Dr/ Mahmoud Medhat 0113004901 I Definition Optic neuropathy, in which the intraocular pressure (IOP) is sufficiently elevated to cause optic nerve damage > characteristic visual field changes. Normo-tensive_glaucoma: A type of glaucoma, in which the characteristic glaucomatous optic nerve damage & field changes take place inspite of a normal IOP. Ocular hypertension: tt IOP above the normal range, without optic nerve damage. Intraocular pressure (IOP) Importance Preserve the shape of the retina during ocular ‘movement 2. Keep the aqueous humour circulating Generation_of 10! Secretion, circulation & drainage of the aqueous humour. Aqueous humour is secreted by the ciliary processes © posterior chamber => anterior chamber, by passing through the pupil draining into the trabecular meshwork => canal of schlemm => aqueous veins, Drainage of the aqueous humour: 1, Trabecular route (90%), 2, Uveo-scleral route (10%): This is a conventional pathway, draining the aqueous into the suprachoroidal space into veins of the ciliary body, choroids & sclera. 3. Minor amount is drained into the iris crypts. - 106 -Dr/ Mahmoud Medhat 0113004901 “rime ot dey 1OP values aot s7 Wiss rew i _s7 Der bey © Normal: Ranges from 10-21 mmHg. £ E ' * Normal diurnal variation: Not exceeding 4 fy mmHg. Being highest in the morning & 1 = lowest in the evening * Normal difference between both eyes never exceeds 2-3 mmHg ¢ Drinking 2 liters of water elevates the IOP within 30 minutes (Not exceeding 4 mmHg). Factors affecting IOP 1. Blood pressure. 3. Body temperature. 2. Heart rate. 4, Hormonal changes. Measurement of IOP (Tonometry) 1 ital tonometry: * Rough indication of IOP. © The patient is asked to look down, without closing his eyes. The eye is fluctuated between both index fingers of the examiner (At right angle 10 each other). 1OP is described as: Normal, Soft or Hard. 2. Indentation tonometry (Schiotz): * More accurate technique. * With the patient supine, apply the tonometer perpendicular to the cornea. A small plunger indents the cornea by its weight, while the cornea pushes back by an equal force. This force is read on a scale, then converted into mmHg using a special table. © This technique is very popular, but causes marked underestimation in patients with 4 scleral rigidity (High myopes) -107-Dr/ Mahmoud Medhat 0113004901 3. Applanation tonometry (Goldmann): Fr © The most accurate. © With the patient at the slit lamp, instill fluorescin, drops. A cone, 3.06 mm in neter, applanates an equal area of the cornea 4. Air-puff tonometry: © Useful in screening programmes Air puff applanates a known area of the cornea. This applanated area acts as a mirror, reflecting a light projected onto the cornea toa light sensor. Gonioscopy Definition: Visualization of the angle of the anterior chamber using a gonio lens (e.g. Goldmann), Aim 1. Visualization of the angle structures, detecting abnormalities 2. Estimation of the angle width (Classification of glaucoma) 3. During certain surgeries (e.g. Goniotomy) Structures visualized by gonioscopy (Krom the cornea to the iris) 1. Schwalbe's line: Opaque line, representing the margin of Descemet's membrane. 2. Trabecular meshwork: Broad grey zone. 3. Scleral spur: White line, representing an internal scleral projection 4. Ciliary body: Dark band. Root of the iris. wn = 108 -Dr/ Mahmoud Medhat 0113004901 Dimensions of the angle 1. Normal angle: Equal to the corneal thickness. Somehow normal: 3/4 the corneal thickness. Moderately normal: 1/2 the corneal thickness. . Narrow: 1/4 the corneal thickness. wewR . Closed angle: Just the iris opposed to the cornea. Classification of glaucoma I ima = Opsnangle PONG) + Angle closure u Sccondan + Opsnangt + Closed angle 1M Bupltins (Prinmy congenital glaucoma. Primary Open Angle Glaucoma (POAG) Definition Bilateral, genetically determined elevation of the IOP, incompatible with the health & function of the optic nerve fibers, leading to progressive field changes and visual lo sociated with wide AC angle as seen on gonioscopy. Incidence © The most common type of glaucoma © Affects both sexes equally. © More in the black race. isk factors Strong family history 2. Dark races: More common, more aggressive, more difficult treatment. 3. Myopia: The two diseases may be genetically determined. 