The simplest of

Ophthalmology
For medical students

Glucoma
Dr Hossam El Ayashi
M.B B.CH Ain Shams Universty

Dok Ayman Khalil

5th Year Ain Shams Universty

2011 201 2011-2012

Dr / Hossam El Ayashi

Dok Ayman Khalil

Chapter8 Chapter8 | Glucoma

A) Physiology : -The pressure inside the eye depend on the volume of its contents . -All the ocular contents are almost static from the volume point of view as: Lens , Retina , Vitreous body , Uveal tract except the aqueous humour which is a dynamic state it is always produced and drained to maintain a normal level of IOP. 1) Aqueous production : (fig 8.1) It is produced by the ciliary processes by filteration and ultra filteration from the blood vessels of ciliary processes. Its production need alpha , beta receptors and carbonic anhydrase enzyme. It starts in the posterior chamber then circulates through the pupil and then fills the anterior chamber. 2) Aqueous drainage : it is filtered through:(fig 8.2)

a)Angle of anterior chamber (80% of aqueous)

b)Uveoscleral pathway (20% of aqueous)

Trabecular meshwork ( present in the angle of anterior chamber)

Absorbed by vessels of the uveal tract or through ciliary body

Enter the canal of Schlemm

Supra choroidal space

Collector channels and aqueous veins

blood vessels of sclera

Outer surface of the sclera

Episcleral veins

Systemic circulation

3) Functions of the aqueous humour : 1) Supplies ocular tissues specially avascular parts ( the cornea and the lens) with O2 and nutrition and carries the waste products of their metabolism ( it is the lymph of the eye ) 2) Regulate the IOP.

The Simplest of Ophthalmology

| Page 2

Dr / Hossam El Ayashi

Dok Ayman Khalil

4) Intraocular pressure ( IOP) : - It ranges from 10-21 mmHg above the atmospheric pressure . -It is higher than the pressure in any other tissue in the body in order to : a) Maintain the regular shape of the globe which is essential to maintain its optical properties against the forces exerted on it by the lid and the extra ocular muscle. b) Regulate the perfusion of the ocular tissues from the capillaries .

1) Low IOP ( Hypotony )

2) High IOP

Tissue edema ( optic disc edema)

Impair tissue perfusion ( Ischemia)

Pathological changes specially in optic nerve (fig 8.3) B) Anatomy of A.C angle : (fig 8.4) It appears triangular in cross section. It formed of 5 structures : 1) Schwalbe s line : Corresponding to the peripheral thick end of Descemet's membrane of cornea. 2) Trabecular meshwork : -Uveal trabecular meshwork ( Large pores ). -Corneoscleral trabecular meshwork ( smaller pores ). -Endothelial trabecular meshwork ( Very small pores ). It is formed of connective tissue occupies the area between the Schwalbe s line and scleral spur. The perforations in each layer alternate with those in the next layer creating some resistance to aqueous drainage . It is translucent but become pigmented in ( dark races , old age , certain types of glaucoma) 3) Scleral spur : It is inward projection of inner surface of the sclera at its most anterior part. It gives attachment to the ciliary muscle posteriorly and the trabecular meshwork anteriorly. It appears as a dens white band or line during gonioscopy. 4) Part of anterior surface of ciliary body : this is the darkest part of the angle. 5) Root of the iris : As it inserts in the anterior surface of the ciliary body. Canal of Schlemm : is a circumfrential venous like channel situated at the corneo-scleral junction on the outer aspect of posterior 2/3 of the trabecular meshwork.

The Simplest of Ophthalmology

| Page 3

Dr / Hossam El Ayashi

Dok Ayman Khalil

Glaucoma
1) Definition:
Pathological increase in the I.O.P lead to pathological harmful damage to the ocular structures specially the optic nerve which lead to visual field defect so glaucoma is trait. N.B - Increase IOP +Normal optic nerve+ Normal field=Ocular hypertension. - Normal IOP + Optic nerve damage+ Field defect=Low Tension glaucoma.

