Hyphema

the risk of Rebeelding is greatest 3-5 days after the injury

Hyphema Grades:
Grade I → <1/3 AC
Grade II → 1/3 - 1/2 AC
Grade III → >1/2 AC
Grade IV → Total AC
Hyphema and high IOP: (AAO)
Grade I to II hyphemas → 13.5% has an IOP increase -

- Grade III hyphemas → 27% has an IOP increase.

- Grade IV hyphemas → 52% experiencing an IOP increase.
- Cases with rebleeding → had a more than 50% chance of having elevated IOP.

POAG
the prevalence is 3-8 times higher at 80 than at 40 years old
FH risk factor of POAG > risk to siblings “brother or sister” is 4 times and to offspring 2 times the normal population risk

the vertical cup-to-disc diameter ratio increases faster than the horizontal one, leading to an increase of the quotient of
horizontal-to-vertical cup to-disc ratios to values lower than 1.0

Topical or systemic corticosteroids are not a risk factor for POAG; rather, it is a risk factor for steroid induced Secondary
OAG

‫الساحة البصرية‬
A fixation loss occurs when the patient responds as if seeing a light when a target is displayed in his blind
spot.
Intermittently, the perimeter will pause and the motorized light will change position, but no stimulus will be
presented. If the patient presses the button, a false-positive response is recorded.

The most common cause of bleb failure → Episcleral fibrosis

Static perimetry is the most useful for quantifying and tracking visual field changes in a patient with established
glaucoma
 scotoma found in patient
with OAG
Depressed sensitivity in the superior nasal quadrant is the most prominent in the typical arcuate scotoma found in
patient with OAG

The earliest defect due to glaucoma is generalized decreased sensitivity

Paracentral, small, relatively steep depressions constitute approximately 70% of all early glaucomatous field defects
Typically the central island of vision and the infertemporal visual field are retained until late in the course of
glaucomatous optic nerve damage
As nasal fibers and the maculopapular bundle are typically spared until late in the disease process, it is common to have
a central or temporal island of vision remaining in eyes with advanced glaucoma
Paracentral scotomas in glaucoma → most commonly supero-nasally

trabeculoplasty
The basic protocol for Argon laser trabeculoplasty
Spot size of 50 micron
Power of 300-1000mwatt
Spot duration of 0.1 second
Laser spot placed at the junction of the anterior non-pigmented and the posterior pigmented edge of trabecular
meshwork
 IOP
The rise of IOP takes 2-4 weeks or up to 6 weeks after starting ocular steroid
Increase in corneal thickness of 10 microns results in increase IOP by 1mm Hg
IOP is lower when a person sleeps inclined head up, compared to lying flat
Peak pressures are reached during sleep, in the early-morning hours

IOP increases more with → dexamethasone than betamethasone than fluorometholone

Ketamine (at high doses) and Succinylcholine → increase in IOP. Other anaesthetic agents diminish intraocular
pressure
.
General anesthetic agents and sedatives can profoundly lower IOP. Exceptions include chloral hydrate, which does not
affect IOP, and ketamine, which may increase IOP.

Systemic hypertension
Systemic hypertension is associated with a lower risk of the presence of glaucoma because higher blood pressure is
associated with improved optic nerve perfusion, So over treatment of systemic hypertension may be a factor to
glaucoma progression in some cases and should be avoided
Ocular perfusion pressure is the difference between the arterial BP and the intraocular pressure (IOP),and has been
shown in population studies to be linked to increased risk for the development and progression of glaucoma

Disc hemorrhage
Disc hemorrhage most commonly inferotemporally , their presence is a
risk factor for the development and progression of glaucoma
Disc hemorrhages may occur in as many as 1/3 of glaucoma patients at some time during the course of their disease age

Optic disc haemorrhages occur most commonly infero-temporally.

DURG
Oral nicotinic acid “Niacin = Vit. B3) → Causes CME without leakage, in contrast to topical Epinephrine Topical
timolol has been shown to decrease HDL
Allergic Conjunctivitis with Glaucoma drugs → Bromonidine 20%,
Dorzolamide 1-2%. PG analogs more commonly produce conjunctival
hyperemia than true allergic conjunctivitis
Apraclonidine (alpha-2 agonist ) → cause a mid-miosis in normal eyes and mydriasis of Horner's
syndrome eye
CAI may cause idiosyncratic and transient acute myopia
Using CAI → aqueous producdtion in the eye is not significantly reduced
until more than 90% of the carbonic anhydrase activity is inhibited
Adverse effects of PG analogues include conjunctival hyperemia (as a
result of vasodilation ) more with bimatoprost and travoprost
topical latanoprost and oral venlafaxine “SSNRIs Antidepressant” can all cause CME with leakage on
.fluorescein angiogram

Carbonic anhydrase inhibitors can exacerbate corneal oedema due to their effect on the endothelial pump mechanism

Alpha agonists such as brimonidine can precipitate a hypertensive crisis with TCA (e.g. amitryptyline that used also for
trigeminal neuralgia)

The IOP lowering effect of pilocarpine is additive (complimentary to) beta-blockers, but not with prostaglandin
.analogues

