גלאוקומה

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גלאוקומה

  1. 1. Glaucoma Basics Greifner Gabriel, MD Hadassah Medical Center
  2. 2. Glaucoma: What do I want to know The aim of today’s lecture is to:1.Know what glaucoma is2.Be able to identify a patient with glaucoma3.Know what the basic work up is4.Have some familiarity with visual fields5.Have some familiarity with ONH imaging6.Have a basic understanding of medical rx7.Have some familiarity with surgical and laser Rx
  3. 3. Glaucoma: What we will cover1.Definition of glaucoma 1.Definition 2.Risk factors 3.Epidemiology2.Diagnosis of glaucoma 1.IOP 2.Gonioscopy 3.ONH appearance 4.HVF appearance 5.ONH Imaging
  4. 4. Glaucoma: What we will cover3.Different types of glaucoma 1.Open Angle Glaucoma Primary Secondary: Pseudoexfoliation Pigment dispersion Steroid induced Uveitis induced Ghost cell glaucoma Raised EVP Lens induced Trauma induced
  5. 5. Glaucoma: What we will cover2.Angle Closure Glaucoma Primary Secondary Neovascular glaucoma Lens induced Tumor induced ICE
  6. 6. Glaucoma: What we will cover4.Treatment of glaucoma Medical Surgical Laser Incisional
  7. 7. Glaucoma: Definition Glaucoma represents a diverse group of eye conditions that share either the common feature of progressive optic neuropathy (open angle variant) or the common feature of occludable drainage angles in the anterior chamber (closed angle varient).
  8. 8. Glaucoma: DefinitionRisk Factors Elevated intraocular pressure is the most important risk factor for glaucoma. Other risk factors include: -Increasing age -Family history -Race -Myopia -Diabetes Mellitus? -Hypertension?
  9. 9. Glaucoma: DefinitionEpidemiology American data: Prevalence: (no. of instances at a given time): Caucasions-------------2.4% (over age 49) African-Americans--- 4.2%
  10. 10. Glaucoma: What we will cover1.Definition of glaucoma2.Diagnosis of glaucoma1.IOP2.Gonioscopy3.ONH appearance4.HVF appearance5.ONH imaging
  11. 11. Glaucoma: Diagnosis- IOP Intraocular pressure (IOP):-Normal range between 9-21mmHg, but no absolute cut off-Methods of checking IOP:1.Goldmann (gold standard)2.Tonopen3.Schiotz tonometer4.Puff tonometer
  12. 12. Glaucoma: Diagnosis- IOP Intraocular pressure (IOP):-Methods of checking IOP: 1.Goldmann (gold standard)
  13. 13. Glaucoma: Diagnosis- IOP Intraocular pressure (IOP):Goldmann (gold standard): The tonometer is a biprism mounted on a standard slit-lamp, which is used to applanate (flatten) the cornea. The IOP calculation is based on the Imbert - Fick principle, whereby an external force (exerted by the tonometer) against a sphere (the eye) equals the pressure within the sphere times the area flattened by the force (3.06 sq. mm of the cornea).
  14. 14. Glaucoma: Diagnosis- IOP Intraocular pressure (IOP):Unusually thick or thin corneas or irregular corneas can generate errors in IOP readings.CCT (microns)Adjustment for Measured IOP mmHg445+7 515+2 585-3455+6 525+1 595-4465+6 535+1 605-4475+5 545-0 615-5485+4 555-1 625-6495+4 565-1 635-6505+3 575-2 645-7
  15. 15. Glaucoma: Diagnosis- IOP Intraocular pressure (IOP):Goldmann (gold standard):
  16. 16. Glaucoma: Diagnosis- IOP1.Goldmann (gold standard)
  17. 17. Glaucoma: Diagnosis- IOP Methods of checking IOP:1.Goldman2.Tonopen:
  18. 18. Glaucoma: Diagnosis- IOP Methods of checking IOP: 1.Goldman 2.Tonopen:The Tonopen is also an applanation device with a very small “footprint” on the cornea, which makes it easier to use with corneal abnormalities. Since the patient can be done lying or sitting, it is also useful when the patient cannot sit positioned properly at the slit lamp.