2) Classification:

No (1)

Congenital(Infantile) Buphthalmos

Acquired(Adult)

Primary

Secondar Primary Buphthalmos

Secondary Buphthalmos

Primary Glaucoma

Secondary Glucoma

Narrow angle (Angle closure) congestive glaucoma

Open angle Chronic simple Non congestive glaucoma

No (2)

According to age

According to Aetiology

According to gonioscopy

Primary Glaucoma Glaucoma of Adult Congenital Glaucoma (Buphthalmos)

Secondary Glaucoma Angle Closure Glaucoma

Open angle Glaucoma

The Simplest of Ophthalmology

| Page 4

Dr / Hossam El Ayashi

Dok Ayman Khalil

A)Congenital Glaucoma (Buphthalmos)

1)Definition: Increase I.O.P due to Congenital Anomaly closing the angle.( most of cases ) 2)Aetiology:
A) Primary Buphthalmos: ( most of cases ) occurring at birth or 1-3 yrs after birth 1) Abnormal presence of mesodermal membrane called (Barkan's membrane) which obstruct Trabecular meshwork.( it is the most common cause). 2) Failure of complete separation between iris and cornea. 3) Forward insertion of the Ciliary muscle and iris root instead of scleral spure. 4) Absence of canal of schlemm. B) Secondary Buphthalmos: = any cause of 2ry glaucoma in adult + the following 1)Microphthalmos. 2)Sturge Weber syndrome( with haemangioma). 3)Marfan's syndrome. 4)Retinoblastoma.

3) Incidence:
a) Age: 80% of cases before the age of 6 months. b) Sex: more common in male . c) Side: bilateral in 75% of the case.

4) C/P: (fig 8.5 a,b) a) Symptoms: -Early: 1) Start with lacrimation. 2) Photophobia. 3 ) Blephrospasm. 4)Sneezing on exposure
To light. Due to irritation of corneal nerve by Corneal edema due to irritation of 5th nucleus which present beside vagus nucleus

With compression on the nerve by edema Pain received by 5th nerve ( Trigeminal) Then to 7th nerve (Facial) Reflex lacrimation Late : 1) Large eye 2) blue sclera 3) poor vision 4) Heazy cornea

b) Signs: i) Cornea: - in horizontal diameter( N=9.5-10.5mm) become 15mm. - in Curvature. - In transparency( hazy cornea) due to presence of Hoab. - May be blue : due to presence of water vacuoles inside the cornea so when rays fall scattered and the most scattered ray is blue because it has short wave length. ii) Sclera: Blue ( due to pigment of the uveal tract)- Stretched-Thinned.

The Simplest of Ophthalmology

| Page 5

Dr / Hossam El Ayashi

Dok Ayman Khalil

iii) Anterior Chamber: Deep due to forward bulge of elastic cornea. iv) Pupil: Dilated fixed ( non reactive). Due to optic nerve damage. v) Iris : Flattened, displaced( sub laxated). vi) Tension: Increased. vii) Optic disc ( fundus): Cupping or atrophy. Indicate optic nerve fibers damage. viii) Gonioscopy: Reveals abnormalities in the angle. ix) Refraction: Myopia due to flat and ant. Dislocation of the lens. 5) Diagnosis: ( Tetrad): a) Fundus examination first to be done to exclude Retinoblastoma. b) Gonioscopy to see the angle. ( Under general anesthesia) . c) Measurment of the IOP ( under Ketamine anesthesia). Because it does not decrease IOP while the other anesthesetic agents decrease IOP. d) Measurement of corneal diameter.( under general anesthesia).

6) D.D:
Nasolacrimal duct obstruction

1) lacrimation ( watering of the eye) Ophthalamia Neonatrum (conjunctivitis) -Ve test Buphthalmos

1)Regurge Test: 2) Signs

+Ve test

-Ve test

a) Lid edema. b) Injection of eye. c) Discharge.

