GlaucomaGlaucoma

Dr Lee Ming YuehDr Lee Ming Yueh

Ophthalmology UnitOphthalmology Unit

Penang HospitalPenang Hospital

Glaucoma is a sight threatening disease Glaucoma is a sight threatening disease which can cause irreversible visual losswhich can cause irreversible visual loss

Baltimore Eye Survey:Baltimore Eye Survey:

- - by the year 2000 by the year 2000 > 66.8 million primary glaucoma > 66.8 million primary glaucoma

> 6.7 million bilateral > 6.7 million bilateral blindness blindness

DefinitionDefinition

A spectrum of disease characterized byA spectrum of disease characterized by

- progressive optic neuropathy- progressive optic neuropathy

- visual field loss- visual field loss

** IOP is an important risk factor. IOP is an important risk factor.

Optic NeuropathyOptic Neuropathy

Progression of

Glaucomatous

Optic Neuropathy

Visual Field Visual Field LossLoss

Classification:Classification:

Open Angle GlaucomaOpen Angle Glaucoma

Close Angle GlaucomaClose Angle Glaucoma

Congenital GlaucomaCongenital Glaucoma

Trabecular meshwork acts like a sieve…Trabecular meshwork acts like a sieve…

Angle StructureAngle Structure

Open Angle GlaucomaOpen Angle Glaucoma

PrimaryPrimaryRisk factors :Risk factors : Age > 60Age > 60

Race – negro, darkRace – negro, darkFamily history – siblings 4xFamily history – siblings 4x

- parents 2x- parents 2xOcular ds – myopia, Retinitis Ocular ds – myopia, Retinitis

PigmentosaPigmentosaCardiovascular ds, DM, SAS, Cardiovascular ds, DM, SAS,

migraine ?migraine ?SecondarySecondarya.a. Pretrabecular – neovascular/inflammatory membranePretrabecular – neovascular/inflammatory membraneb. b. Trabecular- RBC, pseudoexfoliation, pigmentTrabecular- RBC, pseudoexfoliation, pigmentc.c. Post Trabecular- TED, Carotid-cavernous fistulaPost Trabecular- TED, Carotid-cavernous fistula

Primary Open Angle GlaucomaPrimary Open Angle Glaucoma

Traumatic Hyphaema with Traumatic Hyphaema with secondary open angle glaucomasecondary open angle glaucoma

Pseudoexfoliative SyndromePseudoexfoliative Syndrome

Open Angle GlaucomaOpen Angle Glaucoma

Clinical features:Clinical features:

- ‘silent thief of sight’- ‘silent thief of sight’

- Painless gradual loss of vision; loss - Painless gradual loss of vision; loss of visual field follows by impairment of visual field follows by impairment of visual acuity.of visual acuity.

- Intraocular pressure (IOP) rise - Intraocular pressure (IOP) rise gradually, usually asymptomatic, till gradually, usually asymptomatic, till significant visual impairment occurs.significant visual impairment occurs.

This is what a glaucoma patient This is what a glaucoma patient sees….sees….

ExaminationExamination

1.1. Visual acuityVisual acuity

2.2. Pupil – afferent pupillary defectPupil – afferent pupillary defect

3.3. Intra-ocular Pressure (IOP)Intra-ocular Pressure (IOP)

- IOP > 21 mmHg- IOP > 21 mmHg

- IOP asymmetry > 3 mmHg- IOP asymmetry > 3 mmHg

4.4. Optic nerve head & retinal nerve fibre layer Optic nerve head & retinal nerve fibre layer assessmentassessment

- vertical cup-disc ratio (CDR) > 0.7- vertical cup-disc ratio (CDR) > 0.7

- Asymmetry of CDR > 0.2- Asymmetry of CDR > 0.2

- thinning & notching of neuroretinal rim, - thinning & notching of neuroretinal rim, nasalization & bayonetting of retinal vessels.. nasalization & bayonetting of retinal vessels..

(Normal NRR follow ‘ISNT rule’).(Normal NRR follow ‘ISNT rule’).

- Laminar dots sign- Laminar dots sign

- optic disc haemorrhage- optic disc haemorrhage

5. Evaluation of the angle5. Evaluation of the angle

GonioscopyGonioscopy

- open or close ?- open or close ?

