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Ophthalmology Subject

Glaucoma and Lens Topic
Gloria Romero Lecturer
First/ July 17, 2008 Shifting /Date
Bioman (with Alice in Wonderland & Jason Bourne) Trans group

GLAUCOMA nerve fiber causing changes in the optic disc – visual field
• Includes a complex of eye disease, which have in common an • Symptomatology: may arise from:
abnormal rise of intraocular pressure (IOP) which causes 1. increase IOP
organic changes in optic nerve, produces irreversible blindness 2. disturbance of optic nerve function
through progressive loss of vision.

• Many forms are asymptomatic – they destroy the optic nerve. • If the pressure builds up slowly (primary open glaucoma),
symptoms maybe absent or minimum. Interference of optic
• However, if detected and the abnormal rise of IOP is reduced to nerve function causes little defect, usually unappreciated by
patient until far advance.
normal by medications or surgery, the progression of blindness
can be prevented.
• If there is sudden increase of IOP (acute close angle
• So every doctor should be familiar with the principle and glaucoma), there may be:
method of diagnosis and treatment of glaucoma. 1. severe ocular pain
2. sudden diminution of vision due to corneal edema
• Diagnosis of glaucoma is done by routine eye exam and 3. ciliary injection
measurement of IOP (palpation or tonometry). 4. lacrimation
5. papillary dilatation – due to paralysis of spl. muscle of iris
Ophthalmoscopy – to visualize optic disc in all suspected old patients;
so proper referral to ophthalmologist could be done – saving the sight Diagnostic Methods:
of the patient. • Clinically, it is desirable to diagnose and treat the disease prior to
the development of irreversible organic changes. This can be done
Intraocular Pressure by always having a high index of suspicion on patient with high
• The level of IOP causing damage to the optic disc is not the risk of developing the disease.
same in every eye. However any eye with pressure of 21mmHg
should be regarded as suspect even if optic nerve appears 1. Tonometry – an instrument used to measure the pressure
normal. quantitatively
o Finger touch – done if no tonometer; application of
• On the other hand, if optic nerve shows sign of glaucomatous index finger to eyeball and determine the firmness
cupping or changes even if the pressure is below 21mmHg, of the eyeball
suspicion should be aroused, verification is done by visual field
studies. 2. Ophthalmoscopy – examination of optic disc
o optic disc characterized by big vertically oval and
• The lens, vitreus, retina, and blood flow do not significantly notch cup
affect IOP.  nasalization of central vessels
 spontaneous pulse in central retinal artery
• The IOP then depends on the amount of aqueous production and  hemorrhage in the disc
the aqueous that goes out of the eye (outflow).
3. Visual Field – by use of perimetry
• Aqueous humor production in the ciliary body process in o characteristic visual field defect occur as a result of
posterior chamber – pupil – anterior chamber. damage to individual bundle of nerve fiber in optic
• Impaired outflow may be due to the ff:
- congenital deformities of the trabecular meshwork Angle Closure Glaucoma
- adhesion of iris to the trabecular meshwork I. Primary Type
- edema and scarring due to inflammation • Increased IOP – because aqueous could not flow to trabecular
- clogging of the trabecular meshwork by cellular debris meshwork due to apposition of iris to anterior chamber, which
maybe a result of an:
Effect of increase IOP: a. inherited anatomic defect that causes shallow
anterior chamber
• The effect of IOP is manifested in the optic disc. Increase IOP –
b. stress and excitement may increase production of
ischemia – by impairing blood supply to the optic nerve head,
aqueous humor which hinders the normal
ischemia impairs nutrition to glial tissue in the area of the optic
circulation within.

