Dr. Sharmila Glaucoma clinic Basics in Glaucoma Dr. Sharmila Glaucoma clinic

Glaucoma Glaucoma is an optic neuropathy with characteristic appearance of the optic disc and specific pattern of visual field defects that is associated frequently but not invariably with raised IOP

POAG Adult onset IOP > 21mm Hg Open Angles Glaucomatous nerve damage Visual field loss

Risk factors Age > 65 Black race Positive family history Myopia Thin Corneas

Pathogenesis Increased resistance to aqueous outflow Ischaemic Theory Mechanical theory

pathogenesis Pathogenesis

Symptoms Usually asymtomatic Rarely decreased visual fields

Diagnosis of glaucoma History taking Visual acuity and refractive state Tonometry Gonioscopy Ophthalmoscopy Perimetry

Tonometry Indentation tonometry-schiotz tonometer Applanation tonometry variable force-goldmann Tonopen variable area- maklakov Non contact tonometer

Schiotz indentation Tonometry Body –footplate-rests on the cornea Plunger Weights- 5.5gm –permanently fixed. additional weights-7.5g.10g,15g

Technique of schiotz tonometry Anaesthetise cornea Patient in supine position Fixes on the target Eyelids gently separated Plunger rests on cornea. Look for movement of the needle Additional weights –if reading is <4 IOP derived from conversion table

Sources of error Ocular rigidity High ocular rigidity-high hyperopia,long standing glaucoma,ARMD Low ocular rigidity –high myopia,osteogenesis imperfecta,miotic therapy,retinal surgeries Thick cornea-high value

Other tonometers GOLDMAN APPLANATION TONOPEN

PNEUMOTONOMETER PERKINS TONOMETER

Gonioscopy Goniolens[direct] Koeppe, layden, barken Gonioprism Goldman single mirror, two mirror, three mirror Zeiss four mirror Posner four mirror

Normal angle structures Ciliary body band Scleral spur Trabecular meshwork Schwalbe’s line

Ophthalmoscopy Disc Focal atropy Concentric atrophy Deepening of the cup Advanced glaucomatous cupping Vascular changes Haemorrhage,baring of vessels, bayonetting Retinal nerve fiber layer changes Peripapillary atrophy

Perimetry Kinetic Static Visual fied defects Paracentral scotoma Seidel scotoma Arcuate scotoma Double arcuate scotoma Nasal step

Angle Closure Glaucoma With pupillary block Without pupillary block Diagnosis depends on : Anterior segment examination Gonioscopy

Risk factors Age Gender Asians, Chinese, Eskimos Family history Hypermetropia

Pathogenesis Increased opposition between iris and lens enhance the degree of pupillary block Increased pressure in posterior chamber Increased peripheral iris bowing Iris Bombe High IOP

Types Latent Subacute Acute congestive Post congestive Chronic Absolute

Acute Congestive Glaucoma Symptoms Severe pain and vomiting Unilateral visual loss coloured haloes Headache and vomiting

Signs Shallow AC Corneal edema Semi dilated pupil High IOP Closed angles

Treatment Immediately 2% Pilocarpine Steroid eye drops Β blockers Analgesics and antiemetics Lie in supine position I.V. Mannitol + Oral T. Diamox

Treatment MEDICAL LASER PI IF NOT POSSIBLE TRABECULECTOMY AFTER CORNEA CLEARS LASER PI IF NOT POSSIBLE TRABECULECTOMY

Cont.d… After 1 hr: After 11/2 hr: Pilocarpine 2% Yag PI If IOP is still high 50% oral glycerol 20% Mannitol (1-2g/kg) I.V. over 45minutes

Laser Iridotomy Clear corneas Less than 1800 of angle by PAS Surgery: Trabeculectomy

Congenital Glaucoma 1:10,000 births 65% are boys Pathogenesis: Maldevelopment of the angle of anterior chamber

Classification Congenital Glaucoma Infantile Glaucoma Juvenile Glaucoma

Clinical Features Corneal edema Buphthalmos Breaks in DM Optic disc cupping

Diagnosis Increased IOP Increased Corneal diameter > 11mm at 1yr Treatment: Goniotomy Trabeculotomy trabeculectomy

Lens related Glaucomas Phacolytic: Hyper mature cataract Corneal edema AC reaction – psuedo hypopyon Open angles

