Dr. G. Rajasekhar MBBS, DNB, FRCS (Glasgow)

 IOP  Angle  POAG  PACG  Acute congestive glaucoma  Drugs

 Definition  Production and drainage of aqueous  Normal values  Hypotony and glaucoma  Tonometry  Indentation  Applanation  Non contact

Modes of IOP rise  Open angle  Pre trabecular  Trabecular  Post trabecular  Closed angle  With pupillary block  Without pupillary block  Anterior pull  Posterior push

 Structures in angle  Evaluation of angle

Evaluation of the angle of anterior chamber  Torch light  Slit lamp  Gonioscopy  Ultra sound biomicro scopy

Evaluation of the angle of anterior chamber  Torch light  Slit lamp  Gonioscopy  Ultra sound biomicroscopy

Evaluation of the angle of anterior chamber  Torch light  Slit lamp  Gonioscopy  Ultra sound biomicroscopy

 Structures in angle  Evaluation of angle

 Risk factors  Heredity  Age  Myopia  Diabetes  Smoking  Htn  Thyroid dysfunction

 Provocative tests  Water drinking test (1 litre, IOP every 15 min, >8mm of Hg rise)  Bulbar pressure test  Prescoline test ( >8 mm of Hg)  Caffeine test ( >8 mm of Hg)  Phasing / diurnal variation test ( >8 mm of Hg)

 Etiopathogenesis  Increased trabecular resistance  Steroid responsiveness  Clinical features  Painless progressive field loss  Night blindness (filed loss + delayed dark adoptation)  Early loss of accommodation

 Signs:  Open angles  IOP rise  Disc changes  Visual field changes

BARRING OF THE VESSELS 0.6 CUP Paracentral scotoma

Thinned out NRR 0.7 CUP Nasalization of the vessels Arcuate scotoma

Ronne’s nasal step 0.8 cup

0.9 cup Bayoneting of vessels Ring scotoma

Lamellar dot sign Bayoneting sign splinter haemorrhage BARRING OF THE VESSELS

 Treatment  Medical  Beta blockers (timolol)  Pilocarpine  CA inhibitors (dorzolamide)  Prostaglandins (latanoprost)  Adrenergics (apraclonidine)  Organ LASER trabeculoplasty

 Surgical – Filtering surgery  Trabeculectomy  Non penetrating filtering surgeries  Visco canolostomy  Deep sclerectomy

 Risk factors  Age  Gender  Hypermetropia  Heridity  Precipitating factors  Dim light  Emotional stress  Pharmacological mydriasis

Stages  Angle closure suspect  Intermittent angle closure  Acute angle closure  Chronic angle closure  Absolute angle closure

Angle closure suspect  Family h/o may be present  No symptoms  Shallow angles on evaluation  IOP,Disc and fields normal  Rx  Observation / pilocarpine / Prophylactic Yag PI Intermittent angle closure  Family h/o may be present  h/o unilateral intemittent blurred vision, redness. Pain and coloured halos. Episodes occur in dim light / anger spells  Shallow angles on evaluation, signs of previous brocken attacks  IOP,Disc and fields normal  Rx  Pilocarpine  Prophylactic Yag PI

Acute angle closure glaucoma / acute congestive glaucoma  symptoms  Sudden diminution of vision  Pain  Redness  Lacrimation  Nausea & vomiting  Colored halos

Acute angle closure glaucoma / acute congestive glaucoma  signs  Lid edema  Ciliary congestion  Epithelial edema of cornea  Stromal thickening of cornea  Occluded angle of anterior chamber  Aqueous flare and cells  Vertically oval, mid dilated, fixed pupil  Edematous iris  Raised IOP (>40 mm of Hg)

Acute angle closure glaucoma / acute congestive glaucoma  Treatment  Immediate:  Intra venous CA inhibitors (Eg: Acetazolamide) 500 mg + orally 500 mg  Topical beta blockers  Analgesics and anti emetics as required

Acute angle closure glaucoma / acute congestive glaucoma  Treatment  Once pressure is reduced to below 40 mm of Hg  Topical pilocarpine ( applied in other eye also to prevent similar attack)  If cornea is clear  peripheral YAG LASER iridotomy in both eyes

Acute angle closure glaucoma / acute congestive glaucoma  Treatment  If pressure is high  Oral 50% glycerol mg/kg  IV 20% mannitol 1-2 mg/kg  If YAG LASER not available  Surgical peripheral iridectomy in both eyes

Chronic angle closure glaucoma  +/- Family h/o may be present  +/- H/o acute angle closure  Symptoms depend on level of Glaucomatous damage  Signs: shallow angles, PAS on gonio, raised IOP, +/- signs of brocken attacks  Treatment:  Iridectomy / iridotomy  Medical treatment  Surgical treatment

Absolute glaucoma Painful, blind eye with very high IOP, +/- corneal edema and neovascularisation of iris and complete PAS closure  Treatment  Topical anti-glaucoma medications, steroids and cycloplegics  Cyclodestructive procedures  Retro bulbar alcohol injection  Enucleation

 Topical  Beta blockers ( Eg: timolol)  Parasympathomimetics (Eg: pilocarpine)  CA inhibitors (Eg: dorzolamide)  Prostaglandins (class F2 alfa) (Eg: latanoprost)  Sympathomimetics (Eg: apraclonidine)  Calcium channel blockers ( Eg: verapamil)

 Systemic  CA inhibitors (Eg: acetazolamide)  Hyperosmatic agents  oral (Eg: glycerol, isosorbide)  Intra venous (Eg: mannitol, urea)  LASERS  Argon/diode LASER trabeculoplasty  Nd-YAG LASER peripheral iridotomy  Palliative  Retrobulbar alcohol injection

 Surgical peripheral iridectomy  Filtering surgeries  Trabeculectomy  Non penetrating filtering surgery  Artificial drainage shunts  Setons

 Cyclo destructive procedures  Cyclocryopexy  Diode LASER cycloablation  Nd-YAG LASER cycloablation  Enucleation / evisceration

 Principle  Steps  Diagrams  Complications  Intra operative  Post operative

Filtering bleb