Miss.

Teeranun
Puttala
I201020056 MBBS2010

Ophthalmology
1. Stages and treatments of Acute Angle Closure
Glaucoma (AACG)
Acute Angle Closure Glaucoma is a true ophthalmic
emergency and appropriate therapy must be instituted immediately
to prevent vision loss. It is caused by a rapid or sudden increase in
pressure inside the eye or intraocular pressure (IOP). This typically
happens when the iris is pushed against the trabecular meshwork
(the spongy tissue located near the cornea where the aqueous
humor flows out of the eye) or drainage channels, and the fluid or
aqueous humor (the watery fluid that nourishes the interior of our
eye) that normally drains out of the eye is blocked. This creates the
increase in IOP.
Patients have severe ocular pain and redness, decreased
vision, colored halos around lights, headache, nausea, and vomiting.
The systemic complaints may be so severe that patients are
misdiagnosed as having a neurologic or GI problem. Examination
typically reveals conjunctival hyperemia, a hazy cornea, a fixed mid-
dilated pupil, and anterior chamber inflammation. Vision is
decreased. IOP is usually 40 to 80 mm Hg. The optic nerve is difficult
to visualize because of corneal edema, and visual field testing is not
done because of discomfort.
Stages and treatments of Acute Angle Closure Glaucoma
Acute angle-closure glaucoma is divided into 6 stages
1. Pre-Clinical stage
No any symptoms
Intraocular pressure is normal
Shallow anterior chamber
Narrow angle
2. Prodromal stage
transient attack of raised tension due to cornea edema
transient blurring of vision
rainbow haloes around light
mild eye pain, mild headache
eye looks white, cornea is hazy due to edema
3. Acute congestive stage
in acute congestive stage both eyes are effect kanski
clinical ophthalmology 7th edition free download
sudden increase in IOP
sudden loss of vision
severe eye pain, severe headache, nausea and vomiting
lacrimation occur

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 Miss. Teeranun
Puttala
I201020056 MBBS2010

redness and watering of eye

edema of lid
congestion of ciliary iris, conjunctiva
cornea hazy and intensive
pupil moderately dilated, reaction to light is abolished
angle is shallow

4. Intermittent stage
Intraocular pressure returned to normal
The disease can get temporary relief
Local congestion disappear
Transparent cornea recovered
Vision partially or fully restored
Anterior chamber reopened
5. Chronic stage
chronically elevated IOP
gonioscopically confirmed peripheral anterior synechiae
(PAS) of more than 180
glaucomatous cupping are seen
optic nerve head and visual field changes, with or without
prior symptoms
visual field defects
diminishing in vision,
6. Absolute stage
Uncontrolled in IOP
IOP is high and eyeball becomes stony hard.
The eye is painful irritable and completely blind.
The anterior ciliary veins are dilated with a light ciliary
flush around the cornea.
Cornea becomes hazy
Cornea Bollous karatitis are seen
Iris shows white patches dilatation of pupil occur
Fundoscopy reveals glaucomatous optic atrophy
Treatments of Acute Angle Closure Glaucoma
The goal of treatment is to reduce intraocular pressure as soon
as possible.
1. Medical treatment: To lower the pressure within the eye.
Eye drop
Timolol : Beta-blockers - to reduce intraocular pressure by
slowing down the production of aqueous humour in the eye

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 Miss. Teeranun
Puttala
I201020056 MBBS2010

2% Pilocarpine : Miotic - to pull the peripheral iris tissue

away from the trabecular meshwork helping to eliminate
obstructed aqueous humor flow.
1% prednisolone : Steroid - to reduce ocular inflammation
thereby providing symptomatic relief and augmenting the
affects of other medications.
Apraclonidine : Alpha-adrenergic agonists - used as
adjunct agents to further decrease IOP secondary to their
affect on aqueous humor production.