  19. 19. Glaucoma: Diagnosis- IOP Methods of checking IOP:1.Goldman2.Tonopen:
  20. 20. Glaucoma: Diagnosis- IOP Methods of checking IOP:1.Goldman2.Tonopen:3.Schiotz:
  21. 21. Glaucoma: Diagnosis-IOP Methods of checking IOP: 1.Goldman 2.Tonopen: 3.Schiotz:A form of indentation tonometry, a preset weight is placed on the tonometer which is placed on the anaesthetized cornea. The amount that the plunger sinks into the eye is measured off the scale, and the reading converted to mm Hg reading a conversion table. The further the weight sinks in (the greater the scale reading) the softer the eye (lower IOP). This method is frequently used in emergency departments where applanation tonometry is not available
  22. 22. Glaucoma: Diagnosis-IOP Methods of checking IOP:1.Goldman2.Tonopen:3.Schiotz:
  23. 23. Glaucoma: Diagnosis- IOP Methods of checking IOP:1.Goldman2.Tonopen:3.Schiotz:4.Puff tonometry:
  24. 24. Glaucoma: Diagnosis- IOP Methods of checking IOP: 1.Goldman 2.Tonopen: 3.Schiotz: 4.Puff tonometry:Noncontact (or air-puff) tonometry does not touch your eye but uses a puff of air to flatten your cornea. This type of tonometry is the least accurate way to measure intraocular pressure.
  25. 25. Glaucoma: Diagnosis- IOP Methods of checking IOP:1.Goldman2.Tonopen:3.Schiotz:4.Puff tonometry:
  26. 26. Glaucoma: What we will cover1.Definition of glaucoma2.Diagnosis of glaucoma 1.IOP 2.Gonioscopy 3.ONH appearance 4.HVF appearance 5.ONH imaging
  27. 27. Glaucoma: Diagnosis-Gonioscopy Gonioscopy:A method of viewing the anterior chamber angle.The angle cannot be directly viewed due to total internal reflectionA contact lens is required to neutralize the corneal refractive power and see the angle structures.
  28. 28. Glaucoma: Diagnosis-GonioscopyGonioscopy:
  29. 29. Glaucoma: Diagnosis-Gonioscopy Gonioscopy:
  30. 30. Glaucoma: Diagnosis-GonioscopyGonioscopy:
  31. 31. Glaucoma: Diagnosis-GonioscopyGonioscopy:
  32. 32. Glaucoma: Diagnosis-Gonioscopy Gonioscopy: Gonioprisms/technique
  33. 33. Glaucoma: Diagnosis-Gonioscopy Gonioscopy:-Angle open or closed-Neovascularization-Pigment
  34. 34. Glaucoma: What we will cover1.Definition of glaucoma2.Diagnosis of glaucoma 1.IOP 2.Gonioscopy 3.ONH appearance 4.HVF appearance 5.ONH imaging
  35. 35. Glaucoma: Diagnosis-ONH appearanceThe optic nerve is the collection of the axons ofthe retinal ganglion cells.The optic nerve consists of 700k-1.2millionganglion cell axonsFrom each RGC, a single axon extends into theRNFLThe outer rim of the optic nerve consists ofthese RGC axons. The more axons there arethe thicker the rim.