4. Vasospastic disorders (Raynaud's disease & Migraine) 5. Age: The disease is more common above 45 years. Routine screening above age of 40 is mandatory for identifying the disease before stealing vision. 6. Ocular hypertension = 109-Dr/ Mahmoud Medhat 0113004901 Pathological changes in the angle of the anterior chamber © 11 1OP 1. Degenerative sclerosis of the trabecular meshwork 2. Degenerative sclerosis of the walls of canal of Schlemm 3. Proliferation of the endothelial lining of the draining channels. 4. Elevated pressure in the aqueous veins. Symptoms 1. Asymptomatic: Many es are dentally discovered 2. Defective dark adaptation (Night blindness). 3. Very late in the course of the disease: Tubular vision. Signs 1. 1 10P. 2. Optic dise cupping 3. Field changes, 1. Elevated IOP: Above 22 mmHg is suspicious, but above 26 mmHg is diagnostic. aos (fj > i. Fundus exai ation > Segre (A. Segre Glaucomatous disc cupping The optic disc head is the most important structure to examine in glaucoma. The normal disc head: © Slightly oval, pale pink dise © The physiologic cup: a central whitish area. circular with sloping walls * Normal horizontal disc/cup ratio is 0.3 -110-Dr/ Mahmoud Medhat 0113004901 Damage to the optic nerve by the 1T IOP can be explained by the following theories: 1, Mechanical theory: 11 IOP > backward bowing of the lamina cribrosa > mechanical pressure on the optic nerve fibers, 2. Vascular theory: TT IOP & pressure on the vascular system around the optic nerve = ischaemia of its fibers. 3. Neurocytotoxicity theory: 17 IOP = alteration of the chemical environment of the ganglion cells < apoptosis > release of cytotoxins © killing the other nearby cells. Early glaucomatous disc changes Large cup/ dise ratio 2. Asymmetry of the cup/ disc ratio in the two eyes. 3. Vertical elongation of the optic cup. 4. Notching of the rim of the optic cup. 5. Splinter haemorrhage on the optic disc. 6. 1 visibility of the pores of the lamina cribrosa 7. Nerve fiber layer defect with red free filter. Late glaucomatous changes in optic disc 1. Cup/ disc ratio more than 0.7 2. Deep cup with undermined edges. 3. Nasal shift of the vessels. N.B. Methods for documentation of the optic disc appearance: * Optic disc photography: Not accurate. + Stereoscopic photography: More accurate. + Scanning laser ophthalmoscopy. o@Dr/ Mahmoud Medhat 0113004901 mw. Field changes: Field changes are much earlier than loss of visual acuity. © The most crowded optic nerve fibers are the temporal ones, above & below the macula (Arcuate fibers), this explains why the earliest Glaucoma signs occur in this zone © The least crowded are the macular fibers, so they are spared until late in the disease course, © Glaucomatous disc changes respect the horizontal meredian, as no fibers from the upper half pass to the lower half & vice versa. A, Kinetic perimetry » Paracentral scotoma. » Nasal step. » Peripheral contraction. 1. Paracentral_scotoma (Bjerrum _scotoma): The earliest clinically significant defect in the area between 10 & 20. As the di se progresses the scotoma enlarges circumferentially to involve more arcuate fibers, until it fuses with the blind spot I upper or lower arcuate scotoma (Bjerrum scotoma) When both upper & lower are present, this forms a double arcuate or central ring scotoma. 2. Nasal step (Roenn step): Results from asymmetrical shape of the upper & lower field defects as they meet at the horizontal -112-Dr/ Mahmoud Medhat 0113004901 meredian, This is quite characteristic of Glaucoma. A similar defect can develop at the temporal field (Less common.) It is called temporal wedge f 3. Peripheral contraction (Advanced stage): Peripheral & contraction of the field until it ite fuses with the central scotoma, with preservation of a small island of vision (Tubular vision.) And an accompanying temporal island. roles B. Static perimetry: Visual field changes are detected in terms of statistical deviation from the normal age- not in terms of scotoma. controlled paramet The computer can detect whether the lesion is diffuse, or localized to a certain area, as in glaucoma IV. Optical Coherence __ Tomography (OCT: It is valuable to detect the earliest changes in the nerve fiber layer (The site of the earliest changes) before the stage of pathological cupping. OCT is a sophisticated technique that depends on