Absent

2) Megalocornea 3) Big Eye Enlargement of cornea Buphthalmos -Increase in corneal diameter. See the Signs -Fundus: normal. -Gonioscopy: normal. -No corneal opacity. blunt trauma or rubella 5) Opacities of cornea 4)Blue sclera -Congenital. See sclera Myopia -Retinoblastoma. -Buphthalmos. -Megalocornea. Buphthalmos

- opaque cornea( vertical) - not in lower 1/2 -not branched

- Horizontal,, - in lower 1/2 - branched

7)Complications of Buphthalmos: 1)Loss of vision due to optic atrophy. 2)Decrease of vision due to Complicated cataract,,Subluxation of lens Bilateral Nystigmus,,Unilateral ambylopia,,Axial myopia. 3)Recurrent glaucoma. 4)Susitability to trauma. 8) Treatment:

The Simplest of Ophthalmology

| Page 6

Dr / Hossam El Ayashi
a) In early cases: 1) Corneal diameter is <13mm. 2) IOP <33mmHg. 3) Corneal condition:

Dok Ayman Khalil

Clear

Hazy

1)Goniotomy
1/3 or 1/2 of the angle incised using a special knife to connect the canal of schelem with ant.chamber.

2)Trabeculotomy
-Metal probe is inserted in the canal of schelem -then rotate the probe to cut through the trabeculum and connect the canal to ant.chamber

b) In Late cases: 1) Corneal diameter is >13mm. 2) Fail goniotomy or trabeculotomy

3) Filtering ( External Fistulizing Trabeculotomy) operation

e.g Sub-scleral trabeculotomy in Children there is a greater tendency to closure of the fistula due excessive conjunctival scarring . this controlled by the local use of antimetabolites(5 fu,,mitomycin) at the time of the surgery

4) Shunt Tube( Glaucoma device)

Used only in cases of failure of repeated trabeculectomies

The Simplest of Ophthalmology

| Page 7

Dr / Hossam El Ayashi
Stages of Glaucoma
Prodromal stage Acute congestive stage (fig 8.6 a ) 1) sudden total angle closure. 2) IOP =50mmHg which cause temporary paralysis of sphincter pupillae( ischemia) 3) 50% of cases give a history of previous prodromal attack

Dok Ayman Khalil

Chronic stage

Absolute stage

1)occur as a result of rapid(partial) closure and reopening of the angle. 2)IOP = 45mmHg. 3)Preceded by Precipitating factors. 4) there is closed opening of Vortex veins.

Most of cases follow acute phase or prodromal stage

1) It is complete irreversible 2) It is the end of any uncontrolled glaucoma.

Symptoms 1) Frontal headache. 1) Sever frontal headache. 2) Eye ache. 2) Sever eye ache due to 3) Blurred vision. Stretch of corneal nerves. 4) Transient impaired of 3) Vomiting from sever pain Vision. (reflex vagus stimulation) 5) Colored halos due to 4) Rapid decrease of vision Collected of water in due to corneal edema and Cornea and act as a prism retinal nerve ischemia. analyzing the white light into its compartment wave length. Signs 1) During attack: - Increase IOP. - Corneal edema. 2)Gonioscopy: - narrow angle. - Iris bombi. 3) Provocative tests: its Idea depend on papillary Dilatation. a)Pharmacological test: (mydratic test) -IOP is measured. -weak mydratic added (phenyl ephrine 5%) -Remeasured IOP after Pupil dilated. -Result: if the difference between 2 reading is 8mmHg or more. It indicate increase IOP. - it is diagnostic test b) Physiological test: (Dark room test) Method,result as above.

Resembling POAG

Painful blind eye

1) eye Lid: edema. 2) Conjunctiva: Ciliary congestion. 2) Cornea: -Bullae 3) Cornea: Hazy. 4) Ant.chamber: shallow. 5) Iris: bombi. 6) Pupil: -semidilated. -irreactive. this due to temporary paralsis of sphincter muscle. -vertically oval. 7) IOP > 50 mmHg. 8) The eye is stony hard on digital assessment of ocular tension. 9) DD: 2ry angle closure glaucoma. there is presence of keratopercipitates.