Ophthalmology: Glaucoma and Lens
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• Signs and Symptoms:
- ciliary congestion • Treatment:
- cornea – with edema Usually directed against the existing or associated ocular
- anterior chamber – shallow condition. If the pressure is elevated, measures are done to lower it
- pupil – dilated, fixed, unreactive down.
- iris – atrophy several days after the attack
- ocular pain – discomfort – pain
- nausea and vomiting
- sudden diminution of vision with prodromes of seeing Developmental Glaucoma
colored halos around light • Usually associated with hereditary or familial diseases,
- firm eyeball due to increased IOP regardless to type. Signs and symptoms of various forms of
glaucoma at birth or during infancy are similar.
• Rx: medical use of MIOTICS; carbon anhydrase inhibitors and
hyperosmotic agents – to pull iris away of angle Primary Infantile Glaucoma
If pressure decreased – surgery is done • About 80% of developmental glaucoma are diagnosed before
the first year of life, 70% may affect both eyes.
II. Secondary
• The basic pathology is the same in primary angle closure except • Signs and Symptoms:
that the angle closure is due to the condition in the eye that - lacrimation
causes the iris to move towards the trabecular meshwork. - blepharospasm
- posterior synechae or membranous formation following - photophobia
uveitis - corneal enlargement – due to inability of fibrous coat of the
- dislocated lens eye (sclera and cornea) to withstand rise of IOP
- bulging hyoid in aphakia
- vitreous phase which pushes the lens iris diaphragm forward
• Primary treatment : surgical (external trabeculectomy) success
• Early referral to the ophthalmologist to be able to manage rate is high if done before onset of buphthalmos.
before the attack.
Glaucoma Associated with Hereditary Familial Diseases
• This condition is not always present at birth. The physician
• Treatment directed to cause, following the principle of
therefore should watch for its development if they find a child
treatment of primary angle closure glaucoma.
with hereditary diseases in which glaucoma is associated.
I. Marfan’s Syndrome
Open Angle Glaucoma
o characterized by anacrodactility; cardiac anomalies with
Aqueous has access to anterior chamber at all times.
I. Primary subluxated lens (partial dislocation of lens). Anomaly in
the trabecular meshwork is found, visual defect should
• With no precipitating or pre-existing ocular or systemic diseases
be attended early, corrective glasses are helpful, surgery
can be tagged as causative agent.
to subluxated lens is required for adequated clear vision.
• Characteristic: it is usually bilateral, hereditary tendency
II. Axenfield Syndrome
• Signs and Symptoms: o characterized by corneal arcus called post. Embryotoxon
- usually symptomless, slow progress, chronic o polycoria; ectopia of pupil
- young individual – transient blurring of vision seeing halo
- pain – mild III. Neurofibromatosis
- the condition maybe far advance before patient notice o nodules often visible in iris and maybe the basis of angle
extensive visual blurring of one or both eyes anomaly associated with glaucoma
II. Secondary IV. Marchesani Syndrome or Spherophakia
• Aqueous can permeate the trabecular meshwork however o high myopia, brachycephalic (short stocky and short
includes both inflammatory and non-inflammatory edema and fingers). The spherical lens tends to produce a papillary
exudates as part of the condition. block and angle closure glaucoma.
- uveitic condition – produce inflammatory cells
- age in the anterior chamber V. Aniridia
- scarring or damage to the outflow channels o absence of iris, rudimentary stump is left, adheres to the
- materials from ruptured lens meshwork – glaucoma
• Rx: In cases of spherophakia and Marfan’s syndrome, where
• Caused by or associated with various diseases:
there is papillary block, iridectomy is the choice (surgical
- inflammation procedure)
- neoplasm
• Miotic, CAI has been found ineffective in this cases
- hemorrhage
- physical and chemical agents, drugs
- systemic diseases – diabetes mellitus • Findings that should lead to suspicion:
- neovascularization 1. Family history of glaucoma
- central artery or vein occlusion 2. Diabetic patient
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3. History of ocular trauma 1. aphakia – congenitally absent; accompanied by other ocular
4. Frequent changing of glasses diseases
5. High myopia 2. size - macrophakia
6. Increase IOP following the use of steroid] 3. formation of opacity - cataract
7. Tonometric reading of 21mmHg or increased
8. Ophthalmoscopic finding – optic disc • Absence of the lens can be dx by the ff:
9. Visual field changes 1. deep anterior chamber
10. Pigment deposits at post. pole of cornea 2. iridodonesis – tremors of iris
11. Endothelial dystrophy 3. scar – scleral or corneal (due to surgery)
12. Pseudoexfoliation of lens 4. coloboma of iris – hole in the iris
LENS 5. irregular pupil
6. (-) Purkinje image
• Crystalline, biconvex soft structure behind the iris-pupil
• Lens is smaller than normal, associated with other congenital
diaphragm; in front of the vitreous body.
anomalies of the lens like:
• It is made up of a central hard nucleus and a peripheral soft 1. spherophakia – spherical lens
cortex enclosed by a capsule. 2. ectopia lentis – displaced lens
• It is held in position by zonules coming from the ciliary body. 3. congenital weakness of zonules

