CLINICAL DIAGNOSTIC TEST AND CONCISE MANAGEMENT PLAN

1. GLAUCOMA
CLINICAL INVESTIGATIONS &
MANAGEMENT
DR. SANDEEP NIMASE
ASSOCIATE PROFESSOR
AYURVED MAHAVIDYALAYA RAHURI.
SHALAKYA DEPT.

4. Primary Open Angle Glaucoma
• HISTORY
• 1. SYMPTOMS- PAIN , HEADACHE, VISION LOSS, FIELD DEFECT, HALOWS
• 2. ONSET, PROGRESS FROM PREVIOUS RECORDS
• 3. POSSITIVE FAMILY HISTORY – DETAILS OF DISEASES, SURGERY, OUTCOME
• 4. BASELINE IOP- MAX AND MIN
• 5. DIURNAL PROFILE
• 6. MEDICATIONS IF ANY – LIST OF DRUGS, ALLERGIES, RESPONSE PATTERN,
TIME OF LAST APLLICATION OF MEDICINE
• 7. MANAGEMENT DETAILS- ARGON LASER TRABECULOPLASTY, SURGERY
• 8. SYSTEMIC ILLNESS.

5. Examination
• BEST CORRECTED VISUAL ACUGNITY
• OCULAR ALIGNMENT MOTILITY
• PUPILARY REACTION AND FUNCTION
• SLIT LAMP EXAMINATION- PRE AND POST DILATATION EXAMINATION
• PSEUDOEXFOLIATION GLAUCOMA
• COEXISTING GLAUCOMA
• CORNEAL OEDEMA
• PIGMENT ON ANT. CHAMBER AND ON ENDOTHELIUM
• AC REACTION AND KP
• IRIS- COLOUR, ATROPHY,PUPILLARY RUFF DEFECT,NEOVASULARIZATION
• SHAPE AND THICKNESS OF CRYSTALLINE LENS.
• APPLANATION TONOMETRY
• GONIOSCOPY
• INDIRECT OPHTHALMOSCOPY- 90 D, 78D- CDR, NERVE FIBRE LAYER DEFECT,
THINING, PERIPAPILLARY ATROPHY, DISC HAEMORRHAGE.

6. INVESTIGATIONS
• VISLUAL FIELD DEFECT- 30-2, 10-2, MACULAR THRESHHOLD,
• DISC PHOTOGRAPHY , OCT , PACHYMETRY IHFOR CENTRAL CORNEAL
THICKNESS.
• GENERAL CRITERIA FOR DIAGNOSIS
• IOP- > 21 MM HG
• OPEN ANGLES
• CUPPING > 0.3:1 WITH NRR CHANGES
• VISUAL FIELD CHANGES COEERSPONDING TO DISC CHANGES

7. MANAGEMENT
• PATIENT EDUCATION
• INSTITUTE THERAPYRABE CHICE OF DRUG, DISEASE CONDITION, IOP
REDUCTION NEDED, FINANCIAL STATUS, COMPLIANCE , AGE ,
SYSTEMIC STATUS.
• TOPICAL MEDICATION- SINGLE DRUG & LESS SIDE EFFECT.
• UNILATERAL TRIAL, ADEQUETE FALLOW UP,EXPLAIN LID CLOSURE AND NLD
BLOCKAGE AFTER MEDICATION. ENSURE COMPLIANCE, SWITH OVER TO
OTHER DRUG,
• SURGERY
• ARGON LASER TRABECULEPLASTY
• MILD EXERCISE AVIOD STRESS, CONTROL OF SYSTEMIC DISEASE
• INFORM FAMILY MEMBER REGARDING RISK TO OTHER MEMBERS

8. GUIDELINE FOR TARGET INTRAOCULAR PRESSURE
• MINIMUM OF 20% REDUCTION FROM BASELINE IOP IS REQUIRED AS TARGET IOP TO PREVENT PROGRESSION.
• INITIAL AVARAGE IOP
• LOOK FOR COMPLIANCE , ADVERSE EFFECTS,
• FALLOW UP FIELDS- ONCE FOR STABLE 2-6 MONTH IN UNSTABLE
• CONFORM BEFORE CHANGING MEDICINES OR ADVICING SURGERY
VF DEFECT 50 40 30 20
MILD 30 25 23 16
MODARATE 25 25 20 14
SEVERE 20 20 15 10
TARGET IOP REACHED PROGRESSION DURATION OF CONTROL FOLLOW UPS
YES NO > 6 MONTH 1 -6- MONTH
YES NO MORE THAN 6 MONTH 3-12- MONTH
YES YES NA 1 WEEK -3 MONTH
NO NO NA 1 DAY TO3 MONTH
NO YES NA 1 DA TO 1 MONTH