1) IOP: -High in some. -Hypotonic:IOP<10mmHg due to atrophy of Cilia. body. (Bullous keratopathy) Resembling rupture of bullae lead to POAG Ulcer. Degenerative pannus. due to deposition of ca 3) Ant.chamber: shallow 4) Iris: -atrophic patches Lead to iris shortening -ectropion uvea: due to ischemia of atrophic iris lead to extensive fibrosis 5) Lens: complicated cataract 6) Fundus: optic atrophy Total disc cupping 7) Sclera: staphyloma

The Simplest of Ophthalmology

| Page 8

Dr / Hossam El Ayashi
Prodromal stage Treatment 1) During attack: -Pilocarpine 2%(miotic) to get the iris away from The angle. -Pilocarpine 1% Prophylactic is given to other eye. 2) After attack: -Bilateral peripheral Iridectomy -Bilateral laser iridectomy b) Carbonic anhydrase inhibitors: they decrease IOP by aqueous secretion at ciliary body. e.g Acetazolamide 250mg 2 tablets are given initially Then 1 tablet/6h. c) Miotics: start to act only when IOP is lowered so that the temporary sphincter paralysis is relieved. e.g Pilocarpine 2% d) Beta blockers: decrease the aqueous secretion. e.g Timolol Meleate 0.5% eye drops twice/day Acute congestive stage

Dok Ayman Khalil

Chronic stage Absolute Glaucoma

1) During attack: the patient must be hospitalized -medical preparation for surgery a) Hyper osmotic agents: They are most effective drugs They raise the osmotic pressure of the plasma this lead to draw water out of the eyes. e.g. Mannitol rapid IV drip 1-2gm/Kg.

1) If there is PAS: (peripheral ant. Synechia) -Filtering surgery. 2) If there is no PAS: -Peripheral iridectomy . 3) Prophylactic iridectomy for other eye.

1) Enucleation. 2) Defunctiong operation 3) Peripheral irridectomy for other eye.

2) After attack: using Gonioscopy a) If there is > 50% of the angle open: - Peripheral irridectomy or Laser irridectomy . b) If there is > 50% of the angle closed: - Filtering surgery( Fistulizing operation) c) Prophylactic Irridectomy to the other eye

The Simplest of Ophthalmology

| Page 9

Dr / Hossam El Ayashi

Dok Ayman Khalil

Primary Open Angle Glucoma

( Chronic simple, Compensated, glaucoma simplex) (POAG)
1)Definition: It is a primary glaucoma resulting from decrease in outflow of aqueous through the trabecular Meshwork although the angle is open and looks normal result in increase of IOP lead to damage of optic nerve which result in visual field defect. 2)Incidence: - It is the commonest type of glaucoma the incidence is 2% of general population.
- It is usually bilateral and asymmetrical. - No sex predilection. M=F.

3) Risks:
1) More common in high myopes the incidence is 15%. 2) More common in eyes with retinitis pigmentosa , Fuch s endothelial dystrophy, Diabetes Mellitus, systemic hypertension, Steroids responders. 3) Age: from middle age to old age. 4) Race: black race. 5) Large optic disc cap.

4) Pathogenesis:
- Site of pathology: may be at the endothelium lining Sclemms Canal or its adjoining part of the trabeculum. - The high IOP damage the retinal nerve fibers

Mechanical theory
by direct pressure on the retinal nerve fibers. - Degeneration and atrophy of these fibers result in Characteristic optic cup and visual changes.

Ischemic theory
by compression on the capillaries Interfering perfusion.

5) Clinical Picture: A) Symptoms:

1) It is Symptom less because of the following: Sensory nerves are adapted to the slowly rising IOP so there is no pain or headache. 2) Field defects are usually of negative type( not felt by the patient) ,the visual acuity remains normal till very late stages when the macular fibers are affected. 3) In many cases the disease discovered when one eye is lost. 4) It is common discovered accidentally in patients attending ophthalmic clinics for other reasons e.g Changing glasses. 4) Some cases suffered from: -Delayed dark adaptation from lowered retinal sensitivity caused by ischemia. -Pathological presbyopia: due to weakness of Ciliary muscle and usually progresses faster than the physiological one. -Decreased sensitivity to the light: Patient notices that he need stronger illumination to see around satisfactorily. -Headache and blurring of vision.

The Simplest of Ophthalmology

| Page 10

Dr / Hossam El Ayashi
B) Signs: The diagnostic features are: 1) Changes in IOP. 3) Changes in field of vision.

Dok Ayman Khalil

2) Changes in Optic disc. 4) Open angle.

