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Gluacoma clinical evaluation

Gluacoma clinical evaluation






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    Gluacoma clinical evaluation Gluacoma clinical evaluation Presentation Transcript

    •  Myopia- pigment dispersion, open angle glaucoma (?) Hyperopia- small disc, angle closure glaucoma
    • • Tuberous sclerosis• Neurofibromatosis• Sturge weber syndrome• TAO
    • • Juvenile xanthogranuloma• Oculodermal melanocytosis• Axenfeld rieger syndrome• Orbital varices• CCF
    •  RAPD Corectopia, ectropion uveae
    • • Black adrenochrome deposits• Conjunctival injection• Dec tear production• Foreshortening of the conjunctival fornices and scarring• Bleb• Episcleral vessel dilation• staphyloma
    • • Haab striae• PED• Microcystic epithelial edema• Krukenberg spindle• Exfoliation material• KP• Guttae• “ beaten bronze” appearance
    • • Van Herick method• Iris bombé• Heterochromia• Iris atrophy• Transillumination defects• Neovascularization• LENS – Phacodonesis – PSC
    • 1. diagnostic- identify abnormal angle structures and estimate the width of the AC2. Surgical- LTP, goniotomy Visualize the anterior chamber Eliminates tear- air interface Prevents total internal reflection
    • DIRECT GONIOSCOPY INDIRECT GONIOSCOPY Koeppe, Barkan-Hoskins,  Goldmann, Zeiss, Susman, Swan Jacob Possner done under EUA (supine)  clinic setting (sitting) may examine eye  one eye at a time simultaneously  needs slit lamp needs handheld  confusing mirror image biomicroscope, light source direct image
    •  Goldmann-  needs coupling agent  Stabilizes the globe  Clearest visualization of the AC  Useful for LTP Zeiss, Posner, Sussman-  Four- mirror goniolens  No need for coupling agent  Useful for indentation gonioscopy
    •  Koeppe  Useful for fundus exam  Useful in patients with nystagmus or irregular cornea
    •  Angular width of the angle recess peripheral iris contour Insertion of the iris root
    •  Pressure is applied to the cornea aqueous humor forced into AC  Appositional closure- (+) force opening  Synechial closure- remain closed  Partial synechial closure- partially open/ closed
    •  Scleral spur and schwalbe’s line- most consistent Superior quadrant- narrowest Inferior quadrant- widest Pigmentation- most marked in the inferior angle
    •  Faint red line in the posterior TM Episcleral venous pressure > IOP Hypotony Elevated episcleral venous pressure
    • IRIS PROCESS PAS Open and lacy  More solid or sheet-like Follows the normal  Composed of iris curve of the angle stroma Structures visible in the  Obliterate the angle open space b/n recess processes
    •  Increases with age Darkly pigmented iris PDS PES Malignant melanoma trauma Uveitis/inflammation Surgery hyphema
    • PDS PES Uniform pigmentation  Patchy pigmentation Finer pigment  (+) sampaolesi line
    •  Wide ciliary body band Increased prominence of the scleral spur Torn iris process Variation of ciliary face width and angle depth in different quadrants
    •  Early glaucomatous changes  Loss of axons,blood vessels and glial cells
    • MECHANICAL THEORY ISCHEMIC THEORY Direct compression of  Decresed optic nerve axonal fibers perfusion Distortion of the LC plates  Intraneural ischemia Interruption of axoplasmic flow Death of RGC
    • DIRECT OPHTHALMOSCOPE INDIRECT OPHTHALMOSCOPE Small pupil  Uncooperative patients, Detection of NFL media opacity, high myope No stereosopic detail  Can detect ON cupping but less pronounced with slit lamp method  Magnification- is inadequate
    •  Hruby lens, 60, 78 or 90 D lens  Can detect subtle changes in ONH  High magnification, excellent illumination, stereoscopic view  Quantitative measurement of the diameter of the disc ▪ 60D= x 1 ▪ 78D= x 1.1 ▪ 90D= x 1.3
    • 1. Generalized enlargement of the cup2. Focal enlargement of the cup3. Superficial splinter hemorrhage4. Loss of NFL5. Translucency of the neuroretinal rim6. Developmenmt of vessel overpass7. Asymmetry of cupping b/n patient’s eyes8. Peripapillary atrophy ( beta zone)
    • Cup disc ratio  Measure vertical and horizontal diameter  Large disc- large cup ▪ Eg myopia, aging, blacks  N- < 0.3  5% - 0.6  Asymmetry of >0.2 -?
    •  Notching or narrowing of the rim Inferior and superior temporal poles