  36. 36. Glaucoma: Diagnosis-ONH appearance
  37. 37. Glaucoma: Diagnosis-ONH appearance At the ONH all the axon fiber bundles turn to exit the eyeball thru the posterior scleral foramen. In the posterior scleral canal the ON received collagenous extensions from the surrounding sclera that forms the lamina cribrosa
  38. 38. Glaucoma: Diagnosis-ONH appearance The optic nerve consists of an outer rim of retinal ganglion cell axons inner cup: cup to disc ratio is approximately 0.3 (range of 0.1- 0.4). The shape of the rim depends on: 1.The size of the ON 2.Direction of ON as it enters the eye 3.The number of RGC fibers Thus the fewer the RGC axons, the thinner the rim
  39. 39. Glaucoma: Diagnosis-ONH appearance The average cup to disc ratio is approximately 0.3, with a normal range of 0.1-0.4. Rim width greatest inferiorly>superiorly>nasally>temporally (ISNT)
  40. 40. Glaucoma: Diagnosis-ONH appearance Signs of glaucomatous optic nerve changes: 1.Concetric cup enlargement 2.Temporal cup enlargement 3.Focal cup enlargement (notch) 4.ONH asymmetry 5.Disc homorrhages
  41. 41. Glaucoma: Diagnosis-ONH appearance Signs of glaucomatous optic nerve changes:1.Concetric cup enlargement
  42. 42. Glaucoma: Diagnosis-ONH appearance Signs of glaucomatous optic nerve changes:2.Temporal cup enlargement
  43. 43. Glaucoma: Diagnosis-ONH appearance Signs of glaucomatous optic nerve changes:3.Focal cup enlargement (notch)
  44. 44. Glaucoma: Diagnosis-ONH appearance Signs of glaucomatous optic nerve changes:4.ONH Asymmetry
  45. 45. Glaucoma: Diagnosis-ONH appearance Signs of glaucomatous optic nerve changes:5.Disc hemorrhage
  46. 46. Glaucoma: What we will cover1.Definition of glaucoma2.Diagnosis of glaucoma 1.IOP 2.Gonioscopy 3.ONH appearance 4.HVF appearance 5.ONH imaging
  47. 47. Glaucoma: Diagnosis-HVF appearanceThe visual field is an assessment of the patientsperipheral vision.It can be assessed in several ways: 1.Static perimetry----------- Humphrey visual field 2.Kinetic perimetry----------Goldmann
  48. 48. Glaucoma: Diagnosis- HVF appearance Humphrey visual field:- The most commonly used technique- Sita (Swedish interactive threshold algorithm) is the gold standard.
  49. 49. Glaucoma: Diagnosis-HVF appearance Humphrey visual field:
  50. 50. Glaucoma: Diagnosis- HVF appearance Humphrey visual field: The printoutTest taking parameters Gray scale Mean deviation (MD) Pattern standard deviation (PSD) Total deviation Pattern deviation
  51. 51. Glaucoma: Diagnosis-HVF appearance Typical Visual Field Changes: Nerve fiber bundle defects Nasal step Paracentral Scotoma Temporal Wedge
  52. 52. Glaucoma: Diagnosis-HVF appearance Typical Visual Field Changes: Nerve fiber bundle defects
  53. 53. Glaucoma: Diagnosis-HVF appearance Typical Visual Field Changes: Nasal step
  54. 54. Glaucoma: Diagnosis-HVF appearance Typical Visual Field Changes: Paracentral scotoma
  55. 55. Glaucoma: What we will cover1.Definition of glaucoma2.Diagnosis of glaucoma 1.IOP 2.Gonioscopy 3.ONH appearance 4.HVF appearance 5.ONH imaging
  56. 56. Glaucoma: Diagnosis-ONH imagingONH imaging -Stereo photographs -Optical Coherence Tomography (OCT) RNFL -Heidelberg Retinal Tomograph (HRT) -GDx (Scanning laser polarimetry)
  57. 57. Glaucoma: Diagnosis-ONH imaging ONH imaging-Stereo photographs Photographs of the optic nerve taken several degrees off angle and viewed through a stereo viewer.
  58. 58. Glaucoma: Diagnosis-ONH imaging ONH imaging -Optical Coherence Tomography/RNFL:“RNFL thickness” measures the thickness around the optic nerve head along three high density (256 Ascans/line) circular scans of 3.4mm in diameter, acquired one at a time.It measures the thickness by assessing the degree of interference of a given illuminating light. The thicker the tissue the greater the interference.
  59. 59. Glaucoma: Diagnosis-ONH imaging ONH imaging-Optical Coherence Tomography/RNFL:
  60. 60. Glaucoma: Diagnosis- ONH imaging-OCT/RNFL:Rnfl thickness chartSector averagesQuadrant averages OD/OS graph Tabular data
  61. 61. Glaucoma: Diagnosis-ONH imaging ONH imaging -Heidelberg Retinal Tomograph (HRT):The HRT uses a diode laser to sequentially scan the retinal surface in a 15x15 degree field, up to 64 optical sections. It then uses confocal scanning principals to measure the amount of light relfected form each scanned point, and thus creates a topographic image.