1) Changes in IOP:
-Patients with typical POAG have IOP > 21mmHg. - In eyes with borderline IOP the following tests may be helpful: A) Diurnal variations:- in most normal eyes IOP changes through out the day being usually highest in early morning then decrease gradually by the massaging effect of extraocular muscles. In normal eyes diurnal variation does not exceed 4mmHg. This is due to the effect of corticosteroids in the body ( circadian rhythm of cortisone). - A high diurnal variation is highly suspicious of glaucoma.

B) Difference between the two eyes: if IOP in one eye exceed the other by more than 4mmHg
this is highly suspicious of glaucoma

C) Provocative tests: ( water drinking test) if the patient is asked to drink one liter of water or
large amount of coffee on an empty stomach if there is rise of IOP of 5mmHg or more indicates impaired function of the angle because the normal angle can deal with increased aqueous secretion by increasing aqueous drainage.

2) Changes in optic disc and fundus:

- by examination of nerve fiber layer of the retina using red-free illumination there is defects can be seen and detected even before visible changes in optic disc appear -The normal cup/disc ratio (C/D ratio) varies from 0.0 to 0.3 and depends on the volume of nerve fibers in relation to the size of the scleral foramen. In glaucoma due to atrophy of the fibers, cupping of the nerve occurs in the form of increase in C/D ratio accompanied by deepening of the cup. The cup become large its shape vertical or oval. -Detected by Binocular ophthalmoscopy: - Pallor of the disc . -Nasal shifting of central retinal vessels. - Kinking and undermined retinal blood vessels. - Mechanism:- Mechanical theory: increase IOP lead to backward displacement of lamina cribrosa. - Vascular theory: sclerosis of disc blood vs lead to optic nerve fiber atrophy.

3) Changes in the field of vision:

- Damage to nerve fiber layer of retina in glaucoma tend to involve bundles of fibers resulting in corresponding defects in visual field - The arcuate fibers coming from the temporal retina above and below the papillo macular bundle are the most susceptible to damage by glaucoma. -while the macular fibers are usually the last to suffer. - Field defects in glaucoma start as relative defects and then become absolute in advanced cases. - Normally Scotomata ( blind spot) are usually of the negative( objective) type.

Evaluation of field changes is done by:

1) Static perimeters: (e.g Octopus) which evaluate the sensitivity numerically in each point of the field examined. 2) Kinetic perimeter: (e.g Goldmann perimeter or Bjerrum screen) Used in glaucoma or neurological lesions. Detect the central or peripheral changes Used for follow up. Prognostic Used only in glaucoma. Detect the central changes. Used for early detection . Diagnostic.

The Simplest of Ophthalmology

| Page 11

Dr / Hossam El Ayashi
6)The clinically significant field changes are:

Dok Ayman Khalil

-Central field changes are: (detected by Bjerrum screen).(fig. 8.6b)

a) Baring of blind spot : mean that it become enlarged. It may occur in early the disease but not Specific for the glaucoma. b) Isolated paracentral scotoma: detected in early glaucoma. c) Siedle scotoma: enlargement of paracentral scotoma and fused together with blind spot. d) Arcute scotoma: which arches from blind spot above and not beyond the horizontal meridian. e) Double arcute ( Annular scotoma + Ronne step).: due to fusion of double arcute scotoma may be open nasaly to peripheral field.( peripheral breakthrough).

-Peripheral field changes are: ( detected by Gold man perimeter).

1) The field defects enlarged peripherally and centrally that may end in a Temporal island or Tubular field . 2) Both fields above are disappear end by complete blindess.

