association of glaucoma and cornea

1. GLAUCOMA
&
CORNEA

2. Introduction
• Cornea Primary
Glaucoma Secondary
• Glaucoma Primary
Cornea Secondary

3. CORNEA PRIMARY
GLAUCOMA SECONDARY

4. Cornea Primary
Glaucoma Secondary
• Developmental disorders
• Keratitis / Keratouveitis
• Dystrophies
• Trauma - Chemical Injury
• Post Keratoplasty
• Post LASIK

5. DEVELOPMENTAL
DISORDERS

6. Developmental Disorders
• Peter’s anomaly
• Sclerocornea
• Aniridia
• Axenfeld-Rieger Syndrome

7. Peter’s anomaly
• Called anterior chamber
cleavage syndrome
• Type I – normal lens
• Type II – abnormal lens
• Microphthalmos, myopia,
aniridia, cataract
• Glaucoma occurs in 50%
eyes

8. Axenfeld
• Anteriorly displaced and prominent
Schwalbe’s line (posterior embryotoxon)
• 50% eyes develop glaucoma that occurs
due to the anterior segment dysgenesis

9. Axenfeld

10. Reiger Anomaly
• Midperipheral iris
adhesions to cornea
• Pupillary distortions
• Microcornea or
macrocornea possible

11. KERATITIS / KERATOUVEITIS

12. Keratitis / keratouveitis
• Interstitial keratitis
– Mechanism is concomitant iridocyclitis, open
angle and closed angle mechanisms
– Multiple iris cyst may form causing angle
closure in a few cases

13. Keratitis / keratouveitis
• Herpetic Keratouveitis
– 28% had IOP raised, 10% had glaucoma
damage

14. Keratitis / keratouveitis
• Zoster Keratouveitis
– Sectoral iris atrophy and mutton fat KPs

15. DYSTROPHIES

16. Dystrophies
• ICE Syn.
• PPMD
• Fuch’s Endo. Dys.

17. ICE syndrome
• Primarily a corneal endothelial disease
• A clinical spectrum of disease earlier
thought to as distinct clinical entities
• Progressive iris atrophy
• Chandler syndrome (most common)
• Cogan Reese Syndrome

18. ICE syndrome

19. ICE syndrome
• Female predilection
• Reduced VA
• Pain
• Iris abnormalities
• Corneal edema
• Angle abnormalities
• Glaucoma

20. Progressive iris atrophy
• Corectopia, atrophy, Hole formation
• MC to cause glaucoma

21. Chandler Syndrome
• Typical corneal edema

22. Cogan Reese Syndrome
• Nodular pigmented iris lesions along with
other features

23. Glaucoma in ICE

24. Glaucoma in ICE

25. Glaucoma in ICE
Campbell’s Membrane theory

26. PPMD
• Blisters or vesicles at DM level
• Glaucoma caused due to
– iridocorneal adhesions (not related to
severity)
– High insertion of uveal tissue

27. PPMD
• PAS varieties
– Without membrane
– With IT or IC apposition
– Bridging open TBM
• KP to be avoided until absolutely
necessary as high chances of failure and
recurrence
• Mx to include exam for renal dis.,
hearing loss and hernias

28. Fuch’s
• Reduced cell densities have been
reported in association with ocular
hypertension, angle-closure glaucoma,
exfoliative glaucoma, and
glaucomatocyclitic crisis
• ACG more a/w Fuch’s due to axial
hyperopia and shallow ACs

29. Fuch’s
• Glaucoma incidence is less in Fuch’s
• Topical CAIs to be avoided

30. GLAUCOMA IN CHEMICAL
BURNS

31. Glaucoma in Chemical Burns
• Complex pattern of IOP - Immediate rise
then hypotony then late IOP elevation
• More common after alkali burns
• More accurate measurement with
pneumatic or MacKay Marg

32. Glaucoma in Chemical Burns
• Stage wise mx
– Early rise
• due to scleral shrinkage and release of active
substances
• Beta blockers, Alpha agonists, CAIs, Hyperosmotics
– Intermediate rise
• Due to inflammation
• Aqueous suppressants, cycloplegics and
hyperosmotics, steroids
– Late rise
• Trabecular damage, PAS or intraocular scarring
• Standard medical or surgical rx

33. POST KERATOPLASTY

34. Post Keratoplasty
• Glaucoma is leading cause of irreversible
vision loss post KP
• Important cause of graft failure
• Glaucoma patients have low endothelial
counts already to begin with
– Both in open and closed angle
– More so in Pxf patients

35. Post PKP
• Post PK OHTN incidence is 5.5%-47.9%
• Higher ocular surface disease in
glaucoma pts.
• Keeping donor corneal size 0.5mm larger
does not seem to affect IOP
• Oversizing the graft is protective in
aphakic eyes

36. Types
• Closed angle 59%
• Steroid induced 21%
• Open angle 11%
• Angle recession 3%
• Aqueous misdirection 3%
• Unknown 3%

37. Risk Factors
• Recipient age older than 60 years
• Aphakia
• Preexisting glaucoma (60%cf.15%)
• Adherent leukoma
• Bullous keratopathy
• Herpetic keratitis
• Trauma
• Keratoconus
• Associated vitrectomy (4x)
• Anterior segment reconstruction (4x)
• Repeated transplants