Pilocarpine gel at night is known to induce diffuse corneal haze

Unlike latanoprost and travoprost, which lower IOP by increasing

uveoscleral outflow, bimatoprost decreases IOP by increasing
uveoscleral and trabecular outflow. (Bi = 2)
Unoprostone appears to lower IOP by increasing trabecular outflow
alone. (uno = 1)
Latanoprost and travoprost are prodrugs that penetrate the K and
become biologically active after being hydrolyzed by corneal esterase.
Neither bimatoprost nor unoprostone appears to be a prodrug

Brimonidine is the safest anti-Glaucoma drug in early pregnancy

(However, their use in late pregnancy and during breast-feeding should
be avoided because they can cross the blood-brain barrier causing CNS
depression and apnoea in the neonate)

Topical CAI commonly causes a transient bitter taste

Thymoxamine is alpha receptor blockers that revese pharmachological

dilation
Beta blockers are competitive antagonist of the β-adrenergic receptors.
They inhibit the activation of these receptors in the ciliary processes by
blocking the binding of endogenous adrenergic neurotransmitters
The alpha-2 agonists (apraclonidine and brimonidine) should be avoided in children because they have the potential to
cross the blood-brain barrier

The most common side effect of CAI is Paraesthesia.

Indirect-acting parasympathomimetic agents tend to have the most pronounced systemic and ocular
side effects (e.g. Cataract) compared to direct-acting agents

‫اجهزة‬
Direct Gonioscopy → Koeppe, Richardson, Barkan, Wurst and Swan-Jacob.
Indirect Gonioscopy → Goldmann, Zeiss, Posner and Sussman.

Iridectomy
A large inferior peripheral iridectomy is mandatory when silicone oil is
placed into an eye. The oil is lighter than water, and to prevent pupillary
block glaucoma, an inferior peripheral iridectomy is performed.

Sturge-Weber
Glaucoma is much more common in Sturge-Weber patients with
facial haemangioma involving the upper eye lid
30% of Sturge-Weber syndrome patients develop glaucoma. Most (60%) occur in patients under the age
of 2 years

CRVO
Up to 50% of eyes develop NVG following ischemic CRVO . AAO
Among eyes with severely ischemic CRVO, the incidence of anterior segment neovascularization, iris and
angle, is high (up to 60%). "The Central Vein Occlusion Study"
ERG in Ischemic CRVO > decrease in b/a wave amplitude ratio (sometimes been used to assess
neovascular risk)

Aniridia
Only Sporadic Aniridia (WARG) is associated Wilms Tumor. In contrast, Familial Aniridia is not
associated with Wilms.
AD Anidridia > 2/3 of cases and has no systemic associations (PAX6 mutation)
AR Aniridia (Gillespie syndrome) > 1% of cases. Not caused by PAX6. Cerebellar ataxia and mental
handicap are features.
Aniridia > Glaucoma (75%), usually ACG.

Retinoblastoma
Glaucoma in association with retinoblastoma most commonly is caused by iris NVs followed by displacement of the
iris-lens diaphragm

Pseudoexfoliation
Lens extraction does not alleviate the pseudoexfoliation syndrome.
Pseudoexfoliation often presents unilaterally and the uninvolved eye manifests signs of the disease at a
later time. Mutations in single gene LOXL1 seem to be present nearly in all cases. The risk of progression
to glaucoma also varies widely and can be as high as 40% of patients over 10 year period.

Melanoma
In ciliary body melanoma, anterior displacement of the iris-lens
diaphragm resulting in angle-closure is the most common mechanism
(in Massachusetts, direct invasion of the anterior chamber angle)

Iris melanomas raise IOP by mechanical obstruction of the meshwork,

either by direct angle invasion, or by Melanomalytic

Melanomalytic glaucoma results from blockage of the trabecular

meshwork by macrophages that have engulfed material released from
an intra-ocular melanoma tumor

The most common cause of secondary glaucoma due to intra-ocular

melanoma (Choroidal melanoma or retinoblastoma) is
neovascularisation

Phacolytic
The lack of KPs helps distinguish phacolytic from phacoantigenic “phacoanaphylactic” glaucoma.

‫الزرق الوالدي‬
A newborn's cornea is typically 9.5-10.5 mm in diameter and increases to 10.0-11.5 mm by age 1. Any diameter above
12.5 mm suggests an abnormality, especially if there is asymmetry between the two eyes
Haab's striae = Horizontal = Healed breaks in DM, infantile glaucoma.
Vogt's striae = Vertical = Vagina, birth trauma.

Most cases of primary congenital glaucoma are sporadic

PACG
About one half of PACG are Asian, It increases after 40 years and rare in
person younger than 40 years.
PACG occurs commonly in patients with hypermetropia. It is 2-4 times
more commonly in women than men

Trabeculectomy
A shallow anterior chamber with high IOP post-trabeculectomy can be the result of:
Pupillary block: this is due to a non-patent peripheral iridotomy with iris bombe. The bleb is flat and
Siedl's is negative
Aqueous misdirection: this is due to aqueous being directed posteriorly into the vitreous. The AC is
shallow, the IOP high, the bleb flat and Seidel negative. However, the iridotomy in this case is patent
with no iris bombe.
Suprachoroidal hemorrhage: Chroidal detachement by fundus + U/S
A shallow anterior chamber with low IOP post-trabeculectomy can be the result of:
Scleral flap leak: the bleb is well formed and Seidel test negative
Conjunctival bleb leak: the bleb is flat and Seidel test positive
Ciliary body shutdown: the bleb is flat and Seidel test is negative