    •  Linear red streak on or near the disc Usually located inferotemporally May clear over weeks to months– localized notching of rim and VF loss NTG more likely to have hges Prognostic sign for development or progression of VF loss
    •  Red- free illumination N- plush, refractile appearance Thinning, less visible Diffuse > focal
    • • Tissue between the cup and border• Orange or pink• ISNT rule• More translucent in glaucoma
    •  Alpha zone-  irregular hyper and hypopigmentation of the RPE  Temporal crescent seen in myopia  Seen in normal subjects Beta zone  Choriocapillaries and RPE loss  Choroidal vesels and sclera visible- white appearance  More common in glaucoma patients
    •  Nasalization of vessels Laminar dot sign Bayoneting Baring of circumlinear vessels Narrowing of peripapillary retinal veseels Pale and excavated cup in advanced stages
    •  Confocal scanning laser ophthalmoscopy Scanning laser polarimetry Optical coherence tomography
    •  Measures differential light sensitivity or the ability of the subject to distinguish a stimulus light from background illumination Assess the visual field 1. Identify abnormal visual field 2. Quantitative assessment of normal or abnormal fields to guide follow- up care
    •  1. short wavelength automated perimetry- blue- yellow perimetry 2. Frequency- doubling technology- uses a low spatial frequency sinusoidal grating undergoing rapid phase reversal flicker  Simulates M cells 3. Visually evoked cortical potentials and electroretinography- assess RGC function
    • KINETIC STATIC Moving stimulus of  Non moving stimuli of fixed intensity and size varying intensity Simple confrontation,  Henson, Octopus, tangent screen, Lister Humphrey perimeter, Goldmann  automated perimeter manual
    •  Traquair’s Island of vision Island of sight surrounded by sea of darkness
    •  Nasal= 60 Superior= 60 Inferior= 70 Temporal= 90 Blind spot= 10- 20 temporally
    •  Almost always localized Respects the horizontal meridian Begins nasal to the blind spot almost always detectable within the central 30 Structural loss precedes VF loss 50% RNFL loss before VF defect develops
    •  Generalized depression Paracentral scotoma arcuate-/Bjerrum scotoma Nasal step Altitudinal defect Temporal wedge
    •  Relative or absolute visual loss within 10 of fixation
    •  10- 20 from fixation
    •  Relative depression of one horizontal hemifield compared with the other
    •  Near complete loss of the superior or inferior VF Advanced GON
    • 1. Fixation2. Stimulus luminance3. Size of stimulus4. Presentation time5. Patient refraction6. Pupil size7. Wavelength of background and stimulus
    •  Numerical-  threshold for all points checked Grey scale-  decreasing sensitivity is represented by darker tones  Each change in grey scale tone is equivalent to 5 dB Total deviation-  deviation of the patient’s result from age matched controls
    •  Pattern deviation  Adjusted for any generalized depression in the overall field Probability values  P indicates the significance of the defects  < 5%, < 2%, < 1%, and < 0.5%  The lower the P- greater clinical significance
    •  Fixation losses-  indicate steadiness of gaze during the test False positives-  detected when a stimulus is accompanied by a sound  Trigger happy patients  Grey scale print out appears pale  > 33%- unreliable
    •  False negatives-  detected by presenting a stimulus much brighter than threshold at a location where sensitivity has already been recorded  Indicates inattention or tiredness  May also be an indicator of disease severity  Grey scale print out has a clover- leaf shape  > 33% unreliable
    •  Mean deviation- measure of overall field loss Pattern standard deviation- measure of focal loss or variability within the field taking into account any generalized depression in the hill of vision
    •  Miosis- decreases threshold sensitivity in the peripheral field and increases variability in the central field Lens opacities Uncorrected refractive error Lens rim Ptosis Inadequate retinal adaptation
    • 1. Optic disc less cupped than expected for the degree of VF loss2. Pallor> cupping3. Progression of VF loss is excessive4. Pattern of VF loss is uncharacteristic for glaucoma5. Location of VF loss does not correspond to the location of cupping or thinning of neural rim