7) Management:
A) Medical Treatment: -The initial treatment of POAG is medical for life. - Success of medical treatment means that the IOP is lower to a level which prevents any further deterioration in the appearance of the fundus or in the field of vision. - Regular follow up is an essential step of treatment and should continue for life. - A glaucoma controlled by medical treatment may later on become out of control.. -The members are: ( BBs , Miotics, Adrenaline, Carbonic anhydrase inhibitor). 1) Beta Blockers: ( It is the drug of choice , Expensive) - Mechanism:It decrease IOP by decrease aqueous secretion .( aqueous formation) - Forms: Used in the forms of eye drops.e.g Timolol maleate 0.25 , 0.5% Betaxolol . - Dose: Used once or twice / day.( it is better compliance) - Advantages: 1) Do not alter papillary size. 2) Suitable for all types of glaucoma. - Complication : due to systemic absorption. a) Dry eye so should be taken with artificial tears. b) Decrease in heart rate 3) Bronchospasm. - Contraindication: 1) Heart failure. 2) Heart block. 3) Bronchial spasm. 2) Miotics: ( It is the most effective drug , the Cheapest, the Oldest). - Mechanism of action: ( aqueous formation and aqueous drainage) a) Miosis: -Widening of the angle.( an effect useful only in acute congestive glaucoma) - Strech of the iris increasing its surface and widening the iris crypts available for absorption of aqueous. b) Contraction of ciliary muscle - pulls on the scleral spur widening trabecular meshwork pores. - compress the blood vessels going to ciliary processes decrease aqueous secretion - Side effects: a) The miotics used 4 times / day ( Bad compliance ). b) Miosis : Dimension of vision especially at night and especially in patients with central corneal or lens opacities c) Ciliary muscle contraction : headache and myopic shift. d) May enhance the formation of posterior synechia and anterior cortical cataract.. e) Miotic cysts: Cysts might form at the papillary border.

The Simplest of Ophthalmology

| Page 12

Dr / Hossam El Ayashi

Dok Ayman Khalil

3) Adrenaline or epinephrine( 0.5-2%): ( aqueous Drainage ) Mechanism: Lower IOP by increasing aqueous out flow ( adrenergic effect). Dose: twice/day. Forms: Dipivalyl adrenaline: which are free of systemic side effects as headache and arrhythmias. 4) Carbonic anhydrase inhibitors: ( aqueous formation) Forms: -Tablets: Acetazolamide ( Diamox) 250mg. -Drops: 2-3 times/day not produced side effect , not effective as systemic so used with. other anti glaucoma drugs Side effects of tablets. 1) Parathesia( tingling and numbness) most common. 2) GIT upset and abdominal cramps. 3) Renal stones. 4) Impotence. B) Surgery (or Laser trabeculoplasty) : is indicated in cases of : 1) Failure of maximum medical treatment to lower IOP to a level which stops the deterioration 2) Intolerance to medical treatment. 3) Non compliance of the patient. 4) Patients unable to come for regular follow up. Laser trabeculoplasty: Application of scattered laser burns to the trabecular meshwork It reduce the IOP by 8-10 mmHg but transient. Glaucoma surgery: 1)External Fistulizing ( Filtering) operation: The idea: is to create a passage ( fistula) at the limbus for aqueous to pass to subconjunctival space to be absorbed by blood vs of the conjunctiva and episclera. 2) Defunctioning operation: -These procedures are used only in 1) blind eyes ( absolute glaucoma) in which the filtering surgery is dangerous. 2) Cases of neovascular glaucoma. The idea: Reducing IOP by partial destruction of the ciliary body ( cyclo-destructive procedures) and this lead to decrease the aqueous formation . this is achieved either by: a) Freezing the ciliary body: ( cyclo-cryo-thermy): it is most popular form is done. b) Partial destruction of ciliary body by using laser ( cyclo-photo- coagulation) either applied directly or through the sclera.

The Simplest of Ophthalmology

| Page 13

Dr / Hossam El Ayashi

Dok Ayman Khalil

Primary angle closure glaucoma (Closed angle glaucoma) (Narrow angle, decompensated , congestive glaucoma)
1) Definition: It is increase of IOP due to sudden closure of the angle (Partial or Complete) by peripheral iris. 2) Characters: Bilateral but one eye precede the other eye. 3) Aetiology:

Predisposing Factors

Precipitating Factors

Local Narrow angle as in

General

Pupillary dilatation 1) Mydriatics. Emotion 2) Excitiment. 3) Prolong stay in dark ( small eye) in which the lens

Ciliary congestion

Old age > 35 yrs

Hypermetrope Due to increase in lens thickness pushing the iris and causing the shallowing of ant. chamber and narrowing of the angle