Treatment Anti glaucoma drugs Topical antibiotic steroids surgery

Phacomorphic Galucoma Intumscent cataractous lens Shallow anterior chamber Treatment: Antiglaucoma drugs Laser iridotomy surgery

Neo vascular Glaucoma Retinal ischaemia NVI NVA OPEN ANGLE ANGLE CLOSURE

Causes Ischeamic CRVO Diabetes Mellitus Miscellaneous Carotid disease Intra ocular tumor Long standing RD

Symptoms & Signs Decreased visual acuity Congestion of Globe Very high IOP and corneal edema Severe pain Aqueous flare NVI Gonioscopy - NVA

Treatment Medical – topical Atropine & steroids Retinal ablation / - DIODE CPC Surgery: Trab with MMC Aqueous drainage shunts Retrobulbar alcohol injection Enucleation

Treatment Modalities in glaucoma Medical Laser Surgery – Trabeculectomy combined surgery

Anti Glaucoma Drugs Β blockers Contra indications: Decreases IOP by decreasing aqueous secretion Contra indications: Congestive cardiac failure Heart block Bradycardia Bronchial asthma

Side effects Iotim, Nyolol, Glucomol 0.5% bd Ocular Systemic allergy Bradycardia, Hypotention SPK’s Broncho spasm tear secretion Hallucination, head ache nausea, dizziness

Alpha 2 Agonists Mechanism: Side Effects: Brimonidine, apraclonidine Decreases aqueous secretion Increases uveo scleral outflow Side Effects: Allergic conjunctiviti s Xerostomia Drowsiness and headache

PROSTAGLANDIN ANALOGUES Mechanism Decreases IOP by increasing uveoscleral outflow Latanoprost F2 α analogue.005% Travoprost 0.004% Bimatorpost 0.3% Unoprostone 0.15% BD

Side Effects Conjunctival hypereamia Eye lash growth and hyperpigmentation of periorbital skin Anterior uveitis Cystoid macular edema

MIOTICS Pilocarpine 1% 2% 3% 4% QID Parasympathomimetic stimulates muscarinic receptors in sphincter pupillae & ciliary body In POAG – increases aqueous outflow In PACG – opens the angles

Side Effects Miosis Browache Myopic shift Visual field defect

Carbonic Anhydrase Inhibitors Inhibits aqueous secretion Topical CAI Dorzolamide (Trusopt) Brinzolamide (Azopt) Systemic CAI Acetazolamide 250mg BD

Side Effect Parasthesia Malaise GI upset Renal Stone Blood dyscrasias

Hyper Osmotic Agents Glycerol 1g / kg in 50% solution Mannitol 1-2g/kg in 20% solution Side Effects: Cardiac or renal failure Urinary retention Head ache, nausea

Lasers in Glaucoma Laser Iridotomy: Indications: PACG Occludable angles SACG with pupillary block Combined mechanism glaucoma

Laser PI prerequisites Instil 1% Apraclonidine Miotic pupil Laser settings 4-8 mJ Post laser steroid eye drops Abraham lens

Complications Bleeding Iritis Corneal burn Glare Diplopia

Surgery Trabeculectomy: A conventional filtering procedure creates a new channel for aqueous outflow between the anterior chamber and subtenons space without the use of an artificial device Partial thickness Full thickness

Management of coexistent cataract and glaucoma

Complications Wound leak Excessive filteration Pupillary block Malignant glaucoma Hypotony Choroidal detachment

Failing bleb Initial few weeks critical SIGNS Injection Vascularisation Thickening Localization High domed Bleb Normal / High IOP Low IOP Initial few weeks critical

Failing filtration Frame work for Classification IOP Bleb

Failing filter – High IOP Low localized Bleb External - Subconjunctival fibrosis - Tight scleral flap sutures Internal - Sclerectomy obstruction

Failing filter – High IOP High domed bleb – encapsulated bleb or Tenon’s cyst

Failing filter - Low IOP Elevated diffuse bleb - Over Filtration hypotony Low bleb - Bleb leak

Bleb Failure Argon laser suturolysis 0.2sec 50µ 500-700mw Digital massage Topical steroids 5FU injection DF Nd yag laser Needling of tenons cyst

REFRACTORY GLAUCOMA AQUEOUS DRAINAGE IMPLANTS

Refractory glaucomas Cyclo destructive procedures

New diagnostic and surgical procedures Central corneal thickness assessment

OPTICAL COHERENCE TOMOGRAPHY

ULTRASOUND BIOMICROSCOPY

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