9. OTHER COMMONLY SEEN GLACOMAS AND
RELATED CONDITIONS
• ACUTE ANGLE CLOSURE GLAUCOMA- Angle Closure Glaucoma (Sometimes referred
to as Narrow Angle Glaucoma) is caused when the normal drainage system of
the eye becomes suddenly blocked, causing pressure to build within the eye at a
very rapid rate. Complete blindness can occur in as little as 3 to 5 days!
• SEVERE PAIN
• PRESSURE OVER THE EYE
• CLOUDINESS TO THE CORNEA
• EYE EXTREMELY SENSITIVE TO LIGHT
• HALOS SEEN AROUND LIGHTS.
• NAUSEA AND/OR VOMITING
• MANAGEMENT- IV MANITOL , MAX ANTIGLAUCOMA AND ANTIINFLAMATORY RX,
• OTHER EYE EXAMINATION FOR ANGLE OCLUSION,
• YAG PI, SURGICAL PBI, TRABECULECTOMY.

10. CHRONIC/ CREEPING ANGLE CLOSURE
GLAUCOMA
• DIAGNOSTIC POINTS-
• QUITE EYE
• SHALLOW AC
• RAISED IOP
• PERIFERAL ANTERIOR SYNECHIA ON GONIOSCOPY
MANAGEMENT-
• AS IN POAG
• PROPHYLACTIC PERIPHERAL IRIDOTOMY.

11. OCULAR HYPERTENSION
• DIAGNISTIC POINTS- INTRAOCULAR PRESSURE MORE THAN 21 MMHG
WITH OTHERWISE NORMAL FEATURES INCLUDING VISUAL FIELDS
• MANAGEMENT-
• RULE OUT RISK FACTORS
• PACHYMETRY TO RULE OUT CCT

12. NARROW OR OCCLUDABLE ANGLES
• DIAGNOSTIC POINTS
• MORE THAN 180*ANGLE CLOSURE UP TO POSTERIOR TRABECULAR
MESHWORK WITH OR WITHOUT PROVOCATION TEST.
• NO DILATATION DONE BEFORE PBI TO PREVENT MYDRIASIS INDUCED
ANGLE CLOSURE.
• MANAGEMENT -
• PROPHYLACTIC PERIPHERAL IRIDOTOMY.
• EXAMINATION OF FAMILY MEMBERS.

13. CONGENITAL GLAUCOMA
Congenital Glaucoma results as a condition from birth. Children are born with conditions such as an abnormal
development of the Anterior Chamber angles which prohibit the normal drainage of fluid from the eyes,
which then causes an increase in the pressure within the eye, and subsequent Retinal and Optic Disc damage.
• DIAGNOSTIC POINTS
• LARGE CORNEAL DIAMETER OR INCRESING SIZE
• CLOUDINESS OF THE CORNEA DUE TO EDEMA
• DISTENSION OF THE EYE
• PHOTOPHOBA (SENSITIVE TO LIGHT)
• ANGLE ANAMOLIES
• CUPPED DISC
• MANAGEMENT-
• EXPLAIN PROGNOSTIC OUTCOMES TO BOTH PARENTS
• NEED MULTIPLE PROCEDURES, RISK OF ANAESTHESIA
• AMBLYOPIA AND MANAGEMENT
• RULE OUT METABOLIC AND INFECTIVE CAUSE.
• EXAMINTIONDER ANAESTHESIA , EXTERNAL TABECULECTOMY, TRABECULECTOMY IN ADVANCED
AGE
• FALLOW UP- CHECK IOP. CORNEAL DIAMETER, B-SCAN ONCE IN YEAR,