the computer and plane polarized light to measure the thickness of the nerve fiber layer. -113-Dr/ Mahmoud Medhat 0113004901 Management of POAG Treatment of POAG is medical, unless 1. Progressive pathological changes with the highest tolerated medication, 2. Non compliance to medical treatment 3. Intolerability to the medication or significant side effects I. Medical treatment: 1. Topical: a, Beta-blockers: © Blocking the sympathetic beta receptors in the epithelial cells of the ciliary body > 4 aqueous secretion by 40%. After instilling these drops into the eye, the patient is instructed to digitally occlude his punctum by his little finger (For 1 minute) to reduce the systemic effects (Worsening bronchial asthma, ischaemic heart disease & myasthenia gravis). © Timolol 0.5% (Non-selective) & betaxolol 0.5% (Selective). b. Prostaglandins analogues: © IT uveo-scleral pathway for drainage of aqueous. © Latanoprost & bimatoprost. c. Mioti © Pilocarpine nitrate 1-4% contraction of the ciliary muscle © pulling on. the trabecular meshwork > TT aqueous outflow. -114-Dr/ Mahmoud Medhat 0113004901 d. Adrenergic agonist (c.g. Dipivefrine 0.19%): © Action: © Alpha agonist action on the trabecular meshwork > 1T aqueous outflow, © Alpha agonist action on the ciliary blood vessels > 1! aqueous secretion. © It can replace beta blockers if contraindicated. e. Carbonic Anhydrase inhibitor: 2.Systemic: Systemic carbonic Anhydrase inhibitor: © Very effective, but causes many side effects: ©. Tingling of fingers. co Renal stones. © Nausea, vomiting & malaise. Sugeon's view Focused laser bea { ¢ Preferred in short term therapy: Poel, © 2ry glaucoma. ame \ © Pre-operative & post-operative. II. Laser Trabeculoplasty (LT): * Indications: ‘© Uncooperative patient. © Uncontrolled IOP inspite of adequate medical treatment. © Progressive disc & field changes inspite of adequate medical treatment. © Applying low power laser burns to the trabecular meshwork > shrinkage of the trabecular meshwork > widening of the inter- trabecular spaces > 11 aqueous drainage al -15-Dr/ Mahmoud Medhat 0113004901 IIL. Surgery: Ee eee = cet tame 1, Sub-scleral trabeculectomy: © The standard technique © Done under a scleral flap to minimize excessive infiltration © It increases the aqueous drainage by creating a channel between the Trabeculectomy ns anterior chamber & the subconjunctival space. 2. Glaucoma devices: © Indicated in resistant cases. © A large reservoir is implanted between two rectus muscles & connected to the anterior chamber bya « silicone tube (Ahmed valve & Molteno valve). 3. Ciliary body —_—_ ablation procedures: © Destroying the ciliary epithelium => 1 aqueous secretion. © Cyclodiathermy, cyclocryotherapy & cyclophotocoagulation, -116- onDr/ Mahmoud Medhat Primary angle closure glaucoma Definition Closure of the angle of the anterior chamber by the root of the iris > 1t JOP, which is first transient, then comes in sudden attacks & permanent visual handicapping. Incidence: It is more common in females, hyperopic & nervous persons. Risk factors Family history. Emotions & nervousness, 1 2. Shallow anterior chamber as in hyperopic persons. 3, 1. Mydriasis: Crowding of the iris & closure of the angle 2. Relative pupillary block: The pupillary border of the iris is close to the anterior surface of the lens > TT of the pressure in the posterior chamber © iris bombe > contact between pressure rises as flow through pupil is reduced or blocked. lens Iris ‘bows’ forward under the ‘sticks’ to pressure behind it iris ~ posterior ‘synechiae angle is ‘closed’ or narrowed the root of the iris & the cornea ¢ peripheral anterior synechiae => closure of the angle. 3. Ciliary body congestion: Pushing the iris forwards > closure of the angle. Clinical stages Latent stage, Subacute (intermittent) stage. Chronic stage. Absolute glaucoma, Acute (Acute congestive glaucoma) stage. -7-Dr/ Mahmoud Medhat 0113004901 1. Latent stage: ¢ Asymptomatic with shallow anterior chamber. © Provocative tests (A rise more than 8 mmtlg or more is diagnostic): i. Mydriatic test: Measuring IOP before & after pupillary dilatation using a weak mydriatic (e.g. phenylephrine). ii, Dark room test: Measuring IOP before & after staying awake in a dark room for I hour. © Treatment: i, Narrow angle, routinely discovered > provocative tests: © Positive: Prophylactic peripheral iridectomy or Laser iridotomy. © Negative: Follow-up ii, The fellow eye already | suffered acute or subacute attack: Prophylactic peripheral iridectomy or laser iridotomy. 