Download - Glaucoma
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Glaucoma
Dr. Abdullah Al-AmriOphthalmology Consultant
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Contents
• Anatomy and basic physiology.• Definition of glaucoma.• Classification of glaucoma.• Gonioscopy.• Measurement of IOP.• Primary open angle Vs closed angle glaucoma.• Management of glaucoma. • Secondary glaucomas.
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Anatomy
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Basic physiology
• Aqueous is produced by secretion and ultrafiltration from the ciliary processes into the posterior chamber.
• It then passes through the pupil into the anterior chamber to leave the eye predominantly via the trabecular meshwork, Schlemm’s canal and the episcleral veins
(the conventional pathway).
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• A small proportion of the aqueous (4%) drains across the ciliary body into the supra-choroidal space and into the venous circulation across the sclera
(uveoscleral pathway).• The intraocular pressure level depends on the
balance between production and removal of aqueous humour.
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Definition of glaucoma
• The term glaucoma refers to a group of diseases that have in common a characteristic optic neuropathy with associated visual function loss.
• Although elevated intraocular pressure (IOP) is one of the primary risk factors, its presence or absence does not have a role in the definition of the disease.
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• Three factors determine the lOP:1. The rate of aqueous humor production by
the ciliary body.2. Resistance to aqueous outflow across the
trabecular meshwork-Schlemm's canal system.
3. The level of episcleral venous pressure.
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Classification of glaucoma
Presentation
Acquired
Congenital
Ocular association
Primary
Secondary
Angle
Open
Closed
Course
Acute
Chronic
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Gonioscopy
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Measurement of IOP
• Applanation tonometry is the method used most widely.
• Measurement of lOP in a clinical setting requires a force that indents or flattens the eye.
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• The normal pressure is 15.5 mmHg.
• The limits are defined as 2 standard deviations above and below the mean
(11–21 mmHg).
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Optic nerve cupping
• Cupping is a normal feature of the optic disc.
• The disc is assessed by estimating the vertical ratio of the cup to the disc as a whole (the cup to disc ratio).
• In the normal eye the cup disc ratio is usually no greater than 0.4.
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The visual field
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Primary open angle glaucoma
• Affects 1 in 200 subjects over the age of 40.• Affecting males and females equally. • There may be a family history.• The prevalence among blacks is 3 to 4 times
higher than whites. • Symptomless unless the patient becomes
aware of a severe visual deficit.
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Primary angle closure glaucoma
• Affects 1 in 1000 subjects over 40 years.• Females more commonly affected than males.• Strong family history.• Prevalence is more common among Asians
and Eskimos. • Patients are likely to be hyperopic. • In acute cases, patient may have sever pain,
photophobia, vision loss and nausea.
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• On examination visual acuity is reduced, the eye is red, the cornea is cloudy and the pupil is oval, fixed and dilated.
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Management of glaucoma
1. Medical treatment.2. Laser treatment.3. Surgical treatment.
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Medical treatment
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Yag laser peripheral iridotomy(Yag PI)
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Surgical treatment
• Drainage surgery (trabeculectomy) relies on the creation of a fistula between the anterior chamber and the subconjunctival space.
• The operation is usually effective in substantially reducing intraocular pressure.
• It is performed increasingly early in the treatment of glaucoma.
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Trabeculectomy
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Secondary glaucomaOpen angle:
• Blood (hyphema), following blunt trauma.
• Inflammatory cells (uveitis).• Pigment from the iris.• Deposition of material produced
by the epithelium of the lens, iris and ciliary body in the trabecular meshwork (pseudoexfoliative glaucoma).
• Steroid-induced glaucoma.• Raised episcleral venous
pressure.
Closed angle:
• Abnormal iris blood vessels may obstruct the angle and cause the iris to adhere to the peripheral cornea, closing the angle (rubeosis iridis).
• A large choroidal melanoma may push the iris forward.
• A cataract may pushing the iris forward (phacomorphic).
• Uveitis may cause the iris to adhere to the trabecular meshwork.
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Hyphema
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Rubeosis iridis(Neovasular glaucoma)
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Phacomorphic glaucoma
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Questions