Ophthalmology Glaucoma and Lens Gloria Romero First/ July 17, 2008 Bioman (with Alice in Wonderland & Jason Bourne


Subject Topic Lecturer Shifting /Date Trans group


nerve fiber causing changes in the optic disc – visual field changes. • 1. 2. Symptomatology: may arise from: increase IOP disturbance of optic nerve function If the pressure builds up slowly (primary open glaucoma), symptoms maybe absent or minimum. Interference of optic nerve function causes little defect, usually unappreciated by patient until far advance. If there is sudden increase of IOP (acute close angle glaucoma), there may be: 1. severe ocular pain 2. sudden diminution of vision due to corneal edema 3. ciliary injection 4. lacrimation 5. papillary dilatation – due to paralysis of spl. muscle of iris

Includes a complex of eye disease, which have in common an abnormal rise of intraocular pressure (IOP) which causes organic changes in optic nerve, produces irreversible blindness through progressive loss of vision. Many forms are asymptomatic – they destroy the optic nerve. However, if detected and the abnormal rise of IOP is reduced to normal by medications or surgery, the progression of blindness can be prevented. So every doctor should be familiar with the principle and method of diagnosis and treatment of glaucoma. Diagnosis of glaucoma is done by routine eye exam and measurement of IOP (palpation or tonometry).

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Ophthalmoscopy – to visualize optic disc in all suspected old patients; so proper referral to ophthalmologist could be done – saving the sight of the patient. Intraocular Pressure • The level of IOP causing damage to the optic disc is not the same in every eye. However any eye with pressure of 21mmHg should be regarded as suspect even if optic nerve appears normal. • On the other hand, if optic nerve shows sign of glaucomatous cupping or changes even if the pressure is below 21mmHg, suspicion should be aroused, verification is done by visual field studies. The lens, vitreus, retina, and blood flow do not significantly affect IOP. The IOP then depends on the amount of aqueous production and the aqueous that goes out of the eye (outflow).

Diagnostic Methods: • Clinically, it is desirable to diagnose and treat the disease prior to the development of irreversible organic changes. This can be done by always having a high index of suspicion on patient with high risk of developing the disease. 1. Tonometry – an instrument used to measure the pressure quantitatively o Finger touch – done if no tonometer; application of index finger to eyeball and determine the firmness of the eyeball Ophthalmoscopy – examination of optic disc o optic disc characterized by big vertically oval and notch cup  nasalization of central vessels  spontaneous pulse in central retinal artery  hemorrhage in the disc Visual Field – by use of perimetry o characteristic visual field defect occur as a result of damage to individual bundle of nerve fiber in optic head


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3. Aqueous humor production in the ciliary body process in posterior chamber – pupil – anterior chamber. Impaired outflow may be due to the ff: congenital deformities of the trabecular meshwork adhesion of iris to the trabecular meshwork edema and scarring due to inflammation clogging of the trabecular meshwork by cellular debris


Effect of increase IOP: • The effect of IOP is manifested in the optic disc. Increase IOP – ischemia – by impairing blood supply to the optic nerve head, ischemia impairs nutrition to glial tissue in the area of the optic

Angle Closure Glaucoma I. Primary Type • Increased IOP – because aqueous could not flow to trabecular meshwork due to apposition of iris to anterior chamber, which maybe a result of an: a. inherited anatomic defect that causes shallow anterior chamber b. stress and excitement may increase production of aqueous humor which hinders the normal circulation within.


Ophthalmology: Glaucoma and Lens

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Signs and Symptoms: ciliary congestion cornea – with edema anterior chamber – shallow pupil – dilated, fixed, unreactive iris – atrophy several days after the attack ocular pain – discomfort – pain nausea and vomiting sudden diminution of vision with prodromes of seeing colored halos around light firm eyeball due to increased IOP Rx: medical use of MIOTICS; carbon anhydrase inhibitors and hyperosmotic agents – to pull iris away of angle If pressure decreased – surgery is done Secondary The basic pathology is the same in primary angle closure except that the angle closure is due to the condition in the eye that causes the iris to move towards the trabecular meshwork. posterior synechae or membranous formation following uveitis dislocated lens bulging hyoid in aphakia vitreous phase which pushes the lens iris diaphragm forward Early referral to the ophthalmologist to be able to manage before the attack. Treatment directed to cause, following the principle of treatment of primary angle closure glaucoma.