  62. 62. Glaucoma: Diagnosis-ONH imaging ONH imaging-Heidelberg Retinal Tomograph (HRT):
  63. 63. Glaucoma: Diagnosis- ONH imaging -Heidelberg Retinal Tomograph Topography image Reflection imageHoriz and vert height Mean height contourprofiles graph Stereometric analysis MRA graphed results
  64. 64. Glaucoma: Diagnosis-ONH imaging ONH imaging-GDx (Scanning laser polarimetry):An optical imaging technique based on the birefringence of the RNFL. Laser polarized light is refracted by the RNFL, resulting in two refracted rays. One of the rays travels with the same velocity along the optical axis of the tissue while the other ray travels with a velocity that is dependant on the propagation direction within the tissue. The distance of separation between the two rays increases with increasing tissue thickness.
  65. 65. Glaucoma: Diagnosis-ONH imaging ONH imaging-GDx (Scanning laser polarimetry)
  66. 66. Glaucoma: Diagnosis- ONH imaging-GDX:Fundus imageThickness map Parameter Table: TSNIT avg Superior AvgDeviation map Inferior Avg TSNIT SD Inter-Eye Symmetry NFI TSNIT map
  67. 67. Glaucoma: What we will cover1.Definition of glaucoma 1.Definition 2.Risk factors 3.Epidemiology2.Diagnosis of glaucoma 1.IOP 2.Gonioscopy 3.ONH appearance 4.HVF appearance 5.ONH Imaging
  68. 68. Glaucoma: What we will cover3.Different types of glaucoma 1.Open Angle Glaucoma Primary Secondary: Pseudoexfoliation Pigment dispersion Steroid induced Uveitis induced Ghost cell glaucoma Raised EVP Lens induced Trauma induced
  69. 69. Glaucoma: What we will cover2.Angle Closure Glaucoma Primary Secondary Neovascular glaucoma Lens induced Tumor induced ICE
  70. 70. Glaucoma: ClassificationGlaucoma can be divided into two varieties:Open angleNarrow angle
  71. 71. Glaucoma Classification Glaucoma Open angle Closed angle Primary Secondary Primary Secondary -Pigment Dispersion -Pseudoexfoliation -Pupillary Block -Neovasc. -Iritis Acute Lens induced FuchsNormal Tension Chronic Tumor Posner Schlossman High Tension Inflamm. Idiopathic Plateau ICE Raised EVP Malignant Gl -Trauma CB Swelling Ghost Cell CRVO Steroid induced SB Lens Induced PRP Phacolytic Nanophthalmos Lens Particle Phacoanaphylaxis -Tumor induced Pigment/Cells/NVA Direct invasion
  72. 72. Glaucoma: What we will cover3.Different types of glaucoma 1.Open Angle Glaucoma Primary Secondary: Pseudoexfoliation Pigment dispersion Steroid induced Uveitis induced Ghost cell glaucoma Raised EVP Lens induced Trauma induced
  73. 73. Glaucoma: Classification-POAG POAG:Definition: open angle with no secondary causeOn Gonioscopy:wide open angle with no gross pathologyCupping of ONHThinning of retinal NFLVisual Field: -Typical changes: Arcuate nasal step paracentral scotoma temporal wedge
  74. 74. Glaucoma: Classification-POAG POAG:
  75. 75. Glaucoma: Classification-POAG Normal Tension Glaucoma Same anatomical findings as POAG associated with thin cornea Disc hemorrhages more common HVF: loss close to fixation = paracentral scotoma
  76. 76. Glaucoma: Classification-POAG POAG: Normal Tension Glaucoma-Disc hemorrhages
  77. 77. Glaucoma: Classification-POAG POAG: Normal Tension Glaucoma-paracentral scotoma:
  78. 78. Glaucoma: What we will cover3.Different types of glaucoma 1.Open Angle Glaucoma Primary Secondary: Pseudoexfoliation Pigment dispersion Steroid induced Uveitis induced Ghost cell glaucoma Raised EVP Lens induced Trauma induced
  79. 79. Glaucoma: Classification PseudoexfoliationAnatomical / Clinical Features: Cornea: Pigment deposition Lens: XFM on anterior capsule, phacodonesis Iris: XFM at pupil border peripupillary TID pupil: Poor dilation Gonioscopy: Sampaolesi line (pigment anterior to Schwalbe’s line, and abnormally irregular, heavy TM pigment, narrow angle Asymmetry often Systemic disease