38. • Mechanism of Open angle glaucoma post
KP is really elusive
• Steroid use – 11-35%
• Angle distortion
• Collapse of TBM
• Inflammation
• Retained OVD
• Vitreous prolapse in angle

39. Graft survival
• ~58% cf. ~80% in without glaucoma
• Increased rate of endothelial loss post sx
• Risk category as per indication of PK
– Low
• Keratoconus, stromal dystrophies
– Moderate
• Fuch’s and Herpetic infection
– High
• ABK/PBK, Trauma, ulcers, perf. and ICE

40. • Tonometry more reliable with McKay
Marg, Tonopen, iCare cf. Goldmann or
Perkin's
• For managing, Sihota et al report
– Med rx 51.9%
– Filter sx 29.1%
– Cyclodest. 19%

41. Medical rx
• Avg IOP reduction of 8.7mm Hg on
switching patients to Cyclosporine A
• Topical dorzolamide may cause
irreversible damage to endothelial cells
• Beta Blockers – surface changes,
epithelial toxicity

42. Medical rx
• Pilocarpine – increases blood aqueous
barrier permeability
• Latanoprost – ant uveitis, CME, herpetic
flare up
• Alpha agonists – dry eye and allergic
reactions

43. Surgical rx
• Success without MMC vs with MMC –
25% to 73%
• No diff in IOP control or graft failure
between Trab with MMC (76.5%), tube
shunt (80%) or Cyclophotocoagulation
(63.6%)
• Higher rate of rejection in surgical rx
group

44. Surgical rx
• Higher rate of graft survival and good
IOP control with combined trab and PK
cf. Trab then followed by PK
• Higher graft survival for tube after PK cf.
concurrent or prior to PK (3.8 to 4.7
times)
• Tube placement in AC or vitreous cavity
comparable IOP control

45. Surgical Rx
• Laser trabeculoplasty is promising
• A reported success even after 150
degree PAS

46. Post DALK
• 0-17% incidence
• Acute elevation up to 36% patients
• All DALK patients could be managed with
medical management alone in a study

47. With EK
• 0 to 15% cases
• Mechanisms
– pupillary block related to the air bubble
– obstruction of the trabecular meshwork
resulting from long-term steroid use
– PAS formation
• Prior sx makes it more difficult in
keeping complete AC gas fill to support
EK, increased EK graft dislocation in
perioperative period

48. With EK
• Post DSAEK
– 30-54% incidence
– Pre-existing glaucoma doubles the risk of
Post DSAEK glaucoma exacerbation
– Twice the relative risk of rejection
– Concurrent gonio-synechiolysis is a risk
factor

49. With EK
• Post DMEK
– 6.5–12.1%
• Laser PI is recommended prior to
endothelial keratoplasty
• Some even prefer to do an inferior PI
• Air bubble ≤80% of AC volume is
recommended

50. With Keratoprosthesis
• Incidence before pro implantation ranges
40-76%
• Post op incidence ~15%
• AS-OCT helpful to determine angle status
post sx
• IOP measurement is very unreliable
• Most surgeons rely on digital palpation

51. With Keratoprosthesis
• Implantation of GDD at time of
prosthesis sx is suggested
• Given uncertainty of absorption of topical
medications with OOKP, systemic
medications and surgery are generally
preferred

52. Investigations post KP
• Corneal surface irregularities and
astigmatism post sx limit the usefulness
• FDT has been shown to be independent
of topographic changes

53. POST LASIK

54. Post LASIK
• PISK Pressure induced stromal
keratitis
• Similar to DLK but with raised IOP
• Suspect when keratitis does not respond
to or becomes worse even after
escalating steroids

55. GLAUCOMA PRIMARY
CORNEA SECONDARY

56. Glaucoma Primary
Cornea Secondary
• Pressure induced changes
• Exfoliation induced endothelial change
• Drug induced changes

57. PRESSURE INDUCED
CHANGES

58. Cornea Properties and IOP
• Applanation tonometry is related to
elasticity of the cornea
• Low Corneal Hysteresis is a/w
glaucomatous VF damage and optic
nerve defects
• CH may be strongly a/w glaucoma
diagnosis, risk of progression and
effectiveness of rx

59. Haab’s Striae

60. Acute ACG

61. Exfoliation Syndrome
Significantly lower than
normal cell density

62. Drug induced changes
• Mean CCT increased after Dorzolamide
treatment
• In susceptible individuals, there may be
clinically significant corneal edema
• Ocular surface abnormalities

63. Drug induced changes
• Timolol (BKC) a/w SPK & corneal
anesthesia, OCP
• PG not to be used in post HS keratitis

64. References
• Becker & Schaffer, 8th edition
• Shield’s, 6th edition
• Corneal Transplantation and glaucoma,
Haddadin et al, Seminars in Ophthalmology,
2014;29(5-6):380-396
• Glaucoma following corneal replacement,
Baltaziak et al, Survey Ophthalmology 2017
• Corneal properties and Glaucoma, Gaspar et al,
Arq Bras Oftalmol.2017;80(3):202-6