Optometry

1. OPTOM.ASKAR.PK

2.  Blindness or low vision affects more than 3
million Americans 40 years and older
 This number is projected to reach 5.5 million by
2020

3.  Glaucoma is the second most common cause of
legal blindness in the US
 The leading cause of blindness among blacks
 One half of people are unaware that they have
the disease

4.  Congenital
 Open-angle glaucoma
 Primary
 Secondary
 Closed-angle glaucoma
 Normal (low) tension glaucoma

5.  Glaucoma is an optic nerve disease
 It is often associated with elevated intraocular
pressure

6.  Aqueous is produced by the ciliary body and it
circulates in the anterior portion of the eye to
help maintain a healthy eye pressure
 Aqueous must drain through the trabecular
meshwork to help maintain this eye pressure

8.  In open-angle glaucoma, there is impaired
outflow through the trabecular meshwork
leading to increased intraocular pressure.
 The increased intraocular pressure causes optic
nerve damage
 In closed-angle glaucoma, there is occlusion of
the anterior chamber angle impairing access of
aqueous to the drainage system.

9.  This is a progressive, bilateral, optic
neuropathy
 There is increased intraocular pressure (IOP>21
mm Hg)
 Not caused by another systemic or local disease
 It is the most common form of glaucoma (60-
90%)

10.  Elevated intraocular pressure
 Increased cup:disc ratio
 African American
 3-6 times more likely
 Increasing age
 Inconsistent associated factors:
 Myopia
 Diabetes
 HTN

11.  Asymptomatic
 After loss of >40% of optic nerve fibers,
patients may notice a gradual loss of peripheral
vision
 Can lead to decreased central acuity
 Difficulty functioning in dim light
 Decreased contrast sensitivity
 Glare disability
 Decreased dark/light adaptation

12.  Normal/decreased visual acuity
 Increased intraocular pressure
 Enlarged cup to disc ratio (>0.5)
 Cup to disc ratio asymmetry between two eyes
of 0.2 or more
 Highly asymmetric cup in one eye
 Optic nerve cupping
 Visual field deficits
 Optic disc hemorrhage

17.  Direct fundoscopic exam
 Tonometry
 Visual field testing

20.  Observation
 IOP checks 3-6 months
 Visual field exam 6-12 months
 Annual optic nerve evaluation
 Medical
 Topical prostaglandin analogues are now first-line
drugs given better safety profile
 Topical beta blockers used to be first line treatment

21.  Topical prostaglandin analogues
 Increase aqueous outflow
 Latanoprost (Xalantan), travopost (Travatan),
bimatoprost (Lumigan)
 Topical B-blockers
 Decrease aqueous production
 Timolol maleate (Timoptic), levobunolol (Betagan)
 Can have systemic beta blockade effects

22.  Topical alpha adrenergic agonists
 Decrease aqueous production
 Ex: alphagan
 Used as adjunctive therapy
 Topical carbonic anhydrase inhibitors
 Decrease aqueous production
 Ex: Trusopt
 Adjunctive therapy
 Topical cholinergic medication
 Increases outflow through trabecular meshwork
 Ex: pilocarpine

23.  Goal of IOP is generally 20-40% below
pretreatment pressure
 Regular aerobic exercise can help lower IOP
 If medical management fails, surgery is available
 Laser
 Trabeculoplasty
 Sclerostomy
 cyclophotocoagulation
 Surgical
 Trabeculectomy
 Glaucoma drainage implant
 Cycloablation

24.  This is an emergency!!
 If not treated immediately, damage to the optic
nerve and significant and permanent vision
loss can occur within hours
 Caused by the peripheral iris occluding the
anterior chamber angle, blocking aqueous
outflow.

26.  Blurred vision
 Eye redness
 Frontal HA
 Severe eye pain
 Colored halos around lights
 Nausea
 Vomiting

27.  IOP>30
 Mid-dilated pupil (4-6 mm)
 Sluggish reaction of pupil to direct illumination
 A shallow anterior chamber
 Hazy cornea
 Hyperemic conjunctiva

28.  An attack in predisposed persons can occur
from dim lighting or use of certain
medications:
 Dilating drops
 Anticholinergics(PSL)
 Antidepressants
 Medications such as sulfa derivatives and
Topomax can cause swelling of the ciliary body
and secondary angle closure

29.  Send to ophthalmology
 In the office can give:
 0.5% timolol maleate, 1% apraclonidine, and 2%
pilocarpine one minute apart
 Also give 500 mg tablet of acetazolamide
 These will help decrease IOP
 Eye drops should be repeated three times at 5
minute intervals

30.  Therapy is initiated to lower the IOP, reduce
pain, and clear corneal edema
 Definitive treatment is laser iridotomy
 Surgical iridectomy can be performed if laser
iridotomy is not successful.

31.  Due to local or systemic disorders
 Etiology includes
 Drug induced (ex: steroids)
 Trauma
 Tumors
 Uveitis
 Retinal disease
 Pituitary tumors, Cushing’s syndrome, thyroid dz
 Postoperative

32.  Steroids
 Most common cause
 Correlates with potency and duration of use
 30% of population develop IOP after 4-6 weeks of
topical steroid use
 Viscoelastic agents
 Used during ophthalmic surgery
 Transiently obstructs the trabecular meshwork

33.  Angle recession
 If >2/3 of the angle involved, 10% of pts will
develop glaucoma from scarring of angle structures
 Chemical injury
 Hemorrhage
 RBCs or macrophages that have ingested RBCs
obstruct the TM
 Siderosis/chalcosis
 Toxicity to angle structures from iron or copper
intraocular foreign bodies

34.  Treat increased IOP
 Laser trabeculoplasty is usually not effective
 May require trabeculectomy or glaucoma
drainage implant to lower pressure adequately
 Treat underlying problem

35.  Similar optic nerve and visual field damage as
primary open angle glaucoma but with normal
IOP (<21 mm Hg).
 Pts have a higher prevalence of vasospastic
disorders including migraine, Raynaud’s,
ischemic vascular disease, autoimmune
disease, and coagulopathies.
 Also associated with hx of poor perfusion to
the optic nerve

36.  Asymptomatic
 May have decreased vision or constricted
visual fields in late stages
 Optic nerve cupping
 Visual field defects
 Normal IOP
 Normal or decreased visual acuity

37.  Topical glaucoma medications
 FU ever 6 months with complete eye exam and
visual fields

38.  Onset of glaucoma from birth to 3 months of
age
 Incidence of 1 in 10,000 births
 Three forms
 1/ 3 is Primary
 1/3 is Secondary
 1/3 associated with systemic syndromes or
anomalies

39.  Due to developmental abnormality of the angle
with faulty cleavage and abnormal insertion of
ciliary muscle
 70% bilateral
 65% male
 Multifactorial inheritance

40.  Syptoms: light sensitivity, tearing, and
eventual opacification of the cornea
 Signs: decreased visual acuity, myopia,
amblyopia, increased IOP, corneal edema,
corneal cloudiness, conjunctival injection
 Treatment
 Medical (temporary before surgery) with glaucoma
eye drops
 Surgical
 Correct any refractive error
 Patching or occlusion therapy for amblyopia

41.  Secondary
 Due to inflammation, trauma, tumors
 Can be steroid induced, lens inducted
 Associated syndromes
 Sturge-Weber syndrome
 Neurofibromatosis
 Marfan’s
 Aniridia
 Rubella

42.  THANKUUUU