
Anterior Chamber
Clear, deep
Color of iris : cannot be described
Iris : cannot be described
Pupil : cannot be described
Light reflex : cannot be described
Iris/pupil
Color of iris: Brownies
Iris: regular
Pupil circular, 3 mm, isochor, Direct reflex (+), Indirect Reflex (+)
Canno be described
Lens
clear
Vitreous
Fundus
normal

22. Visual Field Examination
Shadow test :
OD : Negative
OS : Negative
Tonometry
OD : Cannot be examined
OS : cannot be examined
Visual Field Examination
OD : cannot be described
OS : Normal

23. Resume
The patient, male 28 years old came to the clinic with sore, pain and watery of his right eye when he was seeing of light and he felt there was something that blocked in his right eye since a week ago
When he was at 11 years old, he had an injury in his right eye and made him got swollen to his eye and was taken to the hospital for further treatment, because he had no longer to see clearly anymore. He had diagnosed by his doctor that he cannot see anymore, because of the severe damage of his injury

24. Cont..
3 years ago the patient has diagnosed suffered from glaucoma by his doctor. The doctor only able to remove his symptoms by medications. History of fever, nausea, vomiting, headache, smoking were ingnored
In family history, he ignored that his family have never experienced with glaucoma, hypertension and diabetes mellitus.
From physical examination, there were:
OD : eye ball position is exotrophia, movement of palpebral was normal, palpebral was spasm, pain, conjunctiva was redness and watery, cornea was cloudy, iris/pupil was not clear enough because of cloudy. OS: palpebral was no pain and spasm, conjunctiva ws no redness, no edema and cloudy of the cornea, COA was clear and deep, iris and pupil were normal (direct or indirect reflex (+), isochor, 3mm)

25. Differential Diagnose OD
OD : Secondary glaucoma due to staphyloma
OS : Normal
Differential Diagnose OD
Leucoma
Secondary Glaucoma to trauma
Planning for additional examination
Ultrasonography

26. Treatment Timolol eye drops 0,25 % 2 x 1
Sodium Hyaluronate 0,1% drops every hour
Indometacin 100 mg tablets 2 x 1

27. Prognosis OD
Ad vitam : bonam
Ad functionam : malam
Ad sanactionam : malam OS
Ad functionam : bonam
Ad sanactionam : bonam

28. Discussion
The diagnosis to the patient is secondary glaucoma due to staphyloma
Firstly, the formation of the staphyloma, because of the trauma about 17 years ago, It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer or called as intercalary staphyloma
So that, in the right eye of the patient there is localised bulge in limbal area lined by root of iris. There may be associated secondary angle glaucoma, which may cause progression of bulge if not treated

29. Cont..
The manifestation of secondary glaucoma is an increasing of intraocular pressure occurring as one manifestation of some other eye
Treatment involves controlling intraocular pressure by medical and surgical means but also dealing with the underlying disease if possible

30. Differential Diagnosis
Firstly is leucoma. Is the condition when the cornea is damaged by an infection  the collagen laid down in the repair processes is not regularly arranged, with the result that an opaque patch called a leukoma, may occur
Secondly, secondary glaucoma to trauma is associated with the history of injury from the patient. Contusion injuries of the globe may be associated with an early rise in intraocular pressure due to bleeding into the anterior chamber (hyphema)
Free blood blocks the trabecular meshwork, which is also causing edematous by the injury

31. Medication
Timolol
eye drops 0,25% is useful to suppress of aqueous production
The major contraindications to their use are chronic obstructive airway disease particularly asthma and cardiac conduction defects
Sodium hyaluronate 0,1% eye drops functions as a tissue lubricant and is thought to play an important role in modulating the interactions between adjacent tissues. It forms a viscoelastic solution in water which makes it suitable for aqueous and vitreous humor
Mechanical protection for tissues (iris, retina) and cell layers (corneal, endothelium, and epithelium) are provided by the high viscosity of the solution. Elasticity of the solution assists in absorbing mechanical stress and providing a protective buffer for tissues.

32. Indometacin 100 mg tablets is a non-steroidal anti-inflammatory drug (NSAID) commonly used as a prescription medication to reduce fever, pain, stiffness, and swelling. It works by inhibiting the production of prostaglandins, molecules known to cause these symptoms

33. Summary
To conclude, glaucoma is a condition in which the eye is characterized by the increase intraocular pressure, decreased visual acuity, visual field constriction, and optic nerve atrophy
The cause of glaucoma is poorly understood, it could be due to trauma / impact, or because of other eye diseases such as cataracts (cataract hipermatur), uveitis, and the influence of drugs

34. This patient should need several treatments such as Timolol eye drops 0,25 % 2 x , Sodium Hyaluronate 0,1% drops every hour and Indometacin 100 mg tablets 2 x 1