Physiology: • Rx: If the condition is bilateral and with poor vision, removal
• The lens together with the cornea forms the optical system of of the lens is suggested
the eye. • If unilateral, leave it alone, since the other eye is good and
would do its work. However, if strabismus sets in, surgery is
Hyperopia – when the ciliary muscle relax, zonules become tense, the advised.
lens become thinner, allowing parallel rays of light to be focused
beyond retina Lens coloboma
Myopia – if ciliary muscle contract, zonules loosened, lens thicker, • There is defect in lens equator associated with absence of
parallel rays of light is focused in front of the retina zonular fibers, accompanied by coloboma of iris and ciliary
body. Blurring is due to lenticular astigmatism.
Aqueous Humor – supply nutrients to the lens.
• Rx – corrective lenses
Lens has no blood supply.
Transparency of the Lens is governed by physical and chemical • Spherical protrusion in anterior and posterior surface of the
properties: lens, resulting to visual impairment
1. regular parallel arrangement of fibers and nuclei at the periphery
2. curvature of surface Lens dislocation
3. refractive capsule • The developmental form is congenital and occurs as a defect of
4. location of geometric center at the middle the zonules which may displace the lens, it is associated with
Marfan’s syndrome characterized by the ff:
Causes of Lens Opacity 1. bones – long and thin
A. Physical 2. muscles – weak
1. changes in curvature 3. miosis – pupils are difficult to dilate and atropine
2. insinuation of water between individual fibers
3. deposition of substances in the capsule • The acquired form – may be result from trauma characterized
B. Metabolic by:
1. increase Na 1. blurring of vision – displaced optical center of lens
2. decrease K and ascorbic acid 2. monocular diplopia – if lens equator is seen at the pupil
C. Changes in Aqueous, Vitreous, and Ciliary Body 3. glaucoma – if ciliary body is irritated
1. Diabetes Mellitus – hyperglycemia increase the reduced
(sorbitol) sugar in the AH so by osmosis withdraws some
• Rx: Removal of displaced lens
water from the lens
2. Changes in pH of AH due to inflammation
3. Catalytic change in the ciliary body epithelium is responsible
for the increased formation of aqueous with the aid of • Any opacity of the lens producing visual impairment gradually
carbonic anhydrase but generally progressive.
D. Hereditary, racial predisposition, malnutrition, light, heat,
radiation (U.V.) and endocrine disturbances • Signs and Symptoms:
1. cloudiness of vision
Diseases of the Lens 2. distortion of images
Abnormality of the lens – Non-inflammatory 3. second light – due to lenticular myopia resulting from a
change of the index of refraction of cataractous lens
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o Among presbyopia – can read from near even • The patients should be properly prepared prior to cataract
without glasses surgery, medically and psychologically. Medical illness should
4. Ophthalmoscopy at a distance reveal black spots in the be controlled first like bacterial infection, uveitis and glaucoma;
fundus reflex – immature infection of lids and conjunctiva has to be managed first. Such
o peripheral or cortical (+ROR) conditions may result to serious complications like
o central or nuclear (+ROR) endophthalmitis and may end up losing the eye.
o mature lens (-ROR)
Methods of Cataract Surgery
Complicated Cataract I. Intracapsular lens extraction
When the whole lens is removed together with the
• Associated with local eye pathology such as:
1. infection
2. inflammation
II. Extracapsular lens extraction – when the anterior capsule and
3. glaucoma
nucleus are both removed; leaving behind the posterior
4. vitreous hemorrhage
5. retinal detachment
A. Discission
6. retinitis pigmentosa
Cutting of anterior capsule with a needle or pointed
7. tumors
knife leaving behind nucleus which will be dissolved by a
process initiated by contact with aqueous humor
• With this type of cataract, improvement of vision after lens B. Needling
extraction can’t be predicted because of the other pathology in When anterior capsule is ruptured and nucleus is
the eye. stirred by the same instrument
C. Capsulectomy
Secondary Cataract In young patient with hard nucleus the anterior
• An after cataract or membranous cataract; may result after an capsule is removed and hard nucleus is expressed out
incomplete surgical procedure in removal of the cataractous D. Phacoemulsification
lens or following trauma An apparatus is used to dislocate the lens
anteriorly; fragmented it by ultrafibrication, aspirate the small
Developmental Cataract particles out
o Hereditary – transmitted by recessive or dominant genes, usually E. Lensectomy
bilateral and comes early in life A special instrument is used with thin rotating
o Maternal sharp edge slowly tearing the lens capsule and its substance
- Due to maternal illnesses that alter normal development of into small bits and then aspirate it out
fetus like viral infection; hypoparathyroidism and drugs
ingested during pregnancy (thalidomide) • Intraocular lens – plastic lens placed anteriorly or posteriorly
held in place at the papillary area.
Senile Cataract
- aging process may affect the natural transparency of the lens
- geographical locations, climate, nutrition
- cortical cataract tends to swell and liquefy
- nuclear cataract tends to harden and shrink

Systemic Cataract
1. Diabetes Mellitus
2. Hypoparathyroidism
3. Radiation Exposure
4. long term use of corticosteroids (oral)
5. drugs ingested in big dosage – tranquilizers, drugs which
reduce weight

Management of Cataract
• All mature cataracts have to undergo surgical removal. The
indication for surgery is primarily the inability of the individual
to perform his work (especially the young) even with the aid of
corrective lenses on the good eye. Also to prevent the
occurrence of secondary complication like glaucoma, uveitis,

• The timing of cataract surgery is very important. In the young,
surgery should be done as soon as possible if both eyes have
poor vision or strabismus sets in, otherwise surgery should be
deferred because surgery in the young is prone to serious
complications like retinal detachment, uveitis and glaucoma.