Case Report Staphyloma & Secondary Glaucoma Dwi Permana Putra Tanjungpura University

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

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

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

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.

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

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

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

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

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

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

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

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

Chief Complaint Sore in the right eye

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

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

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

Physical Examination An interview was conducted on 20th March 2014, at 11.30 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

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

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

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

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

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)

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

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

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

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

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

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

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.

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

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

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