Sex F>M 4:1

Age > 35 Yrs

Nervous individuals there is imbalance between sympathetic and parasympathetic tone Lead to unstable vasomotor reaction

Ciliary body congestion With pushing iris forward ( Iris bombe)

4) Iris Forms:
Iris Bombi ( more common) in the eye with narrow angle there is tight apposition of iris to the lens lead to pupillary block result in traps of aqueous in post.chamber so dilatation of pupil lead to relaxation of iris so the trapped aqueous will push the iris root forward lead to angle closure ( do Peripheral iridectomy) Iris Crowdening in which the root of dilated iris is crowded in the angle lead to angle occulosion.

The Simplest of Ophthalmology

| Page 14

Dr / Hossam El Ayashi
5) Comparison between 1ry open and closed angle glaucoma: 1ry closed angle glaucoma 1) Incidence 2) age 3) Sex 4) Patient 5) Eye 6) Cause 7) Prodroma 8) Symptoms 9) ttt Less common > 40 yrs old More in female Nervous Hypermetrope Angle closure Present Marked Surgical

Dok Ayman Khalil

1ry open angle glaucoma more common > 50 yrs old Male = Female Any Any Trabecular sclerosis Absent Few Initially Medical then surgical if medical failed

The Simplest of Ophthalmology

| Page 15

Dr / Hossam El Ayashi

Dok Ayman Khalil

Red Eye
- It is common problem that is encountered by every physician . - It may signify a mild problem or a serious vision threatening problem that need management.

Conjunctivitis

Keratitis

Uveitis

Angle closure Sub conj. glaucoma hemorrhage

A) Symptoms 1) Blurred vision

Improve with blinking due to presence of discharge on ocular surface no pain but - gritty sensation - mild irritation

____

____

_____

_______

2) Pain

present

present

present

______

3) Photophobia
(abnormal sensitivity to the light)

_____

___

Iritis alone or 2ry to corneal Inflammation

______

_____

4) Colored halos

present due to corneal edema present The lids stuck together on walking present present ______

5) Discharge

_____

_____

____

_____

6) Itching 7) Watering
(Excessive tearing)

_____ present _____

_____ present _______ present

____

_____

8) Cosmetic disfiguration

_______

present

The Simplest of Ophthalmology

| Page 16

Dr / Hossam El Ayashi
Conjunctivitis Keratitis Uveitis

Dok Ayman Khalil

Angle closure glaucoma Sub conjunctival hemorrhage

B) Signs 1) decrease visual acuity

2)Ciliary injection

_____

Present

Present

Present

_____

_____ Present

Present ______

Present ___

Present _____ ______

3) Conjunctival Congestion 4) Corneal haze

5)Corneal epithet - lial disruption

______ ______

______ present by fluorescein test

_____ ______

Present ________

_____ ______

6) Pupillary Abnormalities

_____

___

- small due to reflex spasm of iris sphincter -distorted by Post. synechia ____

-oval with wider vertical diameter -sluggish in reaction

___

7) Ant.Chamber depth 8) IOP 9) Discharge

____

______

shallow

____

___ present Purulent : bacterial Serous : viral. Scanty white elastic in allergic conj. -adenoviral conj. -Parinaud oculoglandular syndrome -Upper respiratory tract infection disorder with fever. ( Adenovirus 3 , 7) -Seasonal rhinitis with hay fever ( allergic conj.)

___

___

Elevated

___

____

____

____

___

10) LNs Enlargement

____

____

____

___

C) Systemic associated

____

-D.M -Hypertension. -Blood disease

The Simplest of Ophthalmology

| Page 17

Dr / Hossam El Ayashi

Dok Ayman Khalil

2ry Glaucoma
Definition: It is increase of IOP 2ry to local eye disease. Site of disease: (cornea ant. chamber-iris-lens-intraocular tumors-drugs-trauma-neovascular glaucoma)
The disease of ocular part 1) Cornea a) Infective corneal ulcer ( open angle glaucoma) b) Local adherent + ant. staphyloma which lead to peripheral ant. synechia (PAS) ( Closed angle glaucoma) c) Corneal fitula: after closure lead to PAS ( Closed angle glaucoma) 2) Ant. Chamber normally ant.chamber clear with no presence of any cells or solid particles. Presence of them called(seedling A.C) a) -Hypopyon: Pus in A.C. ( open angle glaucoma). -Hyphema: blood in A.C. ( open angle glaucoma). b) Epithelial cyst: cause pupillary block lead to accumulation of aqueous in post.chamber which elevate the iris lead to closure of angle( closed angle glaucoma) c) Angle recession glaucoma. ( open angle glaucoma) a)Acute iritis: (iridocyclitis) due to presence of hypopyon (open angle glaucoma) b) Chronic iritis: due to seclusiopupillae or occlusiopupillae.(closed angle glaucoma) c) Early rubeosis: Neovessels formed on iris which rupture lead to hge glaucoma.( open angle glaucoma) (fig 8.7) d) Late rubeosis: due to P.A.S (closed angle glaucoma) Management -Atropine.-Antibiotic-Carbonic anhydrase Inhibitor(C.A.I) Keratoplasty + Trabecullectomy

same

1) C.A.I 2)Paracentisis 3)Semi setting

-Cryotherapy (freezing) destruction of ciliary body -Trabeculectomy - C.A.I- Atropine- Steroid -Iridectomy + Trabeculectomy - beta blocker + Gonio-photocoagulation

3) Iris

- Cyclocryotherapy

4) Lens

a) Phacomorphic glaucoma: due to pupillary block ttt of lens condition: remove it ( closed angle glaucoma) b) Phacolytic glaucoma: (open angle glaucoma) c) Ant. Dislocation : due to pupillary block (closed angle Gl) because the aqueous will accumulate and elevate the iris against angle (Glaucoma inversus) . d) Post. Dislocation: due to pupillary block by the vitreous ( open angle glaucoma) . e)Sublaxation: due to iritis ( open angle glaucoma) f) Glaucoma capsulature: part of the lens capsule exfoliated which block the angle. (Pseudoexfolation gl) (open angle glaucoma) g) Aphakic glaucoma: it is increased IOP following cataract extraction due to 1) post operative iritis 2) post operative hyphema 3) pupillary block by the vitreous 4) steroid induced glaucoma h) Micro spherophekia and traumatic cataract

The Simplest of Ophthalmology

| Page 18

Dr / Hossam El Ayashi
5) Retinal causes:

Dok Ayman Khalil

ttt: Enucleation

a) Diabetic Retinopathy and central retinal vessels occlusion. Cause: due to retinal ischemia lead to release of vasogenic factor result in rubeosis iridis or vitreous hge. b) Retinal detachment surgery. Causes: due to 1) Tight scleral buckle. 2) Intraocular injection of gases or silicon oil. 3) Steroid ttt. 6) Intraocular tumors: lead to glaucoma by many ways: a) Direct invasion of the angle in anterior tumours. b) Pushing the iris lens diaphragm forward. c) In loose tumours as in Retinblastoma the malignant cells might rich the ant. Chamber and block the trabecular pores. d) In Rapidly growing tumours might consume most of blood supply creating a state of ischemia (neovascular glaucoma). e) In Rapidly growing tumours there is extensive tumours necrosis lead to toxic iridocyclitis and 2ry glaucoma. f) Acting as a space occupying lesions. g) Pressure on vortex veins lead to vascular engorgement. 7) Drugs: - Steroids: (open angle glaucoma) due to: a) Decrease the aqueous out flow due to deposition of macrophage precipitates in the trabecular meshwork. b) Increase the aqueous formation due to salt and water retention. - Mydriatics: dilate the pupil and push root of iris toward the angle. (closed angle glaucoma). 8) Trauma: which lead to a) Hyphema. b) angle recession glaucoma. 9) Neovascular glaucoma: (fig 8.8) the angle closure is caused by new vessels or hge from ruptured vessels. 10) Miscellaneous : a) Cavernous sinus thrombosis. b) Micro spherophakia. c) Pigmented glaucoma.( occur in young persons with high myopes of dark coloured races) due to deposition of the pigment liberate from the iris in the angle.

The Simplest of Ophthalmology

| Page 19