glaucoma patient evaluation

1. EVALUATION OF A GLAUCOMA
PATIENT
Presented by
Dr. (Maj.) Rashed
F.C.P.S Part-II Trainee
CMH Dhaka

2. Introduction
 Glaucoma refers to a group of diseases
having common characteristic of progressive
optic neuropathy with associated visual field
loss as progresses in which elevated
intraocular pressure (IOP) is one of the key
modifieable factors.
 Normal IOP: 10-22 mmHg.
 Three risk factor determine the IOP:
◦ rate of aqueous humor production by ciliary body
◦ resistance to aqueous outflow across the trabecular
meshwork-Schlemm’s canal system
◦ The level of epischeral venous pressure

4. Classification
 Congenital & Acquired
 Primary & Secondary
 Open angle & Angle-closure

5. Clinical Evaluation
 Appropriate management of glaucoma
depends on the clinician's ability to
diagnose the
◦ specific form of glaucoma in a given
patient,
◦ severity of the condition,
◦ progression in that patient's disease
status.

6. History
 Patient's current complaint
 History of present illness
 Past ocular, medical, and surgical
history
 Refraction history
 Past medications history
 Social history
 History of alcohol and tobacco use
 Occupation
 Family history

7. Clinical examination and
investigations
• BCVA distant & near
• Pupillary reaction, relative afferent pupillary
defect
• Slit lamp examination of lids, lid margins,
conjunctiva, cornea, anterior chamber & lens
• IOP and time of measurement
• CCT
• Gonioscopy
• Detailed examination of:
Lens
Biomicroscopy of ONH and RNFL
Fundus
• Automated perimetry
• OCT of ONH & RNFL

8. Clinical examination
 External Adnexa
◦ Variety of conditions associated with
secondary glaucomas
 Neurofibromatosis type- I
 Oculodermal melanoeytosis (nevus of Ota)
 Axenfeld-Rieger syndrome
 Orbital varices
 Thyroid associated orbitopathy
◦ External ocular manifestations of
glaucoma therapy.
 Prostaglandin analogue

9. Slit lamp biomicroscopy
 Conjunctiva
◦ Acute IOP
◦ Chronic IOP
◦ Long term use of sympathomimetics
and prostaglandin analogoues
◦ Long term use of epinephrine
derivatives
◦ Filtering bleb +/-
 Episclera & Sclera
◦ Dilation of the episcleral vessels
◦ Sentinal vessels

10.  Cornea
◦ Developmental glaucoma
◦ Acute IOP
◦ Medication toxicity
◦ Corneal endothelial abnormality
◦ Scar
◦ CCT
 A/C
◦ Uniformity of depth of the anterior chamber
◦ Width of the chamber angle
** Before dilation of pupil; pupillary light
reaction, iris & A/C should be examined **

11.  Iris
◦ Heterochromia, iris atrophy, transillumination
defects, ectropion uveae. corectopia, nevi,
nodules, exfoliative material & NVI
◦ Trauma
 Lens
◦ Size, shape, clarity & stability of the lens
 Fundus

12. IOP
 Schiotz tonometry: indentation procedure, now
obsolete.
 Goldmann applanation tonometer : most
appropriate
 Noncontact tonometer (NCT): screening
purpose
 Tonopen: very small area, useful in corneal scar or
edema
 Digital pressure

14. Possible source of error in
Tonometry
 Squeezing of the eyelids
 Breath holding or Valsalva maneuver
 Pressure on the globe
 Extra-ocular muscle force applied to a restricted
globe
 Tight collar or tight necktie
 Obesity or straining to sit on slit lamp
 An inaccurately calibrated tonometer
 Excessive or inadequate amount of fluorescein
 High corneal astigmatism
 Corneal thickness greater or less than normal
 Corneal scarring or band keratopathy

15.  Dynamic contour tonometry
The tip of the device exactly matches the contour of
the cornea, the pressure measured by a transducer
placed on its tip.
Measure true IOP irrespective of CCT
Capable of measuring the ocular pulse amplitude

16. Gonioscopy

17. CLASSIFICATION
INDIRECT GONIOSCOPY
 Non-Indentation
 Indentatioin
DIRECT GONIOSCOPY

18. Gonioscopy
 Angle
 Blood vessles
 PAS
 Pigmentation
 Sign of trauma

19. VAN HERICK METHOD
Peripheral
Chamber
Depth
In Corneal
Thickness
Angle
Grade
Comment
≥ Cornea 4 Wide open
1/4 to 1/2 3 Incapable of closure
1/4 2
Should be
gonioscoped
<1/4 1
Dangerously narrowed
angle

20. Shaffer system

21. Optic Disc Evaluation ..
 Slit lamp biomicroscopy : Ideal
◦ Stereoscopic View –Cupping
◦ Measuring the optic disc size
 Direct Ophthalmoscopy
◦ Good Magnification
 Indirect Ophthalmoscopy
◦ Overall View
 Optic disc Photoghraphy.
◦ Documentation,Monitoring for progression.

22. The 7 parameters to look for…
1)Disc size
2)Neuroretinal Rim (NRR):
- ISNT rule
3)Cup: Disc ratio
- Vertical C/ D Ratio.
4) Optic Disc Hemorrhage
5) Nerve Fiber Layer Defect:
- focal & diffuse
6) Para Papillary Atrophy:
- Size, location & Configuration
7) Retinal Arterial Attenuation:
- focal & diffuse

23. Ophthalmoscopic sign of glaucoma
Generalized Focal Less specific
o Large optic cup
o Asymetrical of the
cup
o Progressive
enlargement of
cup
o Notching of the rim
o Vertical elongation
of the cup
o Region pallor
o Splinter
hemorrhage
o Nerve fiber layer
loss
o Exposed lamina
cribrosa
o Nasal
displacement of
the vessels
o Baring of
circumlinear
vessels
o Peripapillary
crescent

24. I>S>N>T I<S<N>T

27. The visual field
An island hill of vision in a sea of darkness

28. Perimentry
 Kinetic
◦ Two dimensional
◦ Moving stimulus
◦ Known Luminance
◦ From non-seeing area
to seeing area until it is
perceived.
◦ e.g. confrontation
Tangent screen
Lister perimeter
Goldmann
perimeter
 Static
◦ Three dimensional
◦ Static stimulus
◦ varying luminance in
the same position
◦ e.g. Octopus
Humphrey
Hensen

29. Glaucomatous visual field defects
Generalized depression
Paracentral scotoma
Arcuate scotoma
Nasal step
Altitudinal defect
Temporal wedge

30. Paracentral scotoma

31. Arcuate scotoma

32. Nasal step

33. Gross cupping with
ring scotoma Tubular
field

34. Progression of glaucomatous damage

35. OCT
Normal Glaucoma
patient

37. Classification based on mechanism
of outflow obstruction
 Open angle glaucoma mechanisms:
• Pretrabecular
• Trabecular
• Post trabecular
 Angle-closure glaucoma mechanisms :
• Anterior (pulling) mechanism
• Postertior (pushing) mechanism
 Developmental anomalies

38. Open angle glaucoma
mechanism:
 Pretrabecular:
• fibrovascular membrane
(e.g. neovascular membrane)
• Endothelial layer
(e.g. iridocorneal endothelial syndrome)
• epithelial downgrowth
• fibrous ingrowth
• inflammatory (e.g. fuch’s iridocyclitis)

39. Open angle glaucoma
mechanism:
 Trabecular:
• Idiopathic (e.g. chronic & juvenile open angle)
• ‘Clogging’ of trabecular meshwork
(e.g. pigmentary, red cell, ghost cell glaucoma)
• Alteration of trabecular meshwork
(e.g. steroid induced glaucoma)
• Trauma (e.g. angle recession)
• Intra ocular foreign bodies

40. Open angle glaucoma
mechanism:
 Post trabecular:
• Obstruction of Schlemm’s canal
• Elevated intra ocular pressure
(e.g. sturge weber syndrome
thyroid ophthalmopathy
retrobulbar tumours)

41. Angle closure glaucoma
mechanism:
 Anterior (pulling) mechanism
• Contracture of membrane
(e.g. neovascular glaucoma)
 Postertior (pushing) mechanism
• With pupillary block
• Without pupillary block
(e.g. malignant glaucoma)

42. Developmental anomalies
 Congenital glaucoma
 Aniridia
 Axenfeld - Rieger syndrome

43. In-direct
gonioscopy
 Non-Indentation
◦ Goldmann three
mirrors
 Indentatioin
◦ Zeiss
◦ Posner
◦ Sussman
Direct gonioscopy
 Diagnostic – Koeppe
 Surgical –
Medical workshop
Barken
Swan- Jacob