GLAUCOMA lectures/Ophthalmology/GLAUCOMA.pdf · -Apoptosis of retinal ganglion cells ... Topical...
Transcript of GLAUCOMA lectures/Ophthalmology/GLAUCOMA.pdf · -Apoptosis of retinal ganglion cells ... Topical...
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GLAUCOMA
Dr Suresh KumarAssociate Professor
Department of OphthalmologyGMCH-32
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What is Glaucoma?
• Glaucoma is a progressive optic neuropathy with characteristic appearance of the optic disc and specific pattern of visual field defects , irrespective of IOP level .
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Physiology of aqueous productionCiliaryBody: Ant Pars plicata (2mm wide)
Post Pars plana (4mm wide)
Aqueous humor is actively secreated by non pigmented epithelium of ciliary processes
Trabecular Meshwork: Uveal meshworkCorneoscleral meshwork
Endothelial(juxtacanalicular)meshwok
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Pathogenesis of Sec. Glaucoma
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Outflow of aqueous
• Posterior chamber – via pupil – Anterior chamber – exits eye by 2 routes :
– Trabecular (conventional) route : 90%
– Uveoscleral (unconventional) route : 10%
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Factors determining IOP
• Rate of aqueous secretion
• Rate of aqueous outflow – difference between the IOP and episcleral venous pressure
• Normal range of IOP 11-21mm Hg
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Investigations• Visual acuity and refractive state• Slit-lamp biomicroscopy (optic disc; 90D)• Goldmann Applanation tonometry• Gonioscopy• Perimetry• OCT
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Tonometry
• Indentation tonometry : Schiotz• Applanation tonometry :
– Goldmann – Perkin– Mackey Marg – Tonopen
• Non contact tonometry : AirpuffPulsair 2000 Keeler
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• Applaanation tonometry based on Imbert-Fick principle : For an ideal, dry, thin walled sphere, pressure inside sphere (P) equals force needed to flatten its surface(F) divided by area of flattening (A) - 3.06mm Goldmanntonometry
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Angle of anterior chamber
• Formed by root of iris , anterior most part of ciliary body , scleral spur , trabecular meshwork and schwalbe line.
• Aqueous humor fills (0.25ml) of anterior chamber and (0.06ml) of posterior chamber
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Gonioscopy• Biomicroscopic visualisation of angle of
anterior chamber using goniolensTypes of Goniolens• Direct : Koeppe goniolens
Swan -Jacob• Indirect : Goldmann three mirror
Zeiss goniolensPosner and Sussman
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Angle structures
Root of irisCiliary bodyScleral spurTrabecular meshwork schlemms canal
Schwalbe line
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Grading of angle width
SHAFFER GRADING SYSTEMGrade 0 – closed angle(0)Slit angleGrade 1 – Schwalbe line(10)Grade 2 – Trabecular meshwork(20)Grade 3 – Scleral spur (25-35)Grade 4 – Ciliary body(35-45)
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Optic disc signs
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Imaging techniques
• Perimertry
• Heidelberg retinal tomograph
• Optical cohererce tomography
• Scanning laser polarimetry
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PRIMARY OPEN ANGLE GLAUCOMA
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POAG• Bilateral , not always symmetrical• Adult onset > 40 years• IOP > 21mmHg • Open angle on gonioscopy• Glaucomatous optic nerve head damage• Visual field loss• Most common 1 in 100 prevelance
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Risk factors and associations• Age : older patients >40 years• Race : black people more than white• Family history and inheritance :
Multifactoral inheritanceIst degree relatives and siblings(10%)
Myopia and DiabetesRetinal diseases : CRVO ,Rheg RD, RP
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Steroid responsiveness• Normal population divided into 3 Groups
IOP response to 6wk course of topical betamethasone
High responders(>30mmHg) 5%Moderate responders(22-30mmHg)
35%Non responders(no change) 60%
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Pathogensis of glaucoma• Ischaemic theory• Direct mechanical theory
-Increased ressistance to aqueous outflow in trabecular meshwork-Apoptosis of retinal ganglion cells-Preterminal event is calcium influx into cell body andincrease in intracellular nitric oxide
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Symptoms
• Insidious and asymptomatic• Mild headache and eyeache• Frequent change of presbyopic glasses• Delayed dark adaptation
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SignsRaised IOPDiurnal fluctuation of IOP(DVT)
Variation of6-8mmHgAsymmetry of 5mmHg in 2 eyes
Optic disc changesVertically oval cupAsymmetry of cups 0.2 bn 2 eyesLarge cupSplinter haemorrhagesPallar of NRRatrophy of retinal nerve fibre layer
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• Advanced changesMarked cupping (0.7-0.9)Thinning of NRRBayonetting signLamellar dot signPulsations of retinal arterioles
Glaucomatous optic atrophy
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• Visual field changesIsopter contractionBaring of blind spotWing shaped paracentral scotomaSeidel’s scotomaArcuate or Bjerrum’s scotomaRing or double arcuate scotomaRoenne’s central nasal stepTubular vision
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• GonioscopyNormal open angle
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Grading of glaucomatous damageMild damage : early visual field defects
MD <-6dB mild cuppingModerate damage : definite arcuate
scotoma MD <-12dB moderate thinning of NRR
Severe damage : extensive VF lossMD >-12dBMarked cupping
End-stage disease : small residual fieldMinimal residual NRR
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Treatment
• Baseline evaluation• Achive target pressure• Monitoring optic nerve and visual field
THERAPUTIC CHOICEMedical therapyArgon or diode laser trabeculoplastyFilteration surgery
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Single drug therapy
• Prostaglandin analoguesLatanoprost (0.005%)Bimatoprost (0.03%)Travoprost (0.004%)
Topical beta blockersTimolol maleate (0.25,0.5%) Betaxolol (0.5%) Carteolol (1%,2%)
Levobunolol (0.5%) Metipranolol ( 0.1%)
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• Alpha-2 agonistBrimonidine (Alphagan 0.2%)Apraclonidine (0.5%, 1%)
MioticsPilocarpine (1%,2%,3%,4%)
Topical carbonic anhydrase inhibitorsDorzolamide (2%)Brinzolamide (1%)
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Combined topical drugs
• Xalacom• Travocom• Cosopt• Timpilo• Combigan
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Systemic carbonic anhydrase inhibiters
• Acetazolamide 250-1000mg• Methazolamide 50-100mg
• Hyperosmotic agentsGlycerol (50%)Mannitol (20%)Isosorbide
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Argon or diode laser trabeculoplasty
• IndicationsAvoidance of polypharmacyAvoidance of surgeryNon compliant patient
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Trabeculectomy
• IndicationsFailed medical therapyFailed laser trabeculoplastyAdvanced diseaseUnsuitability for laser therapy
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Trabeculotomy
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Drainage devices(Tube shunts)
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Diode Laser Cyclophotocoagulation
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SWS; NF
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Direct gonioscopy
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AR Anomaly
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Traumatic Glaucoma: Hyphaema
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Lens Induced Glaucoma
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SACG
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Neovascularisation
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Pigment Dispersion
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Pseudoexfoliation
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Angle Closure Glaucoma