  80. 80. Glaucoma: Classification-PseudoexfoliationLens: PXF deposition
  81. 81. Glaucoma: Classification-PseudoexfoliationIris: XFM at pupil margin
  82. 82. Glaucoma: Classification-PseudoexfoliationGonioscopy, Sampaolesi’sline
  83. 83. Glaucoma: Classification- Pigment Dispersion SyndromeEpidemiology: 20-50yo Males>Females, Males get glaucoma at younger age Myopic (Moderate) 30-50%of pts with PDS go on to develop glaucoma
  84. 84. Glaucoma: Classification- Pigment Dispersion SyndromeAnatomical / Clinical Features: Wide swings in IOP leading to halos, blurring of acuity esp with exercise or pupil dilatation Cornea: Krukenberg spindle Iris: mid-peripheral TID Gonioscopy: Posterior (concave) bowing of iris, 360 degree band of pigment in TM
  85. 85. Glaucoma: Classification- Pigment Dispersion SyndromeMechanism: Posterior bowing of the iris Pigment granules being rubbed by zonules Pigment harmful to epith of TM leading to their death Beams then clogged with pigment that blocks openings. (Campbell)
  86. 86. Glaucoma: Classification- Pigment Dispersion SyndromeCornea: Pigment- Krukenberg spindle
  87. 87. Glaucoma: Classification-Pigment Dispersion SyndromeIris: Transillumination defects: TID’S
  88. 88. Glaucoma: Classification-Pigment Dispersion Syndrome Gonioscopy: Dense TM pigment
  89. 89. Glaucoma: Classification-Pigment Dispersion SyndromeGonioscopy: Posterior iris bowing
  90. 90. Glaucoma: QUIZ
  91. 91. Glaucoma: QUIZ
  92. 92. Glaucoma: QUIZ
  93. 93. Glaucoma: QUIZ
  94. 94. Glaucoma: Classification- Steroid inducedEpidemiology: Response to dexamethasone 0.1% topically 4x/day for 6 weeks: 50% of general population will respond: 95% of glaucoma patients are steroid responders 5% of general population IOP rise of --- 15mmHg 30% --------------------------------------------- 5-14mmHg 65% -----------------------------------------------5mmHg Increased incidence of glaucoma responders in glaucoma relatives, diabetics, high myopia
  95. 95. Glaucoma: Classification-Steroid inducedAnatomical/Clinical Features: Usually after at least two weeks of steroid treatment. May be seen after a very short duration of treatment. May be associated with topical, depot, or systemic steroids. Also seen with periocular skin ointments. Weaker steroids cause less of a response than stronger ones May mimic NTG because is ‘burnt out’ high pressure glaucoma Anatomically identical to POAG
  96. 96. Glaucoma: Classification-Uveitis inducedIritis may either lower or raise IOP.HSV associated iritis usually raises IOPImportant to balance uveitis control with steroidresponse.Subtypes of uveitis induced: Posner Schlossman Fuchs
  97. 97. Glaucoma: Classification- Uveitis Induced Posner Schlossman:Anatomical / Clinical Features: Symptoms of slight ocular discomfort, blurred vision, halos lasting Several hours to weeks. Usually self limited attacks. Some pts go on to OAG and VF loss even in fellow eye Minimal physical findings Conj: Mild ciliary flush Cornea: Mild corneal epithelial edema with few fine KPs Iris: Early segmental iris ischemia Anterior chamber: Occasional faint flare Gonioscopy: Open angle with no PS IOP: 40-60mmHg coinciding with duration of uveitis with return to normal between attacks Mechanism unclear with either inflammation of TM or elevated aqueous production secondary to elevated aqueous levels of prostaglandins
  98. 98. Glaucoma: Classification-Uveitis InducedFuchs Heterochromic Iridocyclitis Onset in third or fourth decade Male = Female 87% Unilateral, glaucoma develops in 13% of u/l cases and 33% of b/l Cornea: Colorless, stellate KPs throughout cornea Iris: Heterochromia (lighter iris on side with Fuchs) Gonioscopy: Blood vessels in angle (cause bleed during CE and paracentesis) Mild iritis, minimally responsive to steroids Cataract High percentage with Choriretinal scars