- to exclude secondary cause of glaucoma- to exclude secondary cause of glaucoma

Angle StructureAngle Structure

Grading for Gonioscopy findingGrading for Gonioscopy finding

GradeGrade 00 II IIII IIIIII IVIV

ShafferShaffer closedclosed 1010°° 2020°° 3030°° 4040°°

ModifieModifie

ShafferShaffer

Schwalbe Schwalbe lineline

Not seenNot seen

SchwalbeSchwalbe

Line Line

visiblevisible

TrabTrab

MeshworkMeshwork

visiblevisible

Scleral Scleral spurspur

visiblevisible

Ciliary Ciliary

Body Body

visiblevisible

Shaffer Gonioscopic ClassificationShaffer Gonioscopic Classification

Eclipse SignEclipse Sign

6.6. Visual Field TestVisual Field Test

- Humphrey visual field is gold standard- Humphrey visual field is gold standard

- classical VF defects are - classical VF defects are

: : paracentral scotomaparacentral scotoma

nasal stepnasal step

Arcuate scotomaArcuate scotoma

Temporal wedgeTemporal wedge

Humprey Humprey Visual FieldVisual Field

Optic disc photographOptic disc photograph showing thinning of the inferior showing thinning of the inferior neuroretinal rim and increased cupping, consistent with neuroretinal rim and increased cupping, consistent with

glaucoma.glaucoma.Humphrey visual fieldHumphrey visual field showing showing superior arcuatesuperior arcuate defect defect and and nasal stepnasal step corresponding to the glaucomatous optic corresponding to the glaucomatous optic

nerve changes on the left.nerve changes on the left.

Management:Management:MedicalMedicaltopical anti-glaucoma topical anti-glaucoma - B-blocker eg Timolol, Betoptic- B-blocker eg Timolol, Betoptic- prostaglandin analog - prostaglandin analog - carbonic anhydrace inhibitor- carbonic anhydrace inhibitor- - αα agonist agonist Laser TreatmentLaser Treatment- Argon laser trabeculoplasty /Selective LT- Argon laser trabeculoplasty /Selective LTSurgicalSurgical- Trabeculectomy/augmented trabeculectomy- Trabeculectomy/augmented trabeculectomy- Shunt/valve surgery- Shunt/valve surgery

ConservativeConservative- asymptomatic poor visual prognosis- asymptomatic poor visual prognosis

Indications for surgery:Indications for surgery:

1.1. Failed medical therapyFailed medical therapy

2.2. Disease progression despite maximun Disease progression despite maximun medical therapymedical therapy

3.3. Anticipated fast progressionAnticipated fast progression

4.4. Combined cataract & trabeculectomy Combined cataract & trabeculectomy surgerysurgery

Primary Angle Closure Primary Angle Closure GlaucomaGlaucoma

Risk Factors:Risk Factors:

- - age, average 60 y-oldage, average 60 y-old

- female more common 4:1- female more common 4:1

- race: more common in SEA, Chinese, - race: more common in SEA, Chinese, Eskimos.Eskimos.

- Family: 1- Family: 1stst degree relatives increased risk . degree relatives increased risk .

Anatomical predisposing factorsAnatomical predisposing factors

1.1. Relatively anterior location of iris-lens Relatively anterior location of iris-lens diaphragm.diaphragm.

2.2. Shallow anterior chamberShallow anterior chamber3.3. Narrow entrance to the chamber angleNarrow entrance to the chamber angle

Eyes with PACGEyes with PACG have have-corneal diameter 0.25mm smaller than normal -corneal diameter 0.25mm smaller than normal eyeseyes- shallower anterior chamber (1.8mm)- shallower anterior chamber (1.8mm)- hypermetropic eyes- hypermetropic eyes

Secondary- Pupillary Block Secondary- Pupillary Block GlaucomaGlaucoma

Inflammatory with occlusio or seclusio Inflammatory with occlusio or seclusio pupillaepupillae

PhacomorphicPhacomorphic

Vitreous blocVitreous bloc

Silicone oilSilicone oil

Secondary-NonPupillary Block Secondary-NonPupillary Block GlaucomaGlaucoma

NeovascularNeovascular

Iridocorneal endothelial syndromIridocorneal endothelial syndrom

Ciliary tumour, iris cystCiliary tumour, iris cyst

Suprachoroidal haemorrhageSuprachoroidal haemorrhage

Iatrogenic- tight scleral buckling, post PRPIatrogenic- tight scleral buckling, post PRP

Clinical Features:Clinical Features:

Rapidly progressive blurring of visionRapidly progressive blurring of visionPeriocular pain and congestionPeriocular pain and congestionNausea and vomiting in severe cases.Nausea and vomiting in severe cases.

