angle closure glauc-mt-recent concepts-aios conf kolkata 2010
TRANSCRIPT
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WH O ESTIMATION (CONTD)
Glaucoma is second leading cause of preventable blindness and is a leading cause of irreversible blindness in India & nearly 90% of glaucoma remain undiagnosed in India.
By 2020 nearly 16 million will have glaucoma. Public awareness about Glaucoma-nil.
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CLASSIFICATION OF GLAUCOMA(MANY MET H ODS)
1. Primary and secondary-commonest methodused, some say all glaucoma are secondarysome known, others not.
2. Anatomic and Gonioscopic-Open and Closeangle
3. Bio chemical
4. Genetic
5. Intraocular pressure based- Low vs High.
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ANGLE CLOSURE GLAUCOMA(ACG) E pidemiology of this glaucoma has received less
attention. Most available information is from hospital based
survey or population screening of small high risksubpopulation. ACG is as common as OAG specially in Asia. ACG has PAS and/or iridotrabecular apposition
Presentation-acute or subacute or chronic. For proper and timely therapy early understanding
of pathophysiology is must.
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PAT H OP H YSIOLOGY OF ANGLECLOSUREA. Iris pushed forward from behind
Partial or absolute pupil block. Malignant glaucoma Cyclitis or C.B. Cysts. Plateau iris Choroidal swelling by serous or haemorrhagic choroid
detach. Post segment tumor, silicone oil or air. ROP Anteriorly displaced lens
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B. Iris pulled forward
Inflammatory membrane ICE syndrome Fibrous or epithelial down growth. Iris incarceration in wound
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PRIMARY ANGLE CLOSURE
Leading cause of glaucoma world wide Relative pupillary block cause in 90% cases
Plateau Iris & lens block is cause of primaryangle closure
More common in Asians and Africans .
Acute is more in whites and chronic form morein Asians.
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OCULAR BIOMETRIC AND ACG
Small crowded anterior segment. Short axial length.
Shallow AC , less than 2.1 to 2.5 Thick lens Increased ant lens curvature.
Small corneal diameter Small radius of curvature of cornea.
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OT H E FACTORS OF ACG
Age- Above 40 ,due to increased lens thickness& forward displacement of lens.
Sex- More common in females 2or3:1 More common in Hyperopes. ACG Gene-One ACG gene has been mapped on
chromosome 11 which is Autosomal dominant
nanophthalmos (NNO1) An untreated fellow eye has 40-80% chance of
developing ACG over next 5-10 years.
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PRESENTATIONS OF ACG
1. Acute
2. Subacute
3. Chronic
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OCCLUDABLE ANGLE
Only a small percentage of shallow AC patients developglaucoma.
Long follow up is must. Symptomatology even doubtful should be explained to
pts. Provocative tests limited value. Features of occludable angle
PAS
Increased segmental Trabecular pigmentation H/O previous angle closure Positive provocative test AC less than 2 mm.
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SECONDARY ANGLE CLOSURE W ITH PUPILLARY BLOCK
1. Phacomorphic Glaucoma in which laseriridectomy followed by lens extraction is tt of choice.
2. E ctopia lentis eg Trauma, Marfans syndrome,Homocystinurea, microspherophakia, Weill-Marchesani Syndrome.
3. Aphakic or pseudophakic angle closureglaucoma.
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SECONDARY ACG W ITH OUT PUPILLARYBLOCKA. Neovascular Glaucoma-eg. Systemic vascular disease , diabetes,
CRV & CRA occlusion, E ales disease, Coats disease, ROP, RD,PHPV, chronic uveitis, Retinoblastoma, Trauma, radiation etc.
B. Iridocorneal (IC E ) Syndrome eg. Chandler syndrome, progressivecongenital Iris atrophy.
C. Tumours- Rb, melanoma & metastais.D. InflammationE . Malignant GlaucomaF. RD-Non rhegmatogenousG. E pithelial & fibrous down growthH. TraumaI. Less common-Nan ophthalmos, ROP, and drug induced Secondary
Gl.
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MANAGEMENT OF ACG
Three things in Glaucoma Therapy is Imp.:-1. When to treat2. How to treat3. Risk Vs Benefits of any tt.Types of treatment1. Medical
I. Systemic
II. Local2. Surgical3. Nonsurgical non drug -like laser, cryo etc.
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MEDICAL TREATMENT OF ACG
Aim of medical treatment is prepare pt for laseriridectomy
Goals of medical tt are:- Reduce IOP rapidly to prevent further damage to optic nerve To clear corneal haziness To reduce inflamation. Pupillary constriction. Prevent formation of synechia . Tt is usually individualized based on efficacy, safety
tolerability, status of pt and need of pt.
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DRUGS USED IN ACG
1. SystemicI. MamitolII. GlycerolIII. Acetazolamide
I. OralII. Im/iv
IV. Symptomatic
2. LocalI. PilocarII. TimololIII. Antiinflamatory
Surgical Tt1. Filtering surgery in chronic2. Lens extraction3. shunts
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LASER T H ERAPY IN ACG(TREATMENT OF C H OICE)
1. Laser Iridectomy Argon Laser Nd Yag
2. Laser Gonioplasty or peripheral Iridoplasty-byArgon Laser
Future Therapy Gene therapy Molecular therapy