Treatment: Usually directed against the existing or associated ocular condition. If the pressure is elevated, measures are done to lower it down.

Developmental Glaucoma • Usually associated with hereditary or familial diseases, regardless to type. Signs and symptoms of various forms of glaucoma at birth or during infancy are similar. Primary Infantile Glaucoma • About 80% of developmental glaucoma are diagnosed before the first year of life, 70% may affect both eyes. • Signs and Symptoms: lacrimation blepharospasm photophobia corneal enlargement – due to inability of fibrous coat of the eye (sclera and cornea) to withstand rise of IOP Primary treatment : surgical (external trabeculectomy) success rate is high if done before onset of buphthalmos.

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Open Angle Glaucoma Aqueous has access to anterior chamber at all times. I. Primary • With no precipitating or pre-existing ocular or systemic diseases can be tagged as causative agent. • Characteristic: it is usually bilateral, hereditary tendency • II. • • Signs and Symptoms: usually symptomless, slow progress, chronic young individual – transient blurring of vision seeing halo pain – mild the condition maybe far advance before patient notice extensive visual blurring of one or both eyes Secondary Aqueous can permeate the trabecular meshwork however includes both inflammatory and non-inflammatory edema and exudates as part of the condition. uveitic condition – produce inflammatory cells age in the anterior chamber scarring or damage to the outflow channels materials from ruptured lens Caused by or associated with various diseases: inflammation neoplasm hemorrhage physical and chemical agents, drugs systemic diseases – diabetes mellitus neovascularization central artery or vein occlusion

Glaucoma Associated with Hereditary Familial Diseases • This condition is not always present at birth. The physician therefore should watch for its development if they find a child with hereditary diseases in which glaucoma is associated. I. Marfan’s Syndrome o characterized by anacrodactility; cardiac anomalies with subluxated lens (partial dislocation of lens). Anomaly in the trabecular meshwork is found, visual defect should be attended early, corrective glasses are helpful, surgery to subluxated lens is required for adequated clear vision. II. o o III. o IV. o Axenfield Syndrome characterized by corneal arcus called post. Embryotoxon polycoria; ectopia of pupil Neurofibromatosis nodules often visible in iris and maybe the basis of angle anomaly associated with glaucoma Marchesani Syndrome or Spherophakia high myopia, brachycephalic (short stocky and short fingers). The spherical lens tends to produce a papillary block and angle closure glaucoma.

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Aniridia absence of iris, rudimentary stump is left, adheres to the meshwork – glaucoma Rx: In cases of spherophakia and Marfan’s syndrome, where there is papillary block, iridectomy is the choice (surgical procedure) Miotic, CAI has been found ineffective in this cases o Findings that should lead to suspicion: Family history of glaucoma Diabetic patient

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3. 4. 5. 6. 7. 8. 9. 10. 11. 12. LENS Anatomy

History of ocular trauma Frequent changing of glasses High myopia Increase IOP following the use of steroid] Tonometric reading of 21mmHg or increased Ophthalmoscopic finding – optic disc Visual field changes Pigment deposits at post. pole of cornea Endothelial dystrophy Pseudoexfoliation of lens

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aphakia – congenitally absent; accompanied by other ocular diseases size - macrophakia formation of opacity - cataract Absence of the lens can be dx by the ff: 1. deep anterior chamber 2. iridodonesis – tremors of iris 3. scar – scleral or corneal (due to surgery) 4. coloboma of iris – hole in the iris 5. irregular pupil 6. (-) Purkinje image

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Crystalline, biconvex soft structure behind the iris-pupil diaphragm; in front of the vitreous body. It is made up of a central hard nucleus and a peripheral soft cortex enclosed by a capsule. It is held in position by zonules coming from the ciliary body.

Microphakia • Lens is smaller than normal, associated with other congenital anomalies of the lens like: 1. spherophakia – spherical lens 2. ectopia lentis – displaced lens 3. congenital weakness of zonules • • Rx: If the condition is bilateral and with poor vision, removal of the lens is suggested If unilateral, leave it alone, since the other eye is good and would do its work. However, if strabismus sets in, surgery is advised.