2. Subacute (intermittent) stage: © Symptoms: Transient attacks of frontal headache, impaired vision & haloes. * Signs: o Recurrent attacks of 1T IOP, dilated pupil & mild epithelial corneal edema. © The attack is relieved by miosis (Sleep or exposure to sunlight), © Between attacks: Normal eye with shallow anterior chamber. © Treatment: Prophylactic peripheral iridectomy or laser iridotomy al - 118 -Dr/ Mahmoud Medhat 0113004901 3. Acute (Acute congestive glaucoma) stage: © Sudden attack of tf IOP, due to sudden, Kan SR complete & persistent angle closure by the root of the iris. a. © Symptoms: AS 1. Severe ocular pain: Due to stretching of the ocular coats. 2, Headache: Along the distribution of the trigeminal nerve. . Red eye with photophobia & lacrimation. }. Rapid drop of vision: Due to corneal edema. wa wy Halos around light (Rainbow-coloured), 6. Nausea & vomiting, due to vagal stimulation (simulating acute abdomen). © Signs: 1. Acute red eye with lacrimation & photophobia. Markedly elevated JOP up to 70 mmHg. 2. 3. Eyelid edema. 4. Cormeal edema & haziness. The cornea becomes insensitive. a Very shallow anterior chamber. 6. Semi-dilated. irreactive, [oo vertically oval pupil. . 7, Drop of vision, down to PL in some cases. 8. The fundus is hardly seen, due to corneal edema. This can be overcome by glycerin drops: * Hyperaemie optic dise. + Splinter haemorrhage on the dise. Retinal arterial pulsations al -119-Dr/ Mahmoud Medhat 0113004901 © Fate of the attack: 1. Recovery: Either spontaneously or due to treatment 2. Chronicity: Leaving PAS after recovery. 3. Absolute_glaucoma: Complete blindness, following the attack © Differential diagnos 1, Other causes of red eye: e.g. acute conjunctivitis, comeal ulcer & acute iridocyelitis 2. Other causes of rapidly elevated IOP: * Glaucomatocyclitic © Lens induced: Phakomorphic & phacolytic glaucoma © Management: Essentially surgical, with preoperative medical preparation, for: * Lowering the IOP => more favorable surgical conditions * Releiving pain & headache. * 1 intraocular inflammation I. Hospitalization. II. Preoperative management: a. Hyperosmotic agents: v¥ Mannitol 20-25% IV solution or 50 ml pure glycerol orally. Y Hyperosmotic agents 1 plasma osmotic pressure > withdrawing fluid from the eye into the plasma, v Mannitol is contraindicated in cardiac & hypertensive patients. b. Topical Miotics: Pilocarpine 2-4% every 30 minutes, till constriction of the pupil. ¢. Topical Beta blockers: e.g. Timolol.Dr/ Mahmoud Medhat 0113004901 d. Carbonic Anhydrase inhibitors: Oral or IV. e. Analgesics & anti-emetics. f. Gonioscopy: For examination of the angle of the anterior chamber (Detection of peripheral anterior synechiae) IIL Surgery: a. Recent attack with no evidence of PAS: Conjuncira Surgical iridect surgical iridectomy. rid exe b. Longer attack with evidence of PAS: External fistulizing operation (eg. subscleral trabeculectomy), IV. Prophylaxis of the other eye: a. Prophylactic Pilocarpine. b. Laser iridotomy. ¢. Peripheral iridectomy. 4. Chronic stage: © Pathogenesis: Intermittent subacute attacks or resolving acute attack & gradual progressive formation of PAS nical picture: As POAG + Narrow angle & PAS on gonioscopy. © Treatment: External fistulizing operation:Dr/ Mahmoud Medhat 0113004901 5. Absolute glaucoma (Blind painful eye): © Symptoms: Blind, painful & disfiguring eye. © Signs: Cebus 1. Cornea: Insensitive + Glaucomatous pannus. Shallow /Cha 2. Iris: Atrophic patches, 3. Shallow AC. 4, Pupil: Dilated, vertically oval, fixed pupil, greenish-blue in colour. 5. Tension: Stony hard 6. Fundus examination: Optic trophy. 1. Corea: i, Bullous keratopathy: Comeal edema > vesicles. ii, Degenerative (Glaucomatous) pannus: Granulation tissue invading the cornea at the level of the basement membrane. 2. Sclera: Staphyloma (Interacalary, ciliary & equatorial), 3. Lens: Complicated cataract 4, Atrophia bulbi: Ciliary body atrophy > 11 aqueous humour secretion. © Differential diagnosis: Blind painful eye. ¢ Treatment: © Retro-bulbar injection of absolute alcohol. © Ciliary body ablation. o Enucleation. -122-