SECONDARY GLAUCOMAS Dr. Shinisha Paul

Glaucoma Progressive optic neuropathy associated with visual field defects with/without raise in IOP Primary / Secondary

Secondary Glaucomas Group of disorders in which raised IOP is associated with some primary ocular or systemic disease May show characteristics of either angle closure or open angle glaucoma Outflow channels affected iris pushed forward ACG Pigment deposits in trabecular meshwork OAG

Classification Pseudoexfoliation Pigmentary Neovascular Inflammatory Lens induced Aphakic or Pseudophakic Steroid induced Malignant

Pseudoexfoliation Glaucoma Affects elderly Unilateral in 60% Exfoliative material deposited on iris, ciliary region and capsule of lens Appear as flakes on anterior capsule of lens and pupillary margin Collect in angle of anterior chamber and obstruct aqueous humor drainage Management : as in POAG

Pigmentary glaucoma Pigment release in young male myopes. Complaints of intermittent halos. Krukenberg spindle of pigment on corneal endothelium. Sampolesi line on gonioscopy. Pigment dispersion syndrome. Field loss in few eyes. Long term prognosis is good. Management : as in POAG.

Neovascular glaucoma Extensive retinal ischemia – CRVO and PDR Rubeosis iridis Fibrosis Adhesion of iris to the cornea at angle ACG

Management Medical therapy : to control IOP Filtration surgery Panretinal photocoagulation Prevent further neovascularisation.

Inflammatory Glaucoma Uveitic glaucoma – swelling and dysfunction of endothelial cells or infiltration and obstruction of trabecular meshwork by inflammatory material Postinflammatory glaucoma – extensive posterior synchiae : occlusion pupillae, iris bombe Glaucomatocyclitic crisis – acute, recurrent, mild uveitis, high IOP : resolves in days to week Fuchs heterochromic iridocyclitis – chronic, low grade iritis with cataract and glaucoma

Lens induced Glaucoma Phacomorphic Glaucoma : swollen intumescent lens obliterates the drainage angle Phacolytic Glaucoma :lens protein from hypermature lens escape into aqueous Treatment : extraction of lens after lowering of intraocular pressure. All lens matter must be evacuated.

Aphakic or Pseudophakic Glaucoma Secondary rise of IOP after cataract surgery Caused by viscoelastics, distortion of angle structures or haemorrhage Resolve spontaneously in a few days to week

Steroid induced glaucoma Open angle 5% high responders, 35% moderate, 60% non- responders GAG theory Corticosteroids inhibit release of hydrolases GAG in TM cannot depolarise retain water in ECS narrowing of trabecular spaces decrease in aqueous outflow

Endothelial cell theory Corticosteroids Suppressed phagocytic activity of endothelial cells Collection of debris in TM Decrease in aqueous outflow Prostaglandin theory Inhibits synthesis of PGE & PGF

Management Regular monitoring of IOP Discontinuation of steroids – IOP normalises within 10 d – 4 wks. Medical therapy Filtration surgery

Malignant Glaucoma Aqueous misdirection syndrome Causes : iridectomy, filtering surgery, laser iridotomy, cataract surgery, capsulotomy C/F : severe pain, blurring of vision, shallow AC, high IOP. Management : Cycloplegic (deepens AC), osmotic agent (dehydrates vitreous), beta blockers (carbonic anhydrase inhibitors), YAG laser, hyaloidotomy, pars plana vitrectomy