Slit-lamp exam:Slit-lamp exam:- ciliary flush/circumcornea injection- ciliary flush/circumcornea injection- high IOP (50 -100mmHg)- high IOP (50 -100mmHg)- cornea oedema w epithelial cysts- cornea oedema w epithelial cysts- shallow anterior chamber.- shallow anterior chamber.

Acute Management ofAcute Management of Angle Closure Angle Closure GlaucomaGlaucoma

To lower the IOP fastTo lower the IOP fast

- IV Diamox 500mg /IV Mannitol- IV Diamox 500mg /IV Mannitol

- Topical antiglaucoma- Topical antiglaucoma > pilocarpine 2%> pilocarpine 2%

> timolol 0.5%> timolol 0.5%

> prostaglandin > prostaglandin analog analog

Definitive treatmentDefinitive treatment

- laser peripheral iridectomy/ surgical - laser peripheral iridectomy/ surgical

Further managementFurther management

To To control IOPcontrol IOP to to stop disease stop disease progressionprogression

- IOP, optic nerve changes, visual field- IOP, optic nerve changes, visual field

MedicalMedical

- - ββ blocker, prostaglandin analog carbonic blocker, prostaglandin analog carbonic anhydrace inhibitor, anhydrace inhibitor, αα agonist agonist

SurgicalSurgical- Trabeculectomy- Trabeculectomy

- Shunt/valve surgery- Shunt/valve surgery

TrabeculotomyTrabeculotomy

Aquoues OutflowAquoues Outflow

Congenital GlaucomaCongenital Glaucoma

Congenital GlaucomaCongenital Glaucoma

Primary Primary SecondarySecondary - Anterior segment dysgenesis- Anterior segment dysgenesis- Ocular ds- Ocular ds- Phakomatoses eg. Neurofibromatosis- Phakomatoses eg. Neurofibromatosis- Metabolic ds eg. Lowe’s, Homocysteinuria- Metabolic ds eg. Lowe’s, Homocysteinuria- Congenital rubella- Congenital rubella- chromosomal abn eg. Down’s- chromosomal abn eg. Down’s- Ocular tumour- Ocular tumour- inflammatory eg. Seronegative arthritis- inflammatory eg. Seronegative arthritis

Clinical Features:Clinical Features:

May manifest at birth or develop laterMay manifest at birth or develop later

Signs & SymptomsSigns & Symptoms lacrimationlacrimation PhotophobiaPhotophobia Hazy corneaHazy cornea buphthalmosbuphthalmos rapidly progressive myopiarapidly progressive myopia

BuphthalmosBuphthalmos

Examination under anaesthesiaExamination under anaesthesia

Intraocular pressureIntraocular pressureAnterior segment examinationAnterior segment examination- cornea opacity, Haab’s striae- cornea opacity, Haab’s striae- anterior segment dysgenesis- anterior segment dysgenesisGonioscopyGonioscopy- Thicken trabecular meshwork, Barkhan’s - Thicken trabecular meshwork, Barkhan’s membranemembraneFundus examinationFundus examination- optic cup-disc ratio- optic cup-disc ratio

Management of Congenital GlaucomaManagement of Congenital Glaucoma

Congenital glaucoma is a surgical disease!Congenital glaucoma is a surgical disease!

SurgerySurgery goniotomy goniotomy trabeculotomytrabeculotomy trabeculectomytrabeculectomy

MedicalMedical topical eye drops ie. topical eye drops ie. ΒΒ-blocker, carbonic anhydrace -blocker, carbonic anhydrace

inhibitor, prostaglandin analoginhibitor, prostaglandin analog Alfa-2 agonist contraindicated due to sedative effectAlfa-2 agonist contraindicated due to sedative effect

GoniotomyGoniotomy

Barkhan Goniotomy lens & Swan goniotomy knife

Thank YouThank You