  99. 99. Glaucoma: Classification-Uveitis InducedFuchs Heterochromic Iridocyclitis
  100. 100. Glaucoma: Classification-Uveitis InducedFuchs Heterochromic Iridocyclitis
  101. 101. Glaucoma: Classification-Uveitis InducedFuchs Heterochromic IridocyclitisStellate kps
  102. 102. Glaucoma: Classification-Ghost Cell GlaucomaThree months post vitreous hemorrhage(trauma, DM, other etiology)Usually history of surgery establishing aconnection between anterior and posteriorchambers
  103. 103. Glaucoma: Classification-Raised Episcleral Venous PressureAssociated pathology:CCFSturge Weber syndrome (sporadic, no known inheritance)Retrobulbar tumorsThyroid ophthalmopathyOrbital varicesImportant history:Trauma?Thyroid diseaseSturge Weber (may be masked cosmetically or with laser)
  104. 104. Glaucoma: Classification-Raised EVPAnatomical / clinical features: Face: Port-Wine stain Conj/episclera: Dense episcleral vascular plexus Gonioscopy: Blood in Schlem’s canal, congenitally anomalous appearing angle (Sturge Weber) Choroid: Hemangioma (Sturge Weber)
  105. 105. Glaucoma: Classification-Raised EVP Face: Port-Wine stain
  106. 106. Glaucoma: Classification-Raised EVPDilated/enorged episcleral vessels
  107. 107. Glaucoma: Classification-Raised EVPGonio: Blood in SC
  108. 108. Glaucoma: Classification-Raised EVPChoroid: Tomato Ketchup fundus
  109. 109. Glaucoma: Classification-Lens InducedClassification:opened angle: Phacolytic (Lens protein) glaucoma Lens particle glaucoma Phacoanaphylaxisclosed angle: Phacomorphic glaucoma
  110. 110. Glaucoma: Classification- Lens InducedPhacolytic (Lens protein) glaucoma: intact capsule. Leakage of lens proteins from hypermature cataract. Wrinkling of anterior lens capsule Macrophages and lens proteins block TM Exam shows elevated IOP, conj
  111. 111. Glaucoma: Classification-Lens InducedPhacolytic (Lens protein) glaucoma:
  112. 112. Glaucoma: Classification-Lens InducedLens particle glaucoma: break in capsule (cataract surgery trauma) cortical/inflammatory cells clogging TM. Degree of inflammation is between that of phacolytic and phacoanaphylactic Associated with PS, PAS, inflammatory membranes Rise in IOP ----shortly after the inciting event
  113. 113. Glaucoma: Classification-Lens InducedLens particle glaucoma:
  114. 114. Glaucoma: Classification-Lens InducedPhacoanaphylaxis (rare): following penetrating trauma/surgery sensitization to own lens proteins resulting in granulomatous uveitis. Usually associated with lens material (nucleus) in the vitreous. chronic, relentless, granulomatous uveitis. latent period between inciting event and rise in IOP
  115. 115. Glaucoma: What we will cover3.Different types of glaucoma 1.Open Angle Glaucoma Primary Secondary: Pseudoexfoliation Pigment dispersion Steroid induced Uveitis induced Ghost cell glaucoma Raised EVP Lens induced Trauma induced
  116. 116. Glaucoma: Classification- Trauma inducedMechanisms: 4-9% of those with angle recession greater that 180 degrees Related to angle recession scarring of the TM Significant percent with angle recession glaucoma will develop bilateral disease Elevated IOP may be seen without other obvious damage associated iritis, hyphema, dislocated lens,
  117. 117. Glaucoma: Quiz
  118. 118. Glaucoma: Quiz
  119. 119. Glaucoma: What we will cover3.Different types of glaucoma 1.Open Angle Glaucoma Primary Secondary: Pseudoexfoliation Pigment dispersion Steroid induced Uveitis induced Ghost cell glaucoma Raised EVP Lens induced Trauma induced
  120. 120. Glaucoma: What we will cover2.Angle Closure Glaucoma Primary Secondary Neovascular glaucoma Lens induced Tumor induced ICE

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