Physiology: • The lens together with the cornea forms the optical system of the eye. Hyperopia – when the ciliary muscle relax, zonules become tense, the lens become thinner, allowing parallel rays of light to be focused beyond retina Myopia – if ciliary muscle contract, zonules loosened, lens thicker, parallel rays of light is focused in front of the retina Aqueous Humor – supply nutrients to the lens. Lens has no blood supply. Transparency of the Lens is governed by physical and chemical properties: 1. regular parallel arrangement of fibers and nuclei at the periphery 2. curvature of surface 3. refractive capsule 4. location of geometric center at the middle Causes of Lens Opacity A. Physical 1. changes in curvature 2. insinuation of water between individual fibers 3. deposition of substances in the capsule B. Metabolic 1. increase Na 2. decrease K and ascorbic acid C. Changes in Aqueous, Vitreous, and Ciliary Body 1. Diabetes Mellitus – hyperglycemia increase the reduced (sorbitol) sugar in the AH so by osmosis withdraws some 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 carbonic anhydrase D. Hereditary, racial predisposition, malnutrition, light, heat, radiation (U.V.) and endocrine disturbances Diseases of the Lens Abnormality of the lens – Non-inflammatory

Lens coloboma

There is defect in lens equator associated with absence of zonular fibers, accompanied by coloboma of iris and ciliary body. Blurring is due to lenticular astigmatism. Rx – corrective lenses

Lentiglobulus • Spherical protrusion in anterior and posterior surface of the lens, resulting to visual impairment Lens dislocation • The developmental form is congenital and occurs as a defect of the zonules which may displace the lens, it is associated with Marfan’s syndrome characterized by the ff: 1. bones – long and thin 2. muscles – weak 3. miosis – pupils are difficult to dilate and atropine • The acquired form – may be result from trauma characterized by: 1. blurring of vision – displaced optical center of lens 2. monocular diplopia – if lens equator is seen at the pupil 3. glaucoma – if ciliary body is irritated Rx: Removal of displaced lens


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Any opacity of the lens producing visual impairment gradually but generally progressive. Signs and Symptoms: cloudiness of vision distortion of images second light – due to lenticular myopia resulting from a change of the index of refraction of cataractous lens

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Among presbyopia – can read from near even without glasses Ophthalmoscopy at a distance reveal black spots in the fundus reflex – immature o peripheral or cortical (+ROR) o central or nuclear (+ROR) o mature lens (-ROR) o

The patients should be properly prepared prior to cataract surgery, medically and psychologically. Medical illness should be controlled first like bacterial infection, uveitis and glaucoma; infection of lids and conjunctiva has to be managed first. Such conditions may result to serious complications like endophthalmitis and may end up losing the eye.

Complicated Cataract • Associated with local eye pathology such as: 1. infection 2. inflammation 3. glaucoma 4. vitreous hemorrhage 5. retinal detachment 6. retinitis pigmentosa 7. tumors • With this type of cataract, improvement of vision after lens extraction can’t be predicted because of the other pathology in the eye.

Methods of Cataract Surgery I. Intracapsular lens extraction When the whole lens is removed together with the capsule II. A. Extracapsular lens extraction – when the anterior capsule and nucleus are both removed; leaving behind the posterior capsule Discission Cutting of anterior capsule with a needle or pointed knife leaving behind nucleus which will be dissolved by a process initiated by contact with aqueous humor Needling When anterior capsule is ruptured and nucleus is stirred by the same instrument Capsulectomy In young patient with hard nucleus the anterior capsule is removed and hard nucleus is expressed out Phacoemulsification An apparatus is used to dislocate the lens anteriorly; fragmented it by ultrafibrication, aspirate the small particles out Lensectomy A special instrument is used with thin rotating sharp edge slowly tearing the lens capsule and its substance into small bits and then aspirate it out Intraocular lens – plastic lens placed anteriorly or posteriorly held in place at the papillary area.

B. C. D.

Secondary Cataract • An after cataract or membranous cataract; may result after an incomplete surgical procedure in removal of the cataractous lens or following trauma Developmental Cataract o Hereditary – transmitted by recessive or dominant genes, usually bilateral and comes early in life o Maternal Due to maternal illnesses that alter normal development of fetus like viral infection; hypoparathyroidism and drugs ingested during pregnancy (thalidomide) 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, etc.


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.

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