1. Medical treatment ( cont. )

IV administration
Acetazolamide : Carbonic anhydrase inhibitors - Reduces
rate of aqueous humor formation by direct inhibition of
enzyme carbonic anhydrase (CA) on secretory ciliary
epithelium, causing, in turn, a reduction in IOP.
Mannitol : Hyperosmotics to reduces elevated IOP when
pressure cannot be lowered by other means.
2. Definitive treatment
Laser peripheral iridotomy (LPI). LPI makes a small hole in
the iris, allowing it to fall back from the fluid channel and helping
the fluid drain.
3. Surgery
Surgical iridectomy :When the AACG attack cannot be broken within 3-6 hours
of initiating treatment, and laser gonioplasty (and perhaps LPI utilizing glycerin)
has been unsuccessful, the patient requires surgical iridectomy. Other situations in
which surgical iridectomy may be required are:
When the laser fails to produce a patent iridotomy
When LPIs close repeatedly
When a laser is unavailable
When the patient is uncooperative or has severe nystagmus

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 Miss. Teeranun
Puttala
I201020056 MBBS2010

Acute Angle Closure Glaucoma

Bilateral Acute Angle Closure Glaucoma

2. Stages of Age-related cataract
Age-related cataract is the most common cataract and often
seen in old people with age more than 50 years old. It is vision-
impairing disease characterized by gradual, progressive thickening
of the lens of the eye. It is one of the worlds leading causes of
blindness. Usually bilateral and occurs equally in men and women.
Age-related cataracts are divided into 3 types, depending on
their location.
1. Cortical Cataract is characterized by white, wedge-like opacities
that start in the periphery of the lens and work their way to the
center in a spoke-like fashion. This type of cataract occurs in the
lens cortex, which is the part of the lens that surrounds the central
nucleus. It is divided into 4 stages
1). Incipient stage
- Wedge-shaped opacity with apex directed toward the
centre of lens
- Most common in periphery and lower nasal quadrant.
- Only seen in dilated pupil.
- Irregularities in refraction, visual deterioration and polyopia.
- Cuneiform opacity
- blamellar seperate
- vacuole
- cracks
- no vision damage
2). Intumescent stage or immature stage
- Opacification becomes more diffuse and irregular
- Lens is swollen.
- Iris projection, iris shadow still visible.
- Anterior chamber becomes shallow.
- obvious vision decrease
- myopia

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 Miss. Teeranun
Puttala
I201020056 MBBS2010

- can induce acute angle-closure glaucoma

3). Mature stage
- Complete opacification.
- Whole cortex is involved .
- Lens appears pearly white in colour.
- Also known as ripe cataract.
4). Hypermature stage / Morgagnian Cataract
- Liquefying lens cortex
- Sunken brownish nucleus
- Flecks of calcium salt deposits on the anterior capsule
- Dense capsular opacities can be from epithelial hypertrophy
- May undergone spontaneous rupture to the anterior
chamber, causing inflammatory reaction which is known as
phacoanaphyllaxis uveitis
- May also be complicated with phacolytic glaucoma as the
inflammatory cells become trapped in trabecular meshwork
and obstructed the filtration flow of the aqueous humor

Summary

Incipient - Spoke-like opacity

Stage - Unaffected visual acuity

Intumescent - Visual acuity decreases

or
significantly
Immature
stage - Induced acute glaucoma

- Total opacity of Lens

Mature stage - Fundus cannot be
observed

- Cortex liquefy and nuclear

Hypermature
sink
stage
- Visual acuity increased
suddenly

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 Miss. Teeranun
Puttala
I201020056 MBBS2010

2. Nuclear or sclerotic cataract

Myopic refractive shift which patients notice as an
improvement in their near vision
Decrease in distance vision, difficulty with night driving,
monocular diplopia and loss of color discrimination ability
Gradual opacification of the central portion of the lens nucleus
Age-related, involves the hardening (sclerosis) and either
yellowing or brown to black darkening (brunescense) of the
lens nucleus
3. Subcapsular cataract
Symptoms: glare and decreased visual acuity especially during
bright sunlight, but see well in dim illumination.
Signs: granular opacities in the posterior pole of cortex
adjacent to the posterior capsule.
May be age-related or occur as a complication of other
conditions such as intraocular inflammation (e.g. chronic
uveitis), steroid administration, vitreoretinal surgery and
trauma.
May also be related to irradiation and systemic conditions such
as diabetes mellitus.