14. PIGMENTARY GLAUCOMA
• DIAGNOSTIC POINTS
• PIGMENTARY GLAUCOMA CAN DEVELOP AS A RESULT OF SMALL PIECES OF THE IRIS BREAKING
OFF. THESE SMALL PARTICLES CAN LODGE THEMSELVES IN THE NORMAL DRAINAGE CANALS AND
SUBSEQUENTLY INTERFERE WITH THE NORMAL DRAINAGE OF FLUIDS FROM THE EYE.
• THIRD AND FOURTH DECADES OF LIFE
• KRUKENBERG SPINDLE
• IRIS TRANSILLUNIMATION DEFECTS
• DENCE TRABECULAR MESHWORK PIGMENTATION
• CONCAVE IRIS CONFUGARATION.
• MANAGEMENT-
• AS POAG
• ALT MAY HAVE ROLE IN SOME PATIENTS
• PROPHYLACTIC PBI IN SELECTED PATIENTS
• AQUEOUS SUPRESSANT AMD MIOTICS ARE AVOIDED BECAUSE YOUNG, HIGH MYOPES AND DO NOT
TOLERATE MIOTIC THERAPY SECONDARY TO INCREASED MYOPIA, HEADACHES AND ACCOMMODATIVE
SPASM. ALSO, THE PHYSICIAN NEEDS TO BE CAUTIOUS WHEN INITIATING MIOTIC THERAPY IN THE
MYOPIC PATIENT WITH PIGMENTARY GLAUCOMA BECAUSE OF THE INCREASED RISK OF RETINAL
DETACHMENT ASSOCIATED WITH PILOCARPINE USE.
• PROSTAGLANDINS PREFERED.

15. PSEUDOEXFOLIATION GLAUCOMA
• DIAGNOSTIC POINTS
• AFFECTS PATIENTS OLDER THAN 60 YEARS OF AGE.
• PXF MATERIAL ON PUPILLARY RUFF , ENDOTHELIUM, IN ANGLE
• NON DILATING PUPIL
• TYPICAL PXF PATTERN ON LENS
• ZONULAR WEAKNESS AND LENS DISLOCATION SOMETIMES.
• DILATION CONFORMS DIAGNOSIS
• MANAGEMENT-
• AS IN POAG
• NEEDS PBI IN NARROW ANGLES
• COMBINED SURGERY –MANAGEMENT OF POORLY DILATING PUPIL AND RISK OF SUBLUXATION.

16. NORMAL TENSION GLAUCOMA
• DIAGNOSTIC POINTS-
• NORMAL TENSION GLAUCOMA OCCURS WHEN THERE IS DAMAGE TO THE OPTIC NERVE
DETECTED IN PATIENTS WHO HAVE COMPLETELY NORMAL INTER – OCCULAR PRESSURE.IT HAS
THE SAME CHARACTERISTICS AS PRIMARY OPEN – ANGLE GLAUCOMA.
• HISTORY OF ACUTE HYPOTENSIVE EPISODES, MIGRANE, PERIPHERAL VASCULAR DISORDERS AND
HAEMATOLOGICAL DISORDERS.
• IOP < 21 MM OF HG ON A DIURNAL VARIATION
• OTHERWISE SIMILAR TO POAG
• DISC HAEMORRHAGE MORE FREQUENT
• VISUAL FIELDS HAVE DEEPER STEEPER DEFECTS CLOSER TO THE FIXATION
• MANAGEMENT-
• AS IN POAG CORNEAL THICKNESS MAY BE VARIABLE
• APPROX 50% MAY NOT PROGRESS
• NEEDS AGGRESSIVE TREATMENT IF INITIAL IOP IN LOW TEENS
• EXCLUDE NEUROLOGICAL AND STESTEMIC VASCULAR CAUSES IF INDICATED BY A PALE DISC WITH
VISUAL FIELD CHANGES.

17. NEOVACULAR GLAUCOMA
NEOVASCULAR GLAUCOMA (NVG) IS A SEVERE FORM OF SECONDARY GLAUCOMA CHARACTERIZED BY
PROLIFERATION OF FIBROVASCULAR TISSUE IN THE ANTERIOR CHAMBER ANGLE. FIRST NOTED NEW VESSEL
FORMATION ON THE IRIS (RUBEOSIS IRIDIS) IN EYES WITH CENTRAL RETINAL VEIN OCCLUSION. THIS CONDITION
HAS BEEN NOTED PREVIOUSLY BY NAMES INCLUDING HEMORRHAGIC GLAUCOMA, CONGESTIVE GLAUCOMA,
THROMBOTIC GLAUCOMA, AND RUBEOTIC GLAUCOMA
• DIAGNOSTIC POINTS
• NEOVASCULARISATION (NVI),ISCHEMIC RETINAL FEATURES WITH OR
WITHOUT NEOVASCULARISATION OF THE OPTIC DISC (NVD) AND
NEOVASCULARISATION ELSEWHERE.
• MANAGEMENT-
• RULE OUT CAUSE OF NEOVASCULARISATION
• IDENTIFY THE STAGE OF DISEASE
• IF BLIND OR VISUAL POTENTIAL POOR
• CONSERVATIVE OR SYMPTOMATIC TREATMENT
• MEDICATIONS OR CYCLODESTRUCTIVE PROCEDURES.
• RETROBULBER ALKOHOL INJ. OR ENUCLIATION IN SEVERE CASES.
• IF VISUAL POTENTIAL PRESENT AND TREATEBLE RETINAL CONDITIONS IDENTIFIED
PAN RETINAL PHOTOCOAGULATION WITH OR WITHOUT PERIPHERAL RETINAL
ABLATION.

18. Mechanisms of Anterior Segment
Neovascularization and Predisposing Conditions

19. PLATEAU IRIS SYNDROME
• DIAGNOSTIC POINTS
• FLAT IRIS COUNTER
• INCOMPLETE OPENING OF ANGLES ON GONIOSCOPY, VOLCANO CRATER
APPERANCE WITH COMPRESSION
• RAISED IOP WITH PATENT PI ON DILATATION
• MANAGEMENT-
• UBM MAY BE USED FOR DIAGNOSIS
• PROPHYLACTIC PBI WITH MEDICATION ESPECIALLY MIOTICS
• ARGON LASER IRIDOPLASTY
• SURGERY IN UNCONTROLED PATIENTS.

20. PHACOMORPHIC GLAUCOMA
• DIAGNOSTIC POINTS
• UNIFORMLY SHALLOW AC CENTRALLY MORE
• INTUMESCENT OR HYPERMATURE CATARACT
• CLOSED ANGLES
• MANAGEMENT-
• EXAMINATION OF OTHER EYE FOR OCLUDABLE ANGLE
• AGGRESSIVE IOP MANAGEMENT
• PROPHYLACTIC PBI
• IF LESS THAN 2 WEEKS EARLY CATARACT SURGERY WITH IOL IMPLANTATION
• IF MORE THAN 2 WEEKS COMBINED SURGERY CATARACT WITH TRAB.
• CATARACT SURGERY DONE UNDER MANITOL COVER , SICS PREFERRED .

21. PHACOLYTIC GLAUCOMA
• DIAGNOSTIC POINTS
• MATURE CATARACT,
• PRESENCE OF INFLAMATION
• FLUFFY LENS OR MILKY CORTICAL MATERIAL IN AC AND ANGLE.
• MANAGEMENT
• MEDICAL CONTROL OF IOP AND INFLAMATION
• EARLY CATARACT EXTRACTION WITH IOL IMPLANTATION
• MORE THAN 2 WEEKS TRAB MAY REQUIRED
• SURGERY MAY DONE UNDER MANITOL COVER IF NEEDED.

22. POST TRAUMATIC GLAUCOMA
• DIAGNOSTIC POINTS
• INFLAMATION , HYPHEMA, SUBLUXATED LENS,
• GHOST CELLS IN AC, ELEVATED IOP, ANGLE RECESSION.
• AVOID GONIOSCOPY IN THE PRESENCE OF HYPHEMA
• MANAGEMENT-
• MEDICAL CONTROL OF IOP AND INFLAMATION.
• TRAB MAY NEED AFTER IOP CONTROL
• LENS REMOVAL IF SUBLUXATED
• MANAGEMENT OF HYPHEM
• DO NOT APPLY PRESSURE OVER THE EYE
• RULE OUT CLOTTING DISORDERS – COAGULATION PROFILE
• EIGHT BALL HYPHEMA, GHOST CELL IN AC,CORNEAL STANING AND UNCONTROLLED
IOP NEED EARLY HYPHEMA EVACUATION.

23. POST-INFLAMATORY GLAUCOMA
• DIAGNOSTIC POINTS
• PRESENCE OF INFLAMATION
• KP (OLD OR FRESH)
• STEROID INDUCED LOOK FOR DEPOT
• IRIS BOMBE
• IRIS ATROPHY
• SYNECHIAL ANGLE CLOSURE
• MANAGEMENT
• MEDICAL CONTROL OF IOP AND INFLAMATION
• PBI FOR IRIS BOMBE
• IN STEROID INDUCED GLAUCOMA
• CEASE STEROIDS AND MEDICAL CONTROL OF IOP FOR 2 MONTH
• THEN DISCONTINUE AND RE-EVALUATE IOP IF ELEVATE CONTINUE RX OR SURGERY
• EXPLAIN CHANCES OF POAG IN LATER LIFE.
• MONITOR IOP REGULARLY ATLEAST YEARLY AND LIFELONG.
• PERIODIC GONIOSCOPY IN CHRONIC UVEITS.

24. IRIDOCORNEAL ENDOTHELIAL SYNDROME
• DIAGNOSTIC POINTS
• MIDDLE AGED FEMALE
• IRIS AND /OR CORNEAL CHANGES
• IRIS ADEHESIONS ON GONIOCSOPY.
• MANAGEMENT-
• SPECULAR MICROSCOPY AND PACHYMETRY
• USUALLY NEEDS WITH ANTIMETABOLITES
• REFRACTORY TO TREATMENT.

25. NANOPHTHALMOS
• DIGNOSTIC POINTS
• SMALL PALPABRAL FISSURE
• HIGH HYPEROPIA
• VERY SHALLOW AC NORMAL LENS WITH SMALL OCULAR PARAMETERS ON A-SCAN AXIAL
LENGTH <19 MM
• MANAGEMENT-
• ACURATE A-SCAN FOR AC DEPTH LENS THICKNESS, AXIAL LENGH
• PBI IF NEEDED
• CONTROL OF IOP AND REGULAR FOLLOW-UPS
• NEED FOR CAREFUL CATARACT SURGERY WITH OR WITHOUT TRAB
• USE OF PROPHYLACTIC SCLEROTOMIES IN ALL CASES DURING ANY INTRAOCULAR
PROCEDURE

26. ELEVATED EPISCLERAL VENUS PRESSURE –
INDUCED GLAUCOMA
• DIAGNOSTIC POINTS
• RAISED IOP WITH DILATED EPISCLERAL VESSELS
• BLLOD IN SCHLEMM’S CANAL WITH GONIOSCOPY.
• MANAGEMENT
• B-SCAN FOR SUPERIOR OPHTHALMIC VEIN
• RULE OUT FISTULAS MRI PREFERABLE
• RULE OUT SYSTEMIC DISEASE LIKE HYPO- HYPER THYROIDISM AND OTHER
CAUSES OF RAISED EPISCLERAL VENUS PRESSURE
• TREAT SYSTEMIC CONDITION
• CONTROL IOP MEDICALLY OR SURGICALLY WITH ANTIMETABOLITES.

27. MALIGNANT GLAUCOMA
• DIAGNOSTIC POINTS
• SHALLOW OR FLAT AC
• PATENT PBI
• ELEVATED IOP IN POST SURGICAL SITUATION
• ANTERIORLY ROTATED CILLARRY PROCESSES ON UBM IN THE ABSENCE OF OTHER
CAUSES.
• MANAGEMENT
• UBM IS REQUIRED TO SEE IF CHOROIDAL EFFUSION IS PRESENT IN THIS COSERVATIVE
APPROACH MAY HELP.
• MEDICAL CONTROL-
• ANTIGLAUCOMA MEDICATIONS ESPECIALLY AQUEOUS SUPRESSENT , ACETAZOLAMIDE.
• CYCLOPLEGICS MAY NEED FOR 6 MONTHS
• STEROIDS IN ACUTE PHASE
• YAG HYLOIDO ITOMYPSEUDOPHAKES AND APHAKICS
• VITRECTOMY IN SELECTED CASES