پاتو فیزیو لوژی گلوکوم اطفال دکتر علی صالحی
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Transcript of پاتو فیزیو لوژی گلوکوم اطفال دکتر علی صالحی
اطفال گلوکوم لوژی فیزیو پاتو
علیصالحی دکتر
Types of Glaucoma
• Open-Angle Glaucoma• Angle-Closure Glaucoma• Normal-Tension Glaucoma (NTG)• Congenital Glaucoma• Secondary Glaucoma• Pigmentary Glaucoma• Pseudoexfoliative Glaucoma• Traumatic Glaucoma• Neovascular Glaucoma• Irido Corneal Endothelial Syndrome (ICE)
Congenital Or Infantile Glaucoma
• Primary congenital, or infantile, glaucoma is elevated
intraocular pressure with onset in the first year of
life.
• It occurs in about 1 out of 10,000 births and results
in blindness in approximately 10% of cases and
reduced vision (worse than 20/50) in about half of all
cases.
• approximately 70% of cases are bilateral.
• Although diagnosis is made in only 25% of
affected infants at birth, disease onset occurs
within the first year of life in more than 80% of
cases.
Pediatric glaucomas• Constitute a heterogeneous group of diseases that may
result from an intrinsic disease or structural
abnormality of the aqueous outflow pathways
(primary glaucoma)
• Or from abnormalities affecting other regions of the eye
(secondary glaucoma).
• A variety of systemic abnormalities are also associated
with pediatric glaucoma.
Systemic diseases with Glaucoma
• Aniridia
• Marfan's syndrome
• Sturge-Weber syndrome
• Neurofibromatosis
• Down's syndrome
• Steroid therapy, including inhaled steroids for
asthma and nasal steroids for allergies .
causes• Genetic (e.g. congenital glaucoma, infantile
glaucoma, juvenile glaucoma) • Following cataract surgery (aphakic glaucoma) • Due to ocular inflammation (iritis) • Trauma • Malformations of the eye (Axenfeld-Rieger,
aniridia , Peters anomaly) • Diseases which affect the rest of the body
(Sturge-Weber Syndrome, Lowe Syndrome, congenital rubella)
Aniridia
Axenfeld anomaly
Peters anomaly
• Primary congenital glaucoma typically presents in
the neonatal or infantile period with the classic
triad of epiphora, photophobia, and
blepharospasm.
• Corneal clouding from microcystic edema can occur,
accompanied by gradual enlargement of the
corneal diameter. As the edema extends through
the corneal stroma, breaks called Haab striae can
occur in Descemet’s membrane.
Congenital Glaucoma (Primary Congenital Glaucoma)
Clinical Findings
• Progressive corneal edema with breaks in
Descemet’s membrane (Haab striae)
• Elevated IOP, typically non-sedated between 30
and 40 mmHg
• Corneal enlargement
• The normal intraocular pressure is lower in
infants and young children than adults.
• A newborn has an average intraocular pressure
of 10-12 mm Hg, increasing to 14 mm Hg by age
7 or 8 years of age.
• An asymmetric measurement or an elevated
measurement in the presence of other clinical
signs helps make the diagnosis of glaucoma.
General Pathology
• Primary congenital glaucoma may represent an
arrest of the normal development of the anterior
chamber.
• The iris and ciliary body have an anterior insertion
with an open angle.
• The trabecular meshwork is present and appears
patent, but the trabecular beams are thickened and
the deeper tissues appear compressed.
• The disease is more common in males, typically is
bilateral, and does not have a racial or geographic
preference.
• Most cases are sporadic, but there is an autosomal
recessive(AR) inheritance pattern either autosomal
dominant (AD) for some cases.
• (GLC3A locus on chromosome 2p21).
Risk Factors
• The only known risk factors are genetic
consanguinity and affected siblings.
• The risk of congenital glaucoma in the second
child is approximately 5%, and the risk increases
to 25% with two affected siblings.
Diagnosis
• The diagnosis of primary congenital glaucoma
can often be made clinically, even without an
accurate measurement of intraocular pressure.
The hallmark of the disease, however, is an
elevated intraocular pressure in the absence of
other conditions that can cause glaucoma,
such as Axenfeld-Reiger syndrome or aphakia.
• . 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.
Differential diagnosis
• The differential diagnosis depends on the major
presenting symptom.
• For the classic triad of epiphora, photophobia, and
blepharospasm, the differential diagnosis includes:
nasolacrimal duct obstruction
• conjunctivitis
• corneal abrasion
• and uveitis.
• For corneal clouding and edema, the differential diagnosis
includes :
• congenital corneal dystrophies
• birth trauma with tears in Descemet’s membrane keratitis
• congenital ocular anomalies like sclerocornea or Peters
anomaly or
• storage disesases like mucopolysaccharidoses or cystinosis
• For corneal enlargement, the differential diagnosis includes :
• high axial myopia and megalocornea.
• For optic nerve cupping the differential diagnosis includes:
• physiologic cupping
• optic nerve coloboma
• optic nerve atrophy
• optic nerve hypoplasia
• an optic nerve malformation
Prognosis
• Glaucoma that presents from 3-12 months of age has a
favorable prognosis, with 80-90% of cases achieving
good control of intraocular pressure with angle surgery.
• The vision loss in children is multifactorial and does not
depend exclusively on the health of the optic nerve.
• Affected children can develop significant myopia
from axial elongation of the globe,
• astigmatism from unequal enlargement of the
cornea, corneal scarring
• Even dislocation of the lens from excessive anterior
segment enlargement.
• Correction of the refractive error and aggressive
treatment of associated amblyopia and/or
strabismus is required to maximize visual outcome.
• Visual acuity is worse than 20/50 in at least 50%
of cases.
• This condition is bilateral in about two-thirds of
patients
• occurs more frequently in males (65%) than in
females (35%).
Pathophysiology
• The basic pathologic defect in PCG remains
controversial.
• Barkan originally proposed a Thin, imperforate
membrane that covered the anterior chamber
angle and blocked aqueous outflow.
• By age 1 year, normal corneal diameter is
10-11.5 mm
• a diameter greater than 12.5 mm suggests
abnormality.
• Glaucoma should be suspected in any child
with a corneal diameter greater than 13 mm.
Medical therapy
• Medical therapy for primary congenital glaucoma
is typically used as an adjunct to surgery.
• Oral carbonic anhydrase inhibitors include
acetazolamide (Diamox 10-20 mg/kg/day divided
into 3 or 4 doses) and methazolamide (Neptazane
5-10 mg/kg QID).
• Side affects include weight loss, lethargy, and
metabolic acidosis.
• Topical carbonic anhydrase inhibitors include
dorzolamide 2% (Trusopt) and brinzolamde 1% (Azopt)
drops TID.
• These medications may produce less reduction in
intraocular pressure than oral carbonic anhydrase
inhibitors, but also appear to have fewer systemic side
affects.
• Beta-blockers (timolol or equivalent) can also be
given topically, usually using a lower starting
concentration of 0.25% drops BID. Side affects
include:
• respiratory distress, caused by apnea or
bronchospasm, and bradycardia.
• A combined beta-blocker/carbonic anhydrase
inhibitor (Cosopt) drop BID has been shown to
be effective in reducing intraocular pressure in
children requiring more than one topical
medication.
• Prostaglandin analogs latanoprost 0.005%
(Xalatan), travoprost 0.004% (Travatan), and
bimatoprost 0.03% (Lumigan) have been
effective in reducing intraocular pressure,
although use is discouraged in the presence
of inflammatory condition
• Miotic agents (pilocarpine, echothiophate) and
adrenergic agents (epinephrine, dipivefrin) are
not usually effective.
• The alpha2-adrenergic agonist brimonidine
(Alphagan) is contraindicated in children under
age 2 because of potentially serious lethargy,
hypotonia, hypothermia, and CNS depression.
Medical follow up
• Primary congenital glaucoma requires lifelong
serial measurements of intraocular pressure,
corneal diameter, refractive error, and optic
nerve cupping.
• Any change in medical regimen should be
followed in 1-2 weeks to assess the efficacy of
the new treatment regimen.
Surgical follow up
• In the short term, these patients require frequent follow
up to monitor for infection or excessive inflammation.
Long term, just like patients on medical therapy, these
patients require serial measurements of intraocular
pressure, corneal diameter, refractive error, and optic
nerve cupping. If an adequate assessment of the clinical
response is not possible in the outpatient clinic, an
examination under anesthesia can be performed.
Complications
• The most common complication after surgery is
poor control of intraocular pressure.
• The success rate for angle surgery is approximately
80% after 1 or 2 procedures, while the other
procedures report a success rate of 33-80%.
پزشکان چشم خیریه انجمناصفهان
سوره در آیه خداوند ستایشکسانی 274بقره بهانفاق آشکار و نهان و روز و شب در که پرداخته
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« فلهم وعالنیه سرا والنهار بالیل اموالهم ینفقون الذین
یحزنون الهم و والخوفعلیهم ربهم عند اجرهم
و نهان و روز، و شب در را خود های دارایی که کسانی
پروردگارشان نزد پاداشآنان کنند، می انفاق آشکارا،
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علیم؛ وسع الله و یشاء لمن یضعف
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بیمار هیچ درمان که روزی امید بهبه مالی بضاعت عدم دلیل به چشمی
نیافتد .تاخیر
خیام از زیبا :رباعی
که خورم آن غم کی تا
نه یا دارم
خوشدلی به عمر وین
نه یا گذارم
که باده قدح کن پر
نیست معلوم
بر برم فرو که دم کاین
نه یا آرم
. و راست کره نیم هستش انسان مغز شبیه گردو مغزچپ . کره نیم
. خوردگی چین حتی مغز پایین و مغز باالی قسمتو های
کورتکسمیباشد . نئو شبیه هم اون های پیچیدگیگردو که میدانیم حاضر حال نورونهای ۳۶در مرتبه
رسان پیام . گسترشمیدهد را مغز به
• بد غذای یک شما اگر
باشید خورده را طعم
غذای یک طعم میتوانید
کنید درک را خوب
زندگی تلخیهای از پس،
بتوانید تا درسبگیرید
کنید درک آنرا
قلبهستشو شبیه خوشه روی انگور های حبهاون دونه هر
. نشون تحقیقات امروزه خونی سلولهای شبیهکه داده
. مفیده بسیار قلب حیات برای انگور
میکنید نیم دو وسط از رو فرنگی گوجه وقتیو قرمزه که میبینید خونه تا چهار
و قرمزه هم اون قلبهستشکه مثل دقیقاداره . بخشمجزا تا چهار
رو خون فرنگی گوجه که داده نشون تحقیقاتمیکنه . تصفیه
. و مردمک است انسان چشم شبیه شده حلقه هویجکه نوری خط و عنبیه
. میباشد انسان چشم مانند درست میرسد چشم بهمیدهد نشان تحقیقات
در خون افزایشجریان باعث مصرفهویج که . میشود چشم عملکرد
انسان ... کلیه شبیه درسته کردین؟ دقت قرمز لوبیا به ح7اال تا
هست .
کلیه عملکرد بهبود در قرمز لوبیا که داده نشون تحق7یقات
داره نقشبسزایی
نوع این و است استخوان به کرفسشبیه ساقهسبزیجات از
. میباشد موثر بسیار استخوان استحکام درشده تشکیل استخوانها
کرقسهم ٪۲۳از و داره . ٪۲۳سدیم سدیمچنانچه
کرفس نداره وجود سدیم غذاییشما رژیم درکنه جبران رو کمبود این میتونه
برایسالمت بادمجان و گالبی و آوکادوخانمها در رحم سرویکسو
. نشان تحقیقات امروزه میباشد موثر بسیارخانمها اگر که میدهد
نمایند مصرف آوکادو عدد یک هفته درمیشود متعادل آنها هورمونهای
جالبه . و میکند جلوگیری رحم سرطان بروز ازبدونید ماه ۹که
طول آن میوه رسیدن تا آوکادو کردن شکوفه ازمیکشه .
افزایش باعث هستشکه دونه از پر انجیرو تعداد
از جلوگیری همچنین و مرد اسپرم حرکتمیشود . شدن عقیم
تخمدان عملکرد و سالمت به زیتونمیکند .کمک
های غده شبیه مرکبات انواع و پرتقال و فروت کریپ7و هستند شیری
موثر سینه در لنفاوی غدد جنبش7 و سینه سالمت7 دراست7 .
. امروزه میباشد بدن سلولهای شبیه پیاز
است داده نشان تحقیقات
بدن در زائد مواد خروج در نقشمهمی پیاز که
و داراست را
مخاطی الیه شستشوی ریزشاشکو